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CLINICAL  LECTURES 


PRINCIPLES  AND  PRACTICE 
OF  MEDICINE. 


BY 

JOHN  HUGHES  BENNETT,  M.D,  r.I{.S.E. 

PROFESSOR   OP   THE   INSTITUTES   OF   MEDICINE, 
AND    SENIOR   PROFESSOR   OF   CLINICAL   MEDICINE   IN   THE   UNIVERSITY   OP   EDINBURGH. 

Formerly  Lecturer  on  the  Practice  of  Physic,  Physician  to  the  Fever  Hospital, 

Director  of  the  Poli-Clinic  at  the  Koyal  Dispensary,  and  Pathologist  to  the  Eoyal  Infirmary,  Edinburgh  ; 

Member  of  various  Scientific  and  Medical  Societies  in  Edinburgh,  St.  Andrews, 

Philadelphia,  New  York,  Paris,  Vienna,  Berlin,  Jena,  Stockholm, 

Copenhagen,  Amsterdam,  etc.,  etc. 


FROM    THE     LAST    EDINBURGH     EDITION. 

iLMitlj  JilJC  ?i1untirrB  illustrations  on  tLJUooU. 


NEW    YORK: 
SAMUEL   S.  &   WILLIAM  WOOD,  389   BROADWAY. 

1860. 


^" 


R.     CEAIGHEAD,      PRINTER, 

Caiton  ISuirtiing, 

81,  83,  and  85  Centre  Street, 

N.  T. 


PREFACE. 


Ix  consequence  of  tlie  rapid  exhaustion  of  a  second  edition  of 
this  work,  I  have  been  called  upon  to  prepare  a  new  one  much 
sooner  than  I  could  have  anticipated.  The  whole  of  it,  not- 
withstanding, has  been  most  carefully  revised,  and  the  volume 
extended  by  the  addition  of  fifty  pages,  with  twenty-one  new 
cases  and  thirty-four  new  wood-cuts,  I  have  endeavoured 
throughout,  by  reference  to  indisputable  facts,  to  demonstrate 
the  correctness  of  the  principles  which  have  guided  my  prac- 
tice, and  have,  therefore,  authenticated  every  case  with  the 
name  of  its  reporter  in  the  hospital  books. 

I  have  availed  myself  of  numerous  illustrations  engraved  on 
wood,  having  long  been  persuaded  that  mere  description  of 
morbid  appearances,  and  especially  of  those  that  are  made  visible 
by  means  of  the  microscope,  communicates  only  feeble  or  imper- 
fect ideas  to  others.  Of  these  illustrations,  such  as  are  borrowed 
have  the  names  of  their  authors  apj^ended ;  such  as  have  no 
name  attached  are  original. 

I  have  again  to  ex|)ress  my  warmest  thanks  to  numero.us 
friends  for  aid  rendered  to  me  in  various  wa^'s,  but  more  espe- 
cially to  Dr.  Markham  of  London  and  to  Dr.  John  Glen,  now 
Medical  Superintendent  of  the  Eoyal  Infirmary,  Dundee.  Dr. 
Markham  has  done  me  the  honour  to  make  a  most  careful  study 
and  critical  analysis  of  the  book,  and  has  favoured  me  wiih 
numerous  valuable  remarks  and  suggestions,  of  which  I  have 


iv  PEEFACE. 

gladly  taken  advantage.  Dr.  Glen,  by  correcting  tlie  sheets 
during  their  progress  through  the  press,  has  not  only  added  to 
the  obligations  I  formerly  owed  him,  but  has  enabled  me  to 
produce  the  present  edition  long  before  it  would  have  been 
possible  for  me,  otherwise,  to  have  completed  the  undertaking. 

I  am  still,  however,  deeply  sensible  of  the  many  imperfections 
with  which  this  work  is  chargeable,  and  for  which  I  must  solicit 
the  kind  indulgence  of  my  medical  brethren.  To  exemplify 
the  entire  subject  of  practical  medicine  by  means  of  cases  in  a 
work  of  moderate  compass,  is  obviously  impossible.  But  sufl&- 
cient  examples,  I  trust,  have  been  given  to  illustrate  the  more 
important  modifications,  which  the  advanced  state  of  diagnosis 
and  pathology  has  effected  in  the  treatment  of  diseases.  The 
flattering  manner  in  which  it  has  been  received  by  the  profes- 
sion, and  noticed  by  the  press,  confirms  the  conviction  I  formerly 
ventured  to  state,  viz.,  that  such  modifications  will  be  shown 
by  further  experience  to  be  not  merely  temporary  changes,  but 
permanent  improvements  in  the  practice  of  the  art. 

J.   HUGHES  BENNETT. 


Edixburgh,  April,  1859. 


CONTENTS. 


List  of  iLLrsTRAxioxs      .... 

Introductiox,       .  .  .  •  • 

The  relation  of  the  science  to  the  art  of  medicine 
Mode  of  conducting  the  cUnical  course 
The  political  state  of  the  medical  profession 
The  social  state  of  the  medical  profession  . 
The  present  state  of  practical  medicine 


Page 
xvi 
1 
2 
6 
9 

12 
13 


SECTION  I. 
EXAMINATION  OF   THE  PATIENT 

Arrangement  of  symptoms,  etc. 
Inspection  of  the  dead  body 
Relative  position  of  internal  organs 
Ikspection  .... 

Inspection  of  the  general  posture    . 
of  the  countenance 
of  the  chest 
of  the  abdomen 
Palpation*  .  .  •  • 

Increased  or  diminished  sensibility  of  parts 
Altered  form,  size,  density,  and  elasticity 
Alterations  of  movement     . 
Mensuration        .  .  .  • 

Percussion  .... 

Of  the  different  sounds  produced  by  percussion 
Of  the  sense  of  resistance  produced  by  percussion 
General  rules  to  be  followed  in  the  practice  of  mediate  percussion 
Special  rules  to  be  followed  in  percussing  particular  organs 
in  percussing  the  lungs 
in  percussing  the  heart 
in  percussing  tlie  liver 
in  percussing  the  spleen 


18 

19 
24 

26 

28 

28 

29 

29 

30 

30 

30 

31 

31 

32 

35 

37 

38 

38 

40 

40 

43 

44 

46 


VI 


CONTENTS. 


Special  rules  to  be  followed  in  percussing  the  stomach  and  intestines 
in  percussing  the  kidneys 
in  percussing  the  bladder 
AUSCUXTATION"         ....... 

General  rules  to  be  followed  in  the  practice  of  auscultation 

Special  rules  to  be  followed  during  auscultation  of  the   pulmonarv 
organs 

Of  the  sounds  produced  by  the  pulmonary  organs  in  health  and  in 
disease     . 

Special  rules  to  be  followed  during  auscultation  of  the  circulatory 
organs 

Of  the  sounds   produced  by  the  circulatory  organs  in  health   and 
disease     ...... 

Auscultation  of  the  abdomen 

Auscultation  of  the  large  vessels    . 
Use  of  the  Microscope    ..... 

Description  of  the  Microscope 

Mensuration  and  demonstration 

How  to  observe  with  a  microscope 
Peixcipal  Applications  of  the  Microscope  to  Diagxosis 

Saliva 

MOk 

The  Blood  . 

Pus 

Sputum 

Vomited  matters 

Foeces 

Uterine  and  vaginal  discharges 

Mucus 

Dropsical  fluids 

Urine 

Cutaneous  eruptions  and  ulcers 
Use  of  Chemical  Tests 

To  detect  albumen  in  the  urine 

To  detect  bile  in  the  urine  . 

To  detect  sugar  in  the  urine 

To  detect  chlorides  in  the  urine 


Page 
46 
48 
48 
49 
49 

51 

51 

55 

55 

5S 
5S 
59 
61 
67 
69 
71 
72 
74 
75 
78 
78 
81 
83 
85 
86 
87 
88 
91 
94 
94 
94 
95 
96 


SECTIOX  11. 

PREs'CIPLES   OF  MEDICINE 

Ox  the  General  Laws  of  Nctritiox  ix  Health  axd  Disease 
Function  of  nutrition  .  .  .  .  , 

Function  of  innervation      .  .  .  .  , 


97 

99 

99 

108 


CONTENTS. 


Vll 


Page 

General  anatomy  and  physiology  of  the  nervous  system     .            .  lOS 

General  pathology  of  the  nervous  system  ....  115 

Simple,  Caxcerous,  axd  Tubercular  Exudatioxs — their  Pathology  axd 

General  Treatment             .            .             .            .            ,            .  123 

Production  of  exudation     ......  123 

Theory  of  exudation            .            ,             ,             .             .             .  126 

Yital  transformations  of  the  exudation       .            .            .            .  128 

Simple  exudation         .             .             .             .             .             .  128 

Cancerous  exudation   ......  133 

Tubercular  exudation  .             .             .             .             .             .  137 

Pathologj'  of  the  three  kinds  of  exudation              .             .             .  138 

Death  of  the  exudation       .            .            ,            .            .            .  141 

Mortification  or  moist  gangrene           ....  141 

Ulceration        .......  144 

General  treatment  of  exudation     .....  146 

Morbid  Growths  of  Texture — their  General  Pathology  and  Treat- 
ment .........  148 

Classification            .......  149 

Fibrous  growths           .             .             .             .             .             .  151 

Patty  growths              .             .             .             .             .             .  159 

Cystic  growths             .             .             .             ,             .             .  161 

Glandular  growths       .            .            ..           .            .            .  170 

Epithelial  growths        .             .             .             .             .             .  173 

Vascular  growths         .             .             .             .             .             .  181 

Cartilaginous  growths ......  186 

Osseous  growths          ......  190 

Cancerous  growths       ......  196 

General  pathology  of  morbid  groAvths         ....  197 

General  treatment  of  morbid  growths          .             .             .             ,  208 

Morbid  Degenerations  of  Texture        .....  210 

Albuminous  degeneration   .             .             .             .             .             .  210 

Fatty  degeneration              ......  216 

Pigmentary  degeneration     .             ,             ,             .             .             .  227 

Mineral  degeneration           ......  234 

Concretions          ........  237 

Albuminous  concretions      ......  238 

Fatty  concretions     .......  238 

Pigmentary  concretions       ......  239 

Mineral  concretions              ......  239 

Urinary  concretions            .             .        '     .             .             .             ,  240 

Prostatic  concretions            ......  244 

Hairy  concretions    .......  244 

Vegetable  fibrous  concretions          .....  245 

Amyloid  and  amylaceous  concretions         ....  247 


VIU  CONTENTS. 


SECTION   III. 


Pathology    ..... 
Cerebral  Hemorrhage— Cases  XVIII.  to  XXVIII. 

Pathology  and  treatment    . 


Page 


ON  THE  RECENT  CHANGES  IN  THERAPEUTICS,  OCCASIONED 
BY  AN  ADVANCED  KNOWLEDGE  OF  DIAGNOSIS  AND 
PATHOLOGY .250 

The  Diminished  Employment  of  Blood-lettixo  and  other  Antiphlo- 
gistic Remedies  in  the  Treatment  of  Acute  Inflammations   .  251 

Proposition  1. — That  little  reliance  can  be  placed  on  the  experience 
of  those  who,  lilve  Cullen  and  Gregory,  were  unacquainted  with  the 
nature  of,  and  the  mode  of  detecting,  internal  inflammations     .  252 

Proposition  2. — That  inflammation  is  the  same  now  as  it  has  ever  been, 
and  that  the  analogy  sought  to  be  established  between  it  and  tlie 
varying  types  of  fevers  is  fallacious         ....  254 

Proposition  3. — That  the  principles  on  whicii  blood-letting  and  anti- 
phlogistic remedies  have  hitherto  been  practised  are  opposed  to  a 
sound  pathology .  .  .  .  .  .  .  257 

Proposition  4. — That  an  inflammation  once  establislied  cannot  be  cut 
short,  and  that  the  object  of  judicious  medical  treatment  is  to  con- 
duct it  to  a  favourable  termination  ....  264 

Proposition  5. — That  all  positive  knowledge  of  the  experience  of  the 
past,  as  well  as  the  more  exact  observation  of  the  present  day, 
alike  establish  the  truth  of  the  preceding  principles  as  guides  for 
the  future  .......  269 

The  Influence  of  Predominant  Ideas  on  the  Healthy  and  Disordered 

Functions  of  the  Body        ......  292 


SECTION    IV. 

DISEASES   OF   THE   NERVOUS   SYSTEM  .  303 

On  the  I'ATnoLoaY  of  Cerebral  and  Spinal  Softenings,  and  on  the 

Necessity  of  employing  the  Microscope  to  ascertain  their  nature  305 

Acute  Hydrocephalus — ^Cases  I.  to  III.  .  .  .  .  312 

Pathology  and  treatment     ......  316 

Cerebral  Meningitis,  Acute — Cases  IV.  to  VI.  .  .  .  319 

Pathology  and  treatment     ......  323 

Chronic — Cases  VIL  and  VIII.  .  .    '         .  .  325 

Cerebritis,  Acute — Cases  IX.  and  X.       .  .  .  .  .  329 

Chronic— Cases  XL  to  XIV.  ....  333 

Pathology  and  treatment  of  cerebritis         ....  343 

Cerebral  Disease  from  Obstruction  of  Arteries — Cases  XV.  to  XVII.  345 


354 
356 
373 


CONTENTS. 


IX 


Cancer  op  the  Brain — Case  XXIX. 

Dropsy  of  the  Brain — Case  XXX. 

Structural  Diseases  of  the  Spinal  Cord — Cases  XXXI 
Treatment   .  .  .  .  ' 

Pathology    .  .  .  .  • 

Functional  Disorders  of  the  Nervous  System — Case 
Classification  of  functional  nervous  disorders 
Pathology  of  functional  nervous  disorders 
Treatment  of  functional  nervous  disorders 
Delirium  tremens —Cases  XXXIX.  to  XLII. 
Poisoning  by  opium — Case  XLIII. 
Poisoning  by  hemlock — Case  XLIV. 
Poisoning  by  lead — Case  XLY. 


Page 

. 

378 

381 

U.  to  XXXVII. 

385 

391 

397 

XXXVIII. 

399 

^ 

402 

404 

408 

410 

^ 

413 

413 

^ 

.      .       418 

SECTION  V. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 
Diseases  op  the  Mouth,  Pharyns,  and  (Esophagus — Cases  XLVI.  to  L. 
Functional  Disorders  of  the  Stomach — Cases  LI.  to  LIII. 

General  pathology  and  treatment  of  dyspepsia 

Vomiting  of  sarcinas — Cases  LIV.  and  LV. 
Organic  Diseases  of  the  Stomach 

Chronic  ulcer  of  the  stomach— Cases  LVI.  and  LVII. 

Chronic  ulcer  of  the  stomach,  with  perforation — Cases  LVIII.  and 
LIX. 

Pathology  and  treatment     . 

Cancer  of  stomacli — Cases  LX.  and  LXI. 
Diseases  op  the  Liver     . 

Acute  congestion — Case  LXII. 

Jaundice— Cases  LXIIL  and  LXIY. 

Jaundice  from  cancer  compressing  the  ducts — Cases  LXV.  and  LXVI. 

Enlargement  of  the  liver — Case  LXVII. 

Fatty  enlargement — Case  LXVIII. 

Cirrhosis — Cases  LXIX.  and  LXX. 

Cancer  of  the  liver — Case  LXXI. 
Diseases  of  the  Intestines 

Diarrhoea — Cases  LXXII.  and  LXXIII. 

Dysentery— Cases  LXXIV.  to  LXXVI. 

Pathology  and  treatment  of  diarrhoea  and  dysentery 

Obstruction  of  large  intestine  from  Cancer — Case  LXXVII. 

Strangulation    of    small     intestine     from     inguinal     hernia  —  Case 

LXXVIII 

Intestinal  "Worms — Cases  LXXIX.  to  LXXXII. 
Peritonitis— Cases  LXXXIIL  to  LXXXVL 


421 

421 
429 
432 
435 
438 
438 

440 
446 
448 
4.53 
454 
454 
458 
463 
464 
467 
472 
476 
476 
479 
483 
486 

488 
492 
499 


CONTENTS. 


SECTION  TL 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Pericarditis — Cases  LXXXTII.  to  XCII. 

Pathology  and  treatment     .... 
Valvular  Diseases  of  the  Heart — Cases  XCUI.  to  CIII. 

Enlarged  foramen  ovale — Case  CIY. 

Pathology  of  valvular  and  organic  diseases  of  the  heart 

Treatment  of  valvular  and  organic  diseases  of  the  heart 
Fuxctioxal  Diseases  of  the  Heart 
Aneurism — Cases  CY.  to  CXIII. 

General  diagnosis  of  thoracic  aneurisms 

Physical  phenomena  of  abdominal  aneurisms 

Pathology  and  treatment  of  aneurisms 


[Page 
512 

514 
527 
532 
548 
550 
555 
556 
557 
587 
590 
590 


SECTION  VII. 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


592 


Laryngitis — Cases  CXIY.  to  CXYIL 

Treatment  by  topical  applications 

Diagnosis  of  laryngitis        .... 
Bronchitis— Cases  CXYIII.  to  CXXII    . 

Pathology  and  treatment     .... 

On  injections  into  the  bronchi  in  pulmonary  diseases 
Pleuritis— Cases  CXXIII.  to  CXXYIL 

Pathology,  diagnosis,  and  treatment  of  Pleuritis     . 

Empyema— Case  CXXYIII. 
Pneumonia— Cases  CXXIX.  to  CXLIII 

On  the  diagnostic  value  of  the  absence  of  chlorides  from  the  urine  in 
pneumonia — Case  CXXXYIIL 

Chronic  pneumonia  and  gangrene  of   the  lung — Cases   CXXXIX. 
toCXLHI 

General  pathology  and  treatment    . 
Phthisis  Pcliionalis — Cases  CXLIY.  to  CL. 

On   the  natural  progress  of  phthisis  pulmonalis — the   tendency   to 
ulceration — the  modes  of  arrestment 

Pathology  and  general  treatment  of  phthisis  pulmonalis 

Special  treatment  of  phthisis  pulmonalis     . 
Cancer  of  the  Lung — Case  CLII. 
Carbonaceous  Lungs— Cases  CLIII.  and  CLIV  . 

Pathology  and  treatment    .... 


593 

59* 
600 
602 
607 
611 
613 
618 
625 
630 

643 

645 
646 
658 

675 
684 
691 
696 
699 
702 


CONTENTS. 


XI 


SECTION  VIII. 

DISEASES   OF  THE   GENITO-URINARY   SYSTEM 


Page 
706 


Ovarian  Dropsy — Cases  CLV.  to  CLVII. 

Pathology  of  ovarian  dropsy  .... 

Treatment  of  ovarian  dropsy  .... 

Nephritis  and  Pyelitis — Cases  CLYIII.  and  CLIX. 

Desquamative  nephritis — Case  GLX.  to  CLXII. 

Suppurative  nephritis — Case  CLXIII. 

Scrofulous  nephritis — Case  CLXIV. 

Calculous  nephritis — Case  CLXV.  .... 

Chronic  pyelitis — Case  CLXVI.       .... 

Pathology  of  cystic  kidney             .... 
Persistent    Albujiinuria,    or    Bright's    Disease — Cases    GLXVII. 
CLXXVI 

Pathology  of  Bright's  disease  .... 

Diagnosis  of  Bright's  disease  .... 

Treatment  of  Bright's  disease  .... 


to 


•706 
721 

724 
72G 
730 
737 
740 
742 
745 
747 

748 
765 
769 

772 


SECTION  IX. 


DISEASES  OP   THE   INTEGUMENTARY  SYSTEM 


774 


Classification  op  Skin  Diseases 

775 

Diagnosis  of  Skin  Diseases 

779 

Porrigo        ..... 

782 

The  Treatment  op  Skin  Diseases 

783 

Dermatozoa          ..... 

789 

Acarus  scabiei        .... 

789 

Entozoon  foUiculorum 

792 

Dermatophyta     ..... 

794 

Favus— Cases  GLXXVII.  to  CLXXXII.    . 

794 

History  of  favus  as  a  vegetable  parasite 

798 

Mode  of  development  and  symptoms  of  favus 

798 

Causes         ..... 

801 

Pathology   ..... 

803 

Treatment   ..... 

810 

Xll 


CONTENTS. 


SECTION  X. 

DISEASES   OF    THE   BLOOD 

Leucocythemia— Cases  CLXXXIII.  to  CLXXXV. 

Pathology  and  treatment     . 

Discovery  of  leucocythemia 
Chlorosis  Ain>  Anaemia — Case  CLXXXVI. 
ICHOR^MiA  OR  (so-called)  Pt^mia — Case  CLXXXVII 

Pathology   ..... 
Glucoblemia— Cases  CLXXXVII  I.  and  CLXXXIX. 

Pathology  and  treatment     . 
Continued  Fever  .... 

Febricula— Cases  CXC.  to  CXCIH. 

Relapsing  fever — Case  CXCIV. 

Typhoid  fever  treated  by  quinine— Cases  CXCV.  to  CXCVII. 

Typhus  fever  treated  by  quinine— Cases  CXCVIII.  to  CCIL 

Typhus  fever  treated  without  quinine — Cases  CCIII.  to  CCXYIII 

Diagnosis  of  continued  fevers 

Morbid  anatomy  of  the  Edinburgh  fever  during  the  winter  1 846-7 

Propagation  of  fever  in  hospitals     . 

Treatment  of  continued  fever 
Remittent  Fever — Can  it  be  separated  from  Acute  Hydrocephalus  ? — 

Case  CCIX.  .... 

Intermittent  Fever — Case  CCX. 

Pathology  and  treatment     . 
Eruptive  Fevers  .... 

Scarlatina— Cases  CCXI.  and  CCXII. 

Treatment  of  scarlatina — Case  CCXVI. 

Erysipelas— Cases  CCXYII.  and  CCXVIU. 

Yariola— Cases  CCXIX.  and  CCXX. 

The  Ectrotic  treatment  of  variola   . 

Yaecination  !  .  .  . 

Pathology  of  variola 
Syphilis  and  Mercurial  Poisoning — Cases  CCXXII.  and  CCXXIII. 

Forms  of  syphilis    .... 

Diagnosis  of  syphilis 

Propagation  of  syphilis 

Pathology  of  sjqibilis 

Treatment  of  syphilis 
Rheumatism  and  Gout    .... 

General  pathology  and  treatment   . 

Treatment  of  rheumatism  by  nitrate  of  potash — Cases  CCXXY.  and 
CCXXVI 

Treatment  of  rheumatism  by  lemon  juice  . 


Page 
813 

814 
827 
840 
844 
847 
849 
852 
854 
856 
859 
860 
862 
866 
869 
870 
872 
875 
876 

880 
882 
883 
884 
885 
887 
892 
893 
894 
897 
897 
899 
902 
903 
904 
905 
906 
909 
909 

910 
914 


CONTENTS. 


XIU 


Rheumatic  iritis — Case  CCXXXIV. 

Chronic  gout — Case  CCXXXY. 
Scorbutus— Cases  CCXXXTI.  and  CCXXXYII.. 

Pathology  and  treatment .  . 
Polydipsia— Cases  CCXXXVIII.  and  CCXXXIX. 
POLTSARCiA  OR  Obesity — Case  CCXL 
CoxcLusiON — The  ethics  of  medicine 
Table  of  Cases     ..... 
General  Index    ..... 


Page 
917 
919 
920 
921 
923 
926 
929 
935 
945 


LIST  OF  ILLUSTEATIONS. 


Fig.  Page 

1.  View  of  internal  organs  after  removal  of  the  thoracic  and  abdominal  parietes  26 

2.  Deep-seated  view  of  same       .........  26 

3.  Remarkable  displacement  of  organs,  in  consequence  of  intestinal  obstruction  27 

4.  The  stethometer  of  Dr.  Quain,  half  the  real  size 32 

5.  Mode  of  applying  the  instrument  when  the  string  is  used       ...  32 

6.  The  chest-measurer  of  Dr.  Sibson,  natural  size 33 

7.  Mode  of  applying  the  chest-measurer 33 

8.  Mode  of  application  of  the  chest-measurer 34 

9.  Stetho-goniometer,  for  measuring  the  inclination  of  the  walls  of  the  thorax  35 

10.  The  Plexmieter 35 

1 1.  The  percussion  hammer  of  Winterich 36 

12.  Anterior  view  of  the  limits  and  intensity  of  dulness  on  percussion  in  health  41 

13.  Posterior  view  of  same 41 

14.  View  of  percussion  in  phthisis,  atrophied  heart  and  liver,  and  abstinence  42 

15.  View  of  percussion  in  pleurisy        ........  43 

1 6.  View  of  percussion  in  pericarditis,  pneumonia,  and  loaded  rectum  .         .  43 

17.  View  of  percussion  in  hypertrophy  of  Uver  and  heart       ....  44 

18.  View  of  percussion  in  hypertrophied  liver  and  spleen — Enlarged  heart    .  45 

19.  View  of  percussion  in  enlarged  spleen — pushed  somewhat  upwards         .  46 

20.  View  of  percussion  in  dropsy  of  the  abdomen,  enlarged  heart,  and  aneurism  48 

21.  Oberhfeuser's  microscope  made  for  medical  men 62 

22.  Grubj''s  compound  pocket  microscope     .......  64 

23.  The  same  microscope  mounted,  ready  for  use  ......  64 

24.  Spaces  equal  to  1-lOOOth  and  1-500  of  an  inch  magnified  250  diameters  linear  68 

25.  SaUvary  corpuscles,  epitheUal  scales,  etc.,  as  seen  in  a  drop  of  saliva       .  72 

26.  Minute  coufervoid  filaments  springing  from  an  altered  epithelial  scale      .  73 

27.  Confervoid  filaments  and  sporules,  in  exudation  on  the  mouth  and  gums  73 

28.  Fringe-like  epithelium,  from  the  surface  of  an  ulcer  on  the  tongue    .         .  73 

29.  Globules  of  cow's  milk 74 

30.  Colostrum  of  the  human  female,  containing  mDk  globules  greatly  varying  in  size  74 

31.  Blood-corpuscles,  drawn  from  the  extremity  of  the  finger        ...  75 

32.  Blood-corpuscles  altered  in  shape  from  exosmosis    .         .         .         .         .75 

33.  Blood-corpuscles  altered  in  form,  and  aggregated  together,  in  thickened  blood  76 

34.  Altered  blood-corpuscles  in  the  fluid  of  an  ha^matocele    .         .         .         .  76 

35.  Appearance  of  blood  once  observed  in  a  case  of  cholera  .        .        .        .  77 


LIST   OF   ILLUSTRATIOXS.  XV 


77 
77 
78 
78 
78 
78 


Fig.  P^« 

36.  Appearance  of  a  drop  of  blood  in  leucocythemia 77 

37.  The  same,  after  the  addition  of  acetic  acid       .... 

38.  The  same,  after  the  blood  has  stood  24  hours  .... 

39.  Pus  corpuscles,  as  seen  in  healtliy  pus 

40.  The  same,  after  the  addition  of  acetic  acid       .... 

41.  Pus  corpuscles,  surrounded  by  a  delicate  cell-wall . 

42.  Irregular-shaped  pus  corpuscles,  in  scrofulous  pus  . 

43.  Mass,  consisting  of  minute  molecules,  frequently  seen  in  disintegrated  tubercle  79 
44  and  45.  Masses  composed  of  molecules  and  oily  granules  varymg  in  size  79 

46.  Mass  partly  composed  of  the  debris  of  a  fibrous  structure         ...  79 

47.  Mass  composed  of  tubercle  corpuscles ''9 

48.  Fragments  of  phosphate  of  lime  occasionally  found  in  the  sputum    .         .  79 

49.  Fragment  of  elastic  tissue  of  the  lung,  in  phthisical  sputum     ...  80 

50.  Fragment  of  areolar  and  elastic  tissue,  from  phthisical  sputum         .         .  80 

51.  Another  fragment  ...........  80 

53.  Fibrinous  coagula  in  sputum,  exhibiting  moulds  of  the  bronchi         .         .  80 

53.  Fibres,  with  corpuscles,  in  a  fibrinous  coagulum  from  a  bronchus    .         .  SO 

54.  Epithelial  cells,  embedded  in  mucus,  expectorated  from  the  fauces  .  .  81 
5.5.  Another  portion  of  expectorated  mucus  from  the  fauces,  acted  on  by  acetic  acid  81 
56  and  57.  Cells  loaded  with  pigment  in  the  sputum  of  a  collier  ...  81 

58.  Appearance  of  starch  corpuscles  after  partial  digestion  in  the  stomach     .  82 

59.  Flake  in  the  rice-water  vomiting  of  a  cholera  patient       ....  82 

60.  Structures  observed  in  certain  rice-water  vomitings  from  a  cholera  patient  82 

61.  Sarcina  Yentricuh 83 

62.  Portions  of  the  urcdo  in  bread  partly  digested  and  disintegrated      .         .  S3 

63.  Structure  of  confervoid  mass  passed  from  the  bowels       ....  83 

64.  The  same  magnified  500  diameters  linear 83 

65.  Bounded  masses  of  earthy  matter 84 

66.  Structure  of  flakes  in  a  rice-water  stool,  from  a  cholera  patient        .         .  84 

67.  Corpuscles  seen  in  a  chronic  leucorrhoeal  discharge         ....  85 

68.  Structure  of  gelatinous  mucus  from  the  os  uteri 85 

69.  The  same,  after  the  addition  of  acetic  acid 85 

70  and  71.  Two  specimens  of  cancerous  juice  squeezed  from  the  uterus         .  86 

72.  Tiscid  greyish  yellow  sputa  of  pneumonia,  treated  with  dilute  acetic  acid  87 

73.  Spermatozoa  as  observed  in  the  fluid  of  Spermatocele      .         .         .         .  87 

74.  Cells  in  fluid,  removed  from  an  ovarian  dropsy 88 

75.  Lozenge-shaped  and  rhomboidal  crystals  of  uric  acid       ....  88 

76.  Aggregated  and  flat  striated  crystals  of  uric  acid 88 

77.  Urate  of  ammonia,  in  a  granular  membranous  form,  and  in  spicular  masses  89 

78.  Triple  phosphate,  with  various  forms  of  urate  of  ammonia        ...  89 

79.  Octahedral  and  dumb-beU  shaped  crystals  of  oxalate  of  lime    ...  89 

80.  Flat  and  rosette-like  crystals  of  cystine 89 

81.  Bodies  observed  in  the  urine  of  a  scarlatina  patient,  24hours  after  being  passed  90 

82.  Cast  of  a  uriniferous  tube 90 

83.  Fatty  casts,  at  an  early  period  of  formation 90 

84.  Fragments  of  faXXy  and  waxy  casts 90 

85.  Epidermic  cells  from  crust  of  Psoriasis 91 

86.  Thalli  of  the  fungus  found  in  the  ear  by  Mr.  Grove          ....  92 

87.  The  fungus  {Achorion  Sclionleini)  from  a  favus  crust        ....  92 

88.  The  same  magnified  500  diameters  linear 92 

89.  Epithelial  cells,  from  the  surface  of  an  ulcer ^of  the  lip      ....  92 


Xvi  LIST    OF    ILLUSTRATIONS. 

rig.                                                                                                                         ,  ^««« 

90.  The  same,  after  the  addition  of  acetic  acid       .....'.  92 

91.  Epidermic  cells  from  the  edge  of  a  softened  epitheUoma  .         ...  93 

92.  Other  cells  from  the  centre  of  the  softened  portion 93 

93    Appearance  of  section  of  cancerous  ulcer  of  the  skin        ....  93 

94.  Transverse  section  of  the  spinal  cord  of  the  iSatoio  saJa?- .         .         .         .109 

95.  Longitudinal  section  of  the  spinal  cord  of  the  <SaZ»io  sator        .         .         .  110 

96.  Longitudinal  section  of  the  spinal  cord  of  the  Pe^rom?/20ftyZwi;«a<i7is         .  110 
97  and  98.  Diagram  illustrative  of  voluntary  and  reflex  motions  .         .         .  114 

99.  Remarkable  atrophj-  of  the  left  side  of  the  face 122 

100.  An  exact  copy  of  a  portion  of  the  web  of  a  frog's  foot  inflamed      .         .  125 

101.  Molecular  fibres  and  plastic  corpuscles,  in  simple  exudation  on  a  serous  smface  128 

102.  A  portion  of  recent  lymph  from  the  pleura 129 

103.  Another  portion  of  the  same,  further  developed 129 

104.  Portion  of  firm  pleural  adhesion 129 

105.  Another  portion  of  the  same,  further  developed 129 

106.  The  last  acted  on  by  acetic  acid 129 

107.  Pus  cells.     Pour  cells  have  been  acted  on  by  acetic  acid        .         .         .  130 

108.  Pus  cells  containing  fatty  molecules,  after  adding  acetic  acid         .         .130 

109.  Scrofulous  pus  cells  after  the  addition  of  acetic  acid        ....  130 

110.  The  same.     In  both  specimens  the  nuclei  are  irregular  or  absent  .         .  130 

111.  Granular  exudation  and  granular  masses,  from  cerebral  softening  .         .  131 

112.  Granular  cells  and  masses  from  cerebral  softening          ....  131 

113.  Two  vessels  coated  with  exudation  from  softening  of  the  spinal  cord     .  132 

114.  Vertical  section  of  a  granulating  sore 132 

115.  Section  shewing  the  arrangement  of  cells  and  fibres  in  scirrhus  of  the  mamma  133 

116.  The  same,  after  the  addition  of  acetic  acid 133 

117.  Isolated  cancer-cells,  from  the  same  growth 133 

118.  The  same,  after  the  addition  of  acetic  acid 133 

119.  Young  cancer-cells  from  the  lung 134 

120.  The  same,  after  the  addition  of  acetic  acid 134 

121.  Somewhat  older  cells  from  the  testicle 134 

122.  The  same,  after  the  addition  of  acetic  acid 13-d 

123.  Still  older  cancer-cells  from  a  tumour  in  the  duodenum         .         .         .134 

124.  The  same,  after  the  addition  of  acetic  acid 134 

125    Highest  development  of  cancer-cells  from  a  tumour  of  the  toe        .         .  134 

126.  Simple  and  compound  cancer-cells  from  the  duodenum        ..         .         .  135 

127.  Colloid  tissue,  with  the  loculi  filled  with  molecular  matter      .         .         .  135 

128.  Colloid  cancer-appearance  of  the  fibrouS  areola  filled  with  cancer-cells  .  136 

129.  The  same,  after  the  addition  of  acetic  acid 136 

130.  Some  of  the  cells  isolated 136 

131.  Fibrous  stroma  deprived  of  the  cells  by  pressure  and  washing        .         .  136 

132.  Corpuscles  from  firm  tubercular  exudation  into  the  lung        .         .         .  137 

133.  Corpuscles,  granules,  and  debris,  from  soft  tubercular  exudation  into  the  lung  137 

134.  The  same,  from  tubercular  infiltration  of  a  mesenteric  gland         .         .  137 

135.  Section  of  a  grey  granulation  in  the  lung 

136.  Section  of  a  firm  miliary  tubercle  of  the  lung 

137.  Moist  gangrene,  following  compound  fracture 

138.  Dry  gangrene  from  debility 

139.  Structures  in  hypertrophied  heart 

140.  Fibrous  structure  of  the  uterus 

141.  The  same,  hypertropliied  from  great  increase  in  size  of  its  fusiform  cells.  151 


137 
137 
142 
143 
151 
151 


LIST   OF   ILLUSTRATIONS.  XVU 

Fig.  ^^^ 

143.  Cell  fibres  and  fibre-cells  from  a  fibro-cellular  growth  in  tlie  stomach  .         l^fl 

143.  Fusiform  cells  from  a  sarcomatous  growth  in  the  kidney       .         .         .         lo3 

144.  Fibro-uucleated  structure,  from  a  so-called  meduUary  sarcoma  of  the  humerus  152 

145.  Fibrous  stroma  of  a  tumour  acted  on  by  acetic  acid     .         .         .         .         152 

146.  Fibres,  from  iuduratiou  of  the  stomach,  with  embedded  nuclei     .         .         153 

147.  Fibrous  tissue,  with  free  nuclei  and  cells,  from  a  white  peritoneal  patch.       153 

148.  The  same,  after  the  addition  of  acetic  acid 153 

149.  Cells  in  the  soft  part  of  a  fibrous  tumour  removed  from  the  neck  by  ilr.  Syme  154 

150.  The  same,  after  the  addition  of  acetic  acid 154 

151.  Fibres  in  various  stages  of  development  from  a  harder  nodule  of  same  tumour  154 

152.  Perfect  fibrous  tissue  from  another  nodule  of  considerable  density         .         154 

153.  Corpuscles  scraped  from  the  surface  of  a  fibro-nucleated  growth  of  the  thigh  155 

154.  The  same,  after  the  addition  of  acetic  acid 15a 

155.  Appearance  of  a  thin  section  of  the  tumour 155 

156.  Another  section  treated  with  acetic  acid 155 

157.  Soft  polypi  growing  from  the  Schneiderian  mucous  membrane      .         .         155 

158.  Fibre  ceUs  and  fibres  from  the  pulpy  interior  of  a  polypus  removed  by  Mr.  Syme  156 

159.  The  same,  after  the  addition  of  acetic  acid 156 

160.  Ciliated  epithelial  and  pus  cells  from  the  exterior  of  the  tumour  .         156 

161.  The  same,  after  the  addition  of  acetic  acid 156 

162.  Section  of  a  dermoid  fibrous  tumour  embedded  in  the  uterine  walls      .  156 

163.  Section  of  a  dermoid  fibrous  tis.sue  from  the  uterus,  acted  on  by  acetic  acid  156 

164.  Section  of  hard  uterine  polypus,  boiled  in  dilute  acetic  acid  and  dried  .  157 

165.  Section  of  Xeuroma  connected  with  three  nervous  trunks    .         .         .  157 

166.  Thin  section  of  a  subcutaneous  tubercle,  composed  of  fibro-cartilage     .  158 

167.  Fibrous  structure  of  a  neuromatous  swelling 158 

168.  Lobulated  Lipoma  of  the  nose 159 

169.  Smooth  Lipoma,  removed  from  under  the  tongue,  one-half  the  natural  size  160 

170.  Two  layers  of  voluminous  fat  cells,  varying  in  size,  from  a  Lipoma      .  160 

171.  Fat  cells  from  the  same  dried,  shewing  crystalline  bundles  ofMargaric  acid  160 

172.  ^tmcinxQ  oi  a.  Fihro-Lipoiiudoustxxmom 161 

173.  Simple  cyst  of  the  broad  ligament  of  the  uterus,  with  very  vascular  walls  162 
174    and  175.  Diagrams  of  compound  cystic  growths          ....  162 

176.  Compound  cystic  sarcoma  of  the  mamma 163 

177.  Structure  of  a  cystic  chorion  belonging  to  an  ovum,  at  the  eighth  week  163 

178.  Colloid  cystic  growths  in  three  lobules  of  the  thyroid  gland  .         .  164 

179.  Delicate  oval  corpuscles  in  transparent  colloid  matter  of  the  ovary        .  164 

180.  Round  and  oval  corpuscles  with  filaments  in  colloid  matter  in  the  ovary  164 

181.  Oval  epithelial  cells  from  the  Uning  membrane  of  an  ovarian  cyst         .  165 

182.  Polygonal  epithelial  cells  from  the  same  lining  membrane    .         .         .  165 

183.  Section  of  the  wall  of  the  same  cyst,  shewing  the  epithelial  cells  in  situ  165 

184.  Cells  from  the  interior  of  a  simple  cyst 165 

1 85.  Structure  of  cholesteatoma 166 

186.  Encysted  tumour,  with  fatty  steatomatous  contents     ....  166 

187.  Contents  of  a  large  atheromatous  cyst,  opened  by  Mr.  Syme        .         .  166 

188.  Adipose  cells,  from  a  steatomatous  encysted  tumour  of  the  ovary  .  166 

189.  Cysts  in  cystic-sarcoma  of  the  mamma,  filled  with  molecular  matter     .  167 

190.  Fibrous  tissue  from  a  sarcomatous  encysted  growth  in  the  kidney  .  167 

191.  Cystic-osteoma  of  the  femur 1*^^ 

192.  Cj-stic-osteoma  of  the  tibia 1^^ 

193.  Cysts  m  cystic-sarcoma  of  the  mamma,  crowded  with  cells  .         .  169 

B 


XVm  LIST   OF   ILLUSTRATIOXS. 

Fig.  Page 

194.  Fibrous  stroma  from  another  part  of  the  same  tumour          ,         .         .  169 

195.  Structure  of  a  cystic  glandular  tumour  of  the  neck       ....  170 

196.  197,  and  198.  Structure  of  a  glandular  tumour  removed  from  the  mamma  171 

199.  New  formed  ti.«sue  in  a  follicle  of  the  thyroid  gland      ....  172 

200.  Cells  in  fluid,  squeezed  from  a  mesenteric  gland,  in  a  case  of  typhoid  fever  172 

201.  The  same  in  another  case     .........  172 

202.  The  same  cells,  after  the  addition  of  acetic  acid    .....  172 

203.  "Warts  on  the  penis 175 

204.  Summit  of  a  papilla  from  a  wart .          .......  175 

205.  Perpendicular  section  of  a  papilla,  after  adding  acetic  acid   .         .         .  175 

206.  Transverse  section  of  the  base  of  a  condyloma      .         .                 .         .  176 

207.  Ulcerated  epithehoma  of  the  lip           .......  176 

208.  Section  of  an  ulcerated  epithelioma  of  the  tongue         .         .         .         .  177 

209.  Compressed  epithelial  cells  immediately  below  the  surface  of  the  ulcer  177 

210.  Epithelial  cells,  one  of  them  very  large,  in  matter  squeezed  from  the  duct  177 

211.  The  same  seen  in  mass       .........  177 

212    Concentric  laminae  of  condensed  epitlielial  scales          ....  178 

213.  Muscular  tissue  immediately  below  the  epitheliomatous  ulcer      .         .  178 

214.  Epidermic  scales,  in  mass  and  isolated,  from  the  scrotum     .         .         .  178 

215.  Group  of  deep-seated  cells,  in  the  same  case 178 

216.  The  same,  after  the  addition  of  acetic  acid  .         .         .         .         .         .  178 

217.  Fragments  of  the  concentric  masses  figured.  Fig.  212,  from  a  lymphatic  gland  179 

218.  Epithelial  cells,  in  yellow  cheesy  matter,  of  the  same  gland           .         .  179 

219.  Cells  in  white  matter,  from  soft  fungoid  epithelioma  of  the  urinary  bladder  179 

220.  The  same,  after  the  addition  of  acetic  acid  .         .         .         .         .         .  179 

221.  Horn  from  an  old  preparation  in  the  Edinburgli  University  Mu.seum  .  180 

222.  True  saccular  aneurism  of  the  aorta,  nearly  tilled  with  coagulated  clot  181 

223.  Eemarkable  spontaneous  varicose  aneurism         .....  181 

224.  Aneurism  of  the  coronary  artery,  completely  filled  with  coagulated  clot  182 

225.  Section  of  erectile  tumour  .         .         .         .         .         .         .         .         .  1S2 

226.  Varicose  cutaneous  vessels  of  the  anus         .         .         .         .         .         .  183 

227.  Dilated  papillffi  of  the  skin 183 

228.  Varicose  vessels  in  the  ca^ra^ /r/^o«M??i  re-s/cfp         .....  184 

229.  Inner  laj'Cr  of  umbilical  artery  of  calf,  eight  inches  long       .         .         .  184 

230.  Succeeding  layer  in  the  same  vessel,  composed  of  spindle-shaped  corpuscles  184 
231  and   232.  Laj-ers  more  external  in  different  stages  of  development  into  fibres  184 

233.  Common  carotid  artery  of  an  embryo  calf,  showing  directions  of  the  fibre  cells  184 

234.  Stellate  cells  in  the  tail  of  the  tadpole,  developing  into  capillary  vessels  185 

235.  Cai^illary  vessels  in  different  stages  of  formation,  from  the  eye  of  fcetal  calf  185 

236.  Branched  cells  in  lymph  exuded  on  the  peritoneum      ....  185 

237.  Vessels  in  an  early  stage  of  formation,  from  a  colloid  tumour  of  the  back  185 

238.  Enchrondroma  of  the  hand  and  fingers          ...                 .         .  186 

239.  Structure  of  a  firm  nodule  in  an  enchrondroma  of  the  humerus     .         .  186 
2i0.  The  same,  after  the  addition  of  acetic  acid    ......  186 

241.  The  cartilage  cells  and  fibrous  tissue  separated,  with  numerous  molecules  186 

242.  Small  cartilage  with  round  granule  cells  in  Solanoma           .         .         .  187 

243.  The  same  cartOage  cells,  after  the  addition  of  acetic  acid      .         .         .  187 

244.  Thin  section  of  a  firm  portion  of  the  same  tumour        ....  187 

245.  Fine  filaments  which  interlaced  the  cells,  these  having  been  washed  out  187 

246.  Great  variety  of  cell  forms  in  an  enchondroma  of  the  femur  .         .         .  187 

247.  Thin  section  of  an  enchondroma,  with  a  bony  capsule          .        .        .  188 


LIST   OF   ILLUSTRATIONS.  XIX 

Fig.  P^ge 

248.  Separated  cartilage  cells  from  a  softened  portion  of  the  same  tumour  .         188 

249.  The  same,  rendered  more  opaque,  after  the  addition  of  acetic  acid         .         188 

250.  Diseased  articular  cartilage 189 

251.  Similar  alteration  in  costal  cartilage  of  the  dog  ....         189 
252  and  2.33.  Different  appearances  of  enlarged  cells  in  diseased  articular  cartilage  189 

254.  Vertical  section  of  cartilage  from  the  surface  of  the  patella  .         .         .         190 

255.  Another  vertical  section  through  the  same  diseased  articular  cartilage         190 
256  and  257.  Two  fibrous  projections,  from  the  surface  of  a  diseased  human  cartilage  190 

258.  Nodulated  exostosis  attached  by  an  osseous  pedicle  to  the  femur          .  191 

259.  Lateral  view  of  an  exostosis 191 

260.  Part  of  a  section  through  one  of  the  prominences  of  the  tumour  .         .  191 

261.  Section  of  a  portion  of  the  tumour 191 

262.  Spicular  growth  of  bone,  in  an  osteo-carcinomatous  tumour  of  the  tibia  193 

263.  Epulis  removed  from  the  upper  jaw 19-t 

264.  Cells  with  many  nuclei  in  epulis 194 

265.  Fibro-cartilage  between  the  separated  portions  of  a  fractured  cervix  femoris  194 

266.  Spiculum  of  bone  projecting  from  the  choroid  membrane     .         .         .  195 

267.  Section  from  the  centre  of  the  crystalline  lens 195 

268.  Loose  membranous  matter  in  the  anterior  chamber  of  the  eye      .         .  195 

269.  Ossified  excrescence  on  the  arachnoid  of  the  thoracic  portion  of  spinal  cord  195 

270.  Bony  laminse  arranged  concentrically 195 

271.  Carcinoma  of  the  breast,  at  an  early  stage 196 

272.  Returning  carcinoma  in  the  breast       .......  196 

273.  Advanced  carcinoma  of  the  mamma 197 

274.  Section  of  small  cancerous  nodule  in  the  raucous  coat  of  the  stomach  .  198 

275.  Appearance  of  cartilage  on  each  side  of  an  incision  made  into  the  patella  199 

276.  Cartilage  cells  from  a  velvety  articular  cartilage  of  the  condyle  of  the  femur  200 

277.  Cells  from  a  cancerous  tumour  of  the  brain 200 

278.  Fibre  of  the  sterno-mastoid  muscle,  in  the  neighbourhood  of  a  cancerous 

growth 205 

279.  Fasciculi  of  muscle,  forming  tlie  flap  in  an  amputation  of  the  thigh      .  206 

280.  Granules,  nuclei,  and  granule  cells  in  a  nerve 206 

281.  Structure  of  the  soft  part  of  tumour  removed  by  Mr.  Page  of  Carlisle   .  206 
282  and  283.  Structure  of  the  more  indurated  parts             ....  206 

284.  Structure  of  the  fungoid  growth  of  the  leg 207 

285.  The  same,  after  the  addition  of  acetic  acid  .....  207 

286.  Structureless  membrane  formed  by  heating  the  clear  fluid  of  pemphigus  211 

287.  Edges  of  albuminous  laminse,  in  a  case  of  hydrocele  .         .         .  212 

288.  Dense  fibrous  structure,  with  naked  nuclei  from  coats  of  the  stomach  212 

289.  The  same,  after  the  addition  of  acetic  acid 212 

290.  Splitting  up  into  fibres  of  the  hyaline  substance  of  cartilage     ,   .         .  213 

291.  Diaphanous  albuminous  bodies,  with  fiitty  cancer  cells  from  the  diaphragm  213 

292.  Groups  of  blood  corpuscles  surrounded  by  an  albuminous  layer  .  214 

293.  A  similar  albuminous  layer,  round  groups  of  bird's  blood-cells      .         .  214 

294.  Substance  of  nerve  tube,  broken  across,  forming  globules  .         .  214 

295.  Cells  of  the  liver,  in  waxy  degeneration  of  that  organ  .         .         .  214 

296.  Section  of  the  thyroid  body,  with  its  glandular  sacs  filled  with  colloid  matter  215 

297.  Radiated  colloid  masses  from  a  cyst  in  an  atrophied  kidney  .         .         215 

298.  Fatty  molecules  in  groups 217 

299.  Granular  corpuscles  and  masses  from  cerebral  softening       .         .         .         217 

300.  Granular  corpuscles  acted  upon  by  pressure 218 


XX  LIST   OF   ILLUSTRATIOXS. 

Fig.  Page 

301.  Early  stage  of  fatty  degeneration  of  voluntary  muscle           .         .         .  218 

302.  Advanced  stage  of  fatty  degeneration  in  the  muscular  fasciculi  of  tlie  heart  218 

303.  Another  example  of  advanced  fatty  degeneration  of  voluntary  muscle  218 

304.  Fatty  degeneration  of  the  psoas  magnus  muscle  of  a  lad  with  morbus  coxarius  219 

305.  Other  fasciculi  of  the  same  muscle,  after  the  addition  of  ffither      .         .  219 

306.  Enlarged  fatty  fusiform  cells  of  the  pregnant  uterus  after  delivery         .  220 

307.  Atheroma  of  a  blood  vessel          .         .         .         .         .         .         .         .  220 

308.  Fatty  granules,  oil  drops,  granule  cells,  and  cholesterine  in  atheroma  220 

309.  Two  groups  of  fatty  molecules,  from  atheroma  of  artery       ,         .         .  220 

310.  Transverse  section  through  the  coats  of  the  popliteal  artery  of  an  aged 

woman            ...........  221 

311.  Cerebral  vessels  of  an  aged  individual  who  died  of  apoplexy        .         .  221 

312.  Vessels  from  softening  of  the  corpus  striatum,  coated  with  granule  masses  221 

313.  YiUi  from  the  placenta  of  a  six  months'  foetus      .....  222 

314.  Fatty  granules  coating  the  blood-ves-sels,  within  the  placental  villi       .  223 

315.  Groups  of  fatt}'  granules  scattered  through  the  substance  of  a  placental  villus  223 

316.  Fatty  granules  coating  the  vessels,  and  in  the  villous  substance            .  223 

317.  Cells  in  fatty  tracheal  cartilage             .......  223 

318.  Horizontal  section  of  the  occipital  bone  in  a  case  of  syphilis         .         .  224 

319.  Thin  section  of  the  same  bone,  showing  one  of  the  canoelli           .         .  224 

320.  Thin  section  of  the  outer  table  of  the  same  bone           ....  224 

321.  New  cells  formed  in  malacosteon 224 

322.  Retrograde  cells,  granules,  and  granular  masses,  in  cancer  reticulum   .  225 

323.  Fatty  and  broken-down  cancer-cells  in  reticulum  of  cancer  of  the  liver  225 

324.  Fatty  granular  matter  from  the  softened  reticulum  of  a  cancer  of  the  breast  225 

325.  Liberated  and  altered  nuclei  in  the  reticulum  of  cancer  of  the  testicle  225 

326.  Crystals  of  hematoidine 227 

327.  "Wartlike  brown  ncbvus  matermis  of  the  female  mamma        .         .         .  228 

328.  Atrophied  bronchial  cartilage,  with  deposition  of  brown  pigment         .  229 

329.  Placental  villi,  containing  brown  pigment  from  an  aborted  foetus          .  229 

330.  Black  pigment  mas.ses  and  molecules  round  a  tubercle  of  the  peritoneum  230 

331.  Transverse  section  of  a  necrosed  tibia          ......  231 

332.  Black  pigment  molecules  from  the  lung 231 

333.  Black  pigment  irregular  masses,  from  an  intestinal  aggregate  gland      .  231 

334.  Polygonal  cells  loaded  with  pigment,  from  the  surface  of  the  pericardium  231 

335.  Cells  loaded  with  pigment,  from  a  melanotic  tumour  of  the  horse          .  231 

336.  Cells  in  a  melanotic  cancer  of  the  cheek       ......  232 

337.  Cells  in  the  black  sputum  of  a  collier 232 

338.  Structure  of  mineral  degeneration  of  the  walls  of  an  aneurism      .         .  234 

339.  Calcareous  incrustation  of  the  small  vessels  of  the  brain       .         .         .  235 

340.  Mineral  degeneration  of  the  nerve-cells  and  tubes  of  the  spinal  cord    .  235 

341.  Mineral  masses  in  a  degenerated  cancerous  tumour  of  the  omentum     .  236 

342.  The  same,  in  a  degenerated  cancerous  mass  in  the  liver       .         .         .  236 

343.  Cancer  cells  infiltrated  with  cretaceous  molecules,  in  a  mesenteric  gland  236 

344.  Mineral  masses  in  a  cretaceous  tubercle  of  the  lung    ....  237 

345.  Section  of  an  amorphous  mineral  mass         ......  237 

346.  Longitudinal  section  of  an  albuminous  concretion         .         .         .         .  238 

347.  Section  of  the  nucleus  of  an  albuminous  concretion      ....  238 

348.  Longitudinal  section  of  an  albuminous  concretion  magnified         .         .  238 

349.  Portion  of  one  of  the  concentric  lamellae  of  an  albuminous  concretion  239 

350.  Transverse  section  of  the  edges  of  the  concentric  lamellae    .         .        .  239 


LIST   OF   ILLUSTRATIONS.  XXI 

Fig.  ?*?« 

35L  Tarious  forms  of  biliary  concretions 240 

352.  Vertical  section  of  renal  tubuli  filled  Avith  urate  of  ammonia         .         .  340 

353.  External  view  of  a  remarkable  renal  calculus 241 

354.  Section  of  the  same  calculus,  with  nucleus  of  uric  acid  and  oxalate  of  lime  241 

355.  Calculus  with  lithic  acid  nucleus           ...'....  241 

356.  Triangular  formed  calculus  of  lithic  acid 241 

357.  Oval  calculus  of  lithic  acid 242 

358.  Oval  calculus  of  uric  acid 242 

359.  The  triple  phcsphate  surrounding  a  mulbeny  concretion  of  oxalate  of  lime  242 

360.  Nodulated  mulberry  calculus 242 

361.  Phosphatic  calculus  formed  round  a  fragment  of  uric  acid  calculus        .  242 

362.  Phosphatic  calculus  formed  round  a  piece  of  slate  pencil       .         .         .  242 

363.  Sections  and  external  appearance  of  the  calcuU  in  Mr.  Mackenzie's  case  243 

364.  Prostatic  calculi 243 

365.  Mass  of  hair  found  in  the  human  stomach             244 

366.  Section  of  a  remarkably  shaped  intestinal  concretion   ....  245 

367.  Section  of  an  intestinal  concretion 245 

363.  Hairs  from  the  caryopsis  of  the  oat,  in  an  intestinal  concretion     .         .  246 

369.  Araj-loid  bodies  embedded  in  a  seemingly  amorphous  matter        .         .         247 

370.  The  same,  after  dilution  with  water 247 

371.  The  same,  after  the  addition  of  acetic  acid 247 

372.  The  same,  after  the  addition  of  nitric  acid  247 

373.  Small  corpora  amylacea,  in  the  auditory  nerve  of  a  deaf  individual       .         248 

374.  Variously  shaped  and  sized  corpora  amylacea,  from  the  human  pancreas      248 

375.  Longitudinal  plan  of  the  arteries  of  the  trunk 261 

376.  Transverse  plan  of  the  arteries  of  the  abdomen  opposite  to  the  liver    .         261 

377.  The  same,  lower  down 261 

378.  Three  air  vesicles  of  a  pneumonic  lung  with  pus  forming  in  them         .         265 

379.  Layers  of  lymph  in  pericarditis,  presenting  the  form  of  large  villi         .         266 

380.  Structure  of  the  villi  in  pericarditis 267 

381.  Structure  of  the  inflammatory  exudative  softening  of  the  spinal  cord  305 

382.  Structure  of  a  tubercular  exudation  in  the  cerebellum  .         .         .         306 

383.  Structure  of  the  softened  cerebellum  306 

384.  Structure  of  the  softened  cerebral  substance 306 

385.  Structure  of  the  softened  pons  varolii 307 

386.  Amyloid  bodies  with  fragments  of  nerve-tubes,  from  the  optic  thalamus       335 

387.  A  blood-vessel  from  the  substance  of  the  brain  coated  with  exudation  343 

388.  Another  blood-vessel  also  coated  with  exudation         ....         343 

344 
374 
375 
380 
380 
382 
451 
451 
451 
452 
452 


389.  Structure  of  a  chronic  grey  soltening  of  the  cerebral  hemisphere 

390.  Section  of  the  capsule  and  coagulum  of  an  old  apoplectic  clot 

391.  Granular  corpuscles  and  masses  in  an  old  apoplectic  clot     . 

392.  Peculiar  vascular  stroma  with  villi  in  cancerous  masses  of  the  brain 

393.  Gland-like  expansions  of  stroma  in  other  portions  of  the  same  mass 

394.  395,  396.  Lateral,  vertical  and  front  views  of  a  hydrocephalic  head 
397.  Appearance  of  the  gastric  glands  in  recent  catarrh  of  the  stomach 
393.  Commencing  cystic  formation  in  a  gastric  follicle 

399.  A  C3'st  in  the  pyloric  portion  of  the  stomach         .... 

400.  Fattj'  degeneration  of  gastric  glands  in  chronic  catarrh  of  the  stomach 

401.  Chronic  catarrh  of  the  stomach  witli  hypertrophy  of  fibrous  tissue 

402.  Fatty   degeneration  aflecting    the    upper  layer   of   gastric  follicular 

epithelium 


452 


457 
465 
469 
471 
471 
475 


Xxil  LIST   OF   ILLUSTRATIONS. 

Fiff.  Page 

403.  Disintegration  of  tlie  hepatic  structure  following  obstruction   of  tho 

biliary  ducts   ......... 

404.  Hepatic  cells  in  various  stages  of  fatt}'  degeneration    . 

405.  Structure  of  a  thin  section  of  liver  in  the  last  stage  of  cirrhosis 

406.  Peri  lobular  fatty  or  nutmeg  liver 

407.  Pigmented  nutmeg  liver 

408.  Remarkable  carcinomatous  cyst  in  the  liver 

409.  Vascular  congestion  and  sugillation  of  the  small  intestine  in  cholera    .  484 

410.  Granular  mass,  in  recent  exudation  on  the  intestinal  mucous  membrane  485 

411.  An  enlarged  Payerian  sac  from  the  colon  of  a  child     ....  485 

412.  Flaccid  pericardium  with  small  amount  of  fluid 529 

413.  Distended  pericardium,  of  a  pyriform  shape 529 

414.  Excessive  distension  of  pericardium 530 

41.5.  Conjoined  attachment  of  two  of  the  aortic  valves          ....  550 

416.  Aortic  orifice  with  one  valve  of  a  funnel-shape 551 

417.  Two  valves  of  the  aortic  orifice,  with  a  rudimentary  one  interposed      .  551 

418.  Congenital  malformation  of  the  aortic  valves 552 

419.  Four  valves  at  the  aortic  orifice  from  the  adhesion  of  one     .         .         .  552 

420.  Five  valves  formed  from  adhesion  and  production  of  the  septre  in  two  valves  552 

421.  Button-hole  contraction  of  the  mitral  orifice 553 

422.  Mitral  orifice,  greatly  constricted,  forming  an  oval  aperture           .         .  553 

423.  Fibrinous  vegetations,  and  atheromatous  degeneration  of  the  aortic  valves  553 

424.  Rough  sketch  of  innominatal  aneurism  and  adjoining  parts           .         .  571 

425.  Diagram  of  an  aneurism  of  the  arteria  innominata         ....  571 

426.  Aneurism  of  the  thoracic  aorta  and  superior  mesenteric  artery     .         .  580 

427.  Plug  of  mucous  or  coagulated  blood  in  a  bronchus       ....  606 

428.  Remains  of  pleural  abscess 619 

429.  Relative  position  of  the  thoracic  and  abdominal  viscera  in  A.  Brown's  case  628 
4.30.  Fragment  of  chicken  bone  found  in  tho  right  bronchus,  in  Neal's  case  .  656 

431.  Fluid  in  the  chronic  abscess  of  the  right  lung,  in  Neal's  case         .         .  656 

432.  Part  of  the  left  lung  with  clots  occupymg  branches  of  the  pulmonary  artery  658 
433    Section  of  a  lung  in  the  first  stage  of  phthisis  pulmonalis      .         .         .  676 

434.  Section  of  a  lung  in  the  second  stage  of  phthisis  pulmonalis          .         .  677 

435.  Section  of  a  lung  in  the  third  .stage  of  phthisis  pulmonahs    ...  678 

436.  Section  of  the  summit  of  the  right  lung  hi  arrested  phthisis           .         .  080 

437.  The  section  of  the  upper  portion  of  the  lung  in  Keith's  case,  seen  from 

within 682 

438.  Chjde  from  the  thoracic  duct  of  a  dog,  three  hours  after  eating  a  meal  686 

439.  Corpuscles  in  cancerous  juice  squeezed  from  the  thjToid  body      .         .  697 

440.  The  same  after  the  addition  of  acetic  acid 697 

441.  Groups  of  columnar  epithelium,  etc.,  in  encephaloma  of  the  ovary         .  723 

442.  Diaphanous  celloid  bodies,  naked  nuclei,  and  granule  cells  in  the  same  723 

443.  The  nuclei  after  the  addition  of  acetic  acid 723 

444.  Structures  occasionally  seen  in  cysts  of  the  kidney       ....  748 

445.  Waxy  degeneration  of  a  malpighian  body,  with  a  few  granule  cells     .  767 

446.  Structures  in  a  fatty  kidney 768 

447.  Portion  of  fatty  renal  tube 763 

448.  Longitudinal  section  of  a  fatty  kidney 769 

449.  Transverse  section  to  the  former  one 769 

450.  Exudative  casts  of  renal  tubes 770 

451.  Desquamative  casts,  with  blood  corpuscles,  naked  nuclei  and  cells       .  770 


LIST   OF   ILLUSTRATIONS. 


xxni 


Fig.  Page 

452.  Fatty  casts  of  renal  tubes  with  granule  cell 771 

453.  Waxy  casts  of  renal  tubes  of  various  .sizes 771 

454.  Tyrozin  masses  in  the  urinary  sediment  of  a  man  with  atrophy  of  the  liver  771 

455.  Leucla  in  a  drop  of  the  same  urine,  allowed  to  evaporate     .         .         .  771 

456.  Pure  tyrozin  from  the  same  urinary  sedinieat      .         .         .         •         .  771 

457.  Dorsal  surface  of  the  female  Acarus  Scabiei          .....  789 

458.  Ventral  surface  of  the  same         .         .......  789 

459.  Ventral  surface  of  the  male  Acarus 789 

460.  Three  follicles  of  the  skin  of  the  dog  containing  enlozoa       .         .         .  792 

461.  Cul-de-sac  of  a  sebaceous  follicle,  with  entozoa  and  ova       .         .         .  792 

462.  Hair  and  its  follicles,  with  entozoa 793 

463.  Crusts  of  favus  in  different  stages  of  development         ....  800 

464.  Branches  of  the  Achorion  Schcenlemi,  iu  an  early  stage  of  development  804 

465.  Fragments  of  the  branches  more  highly  developed       ....  804 

466.  A  light  hair,  containing  branches  of  the  ^c/iorwra  (Sc/itBHfeini        .         .  805 

467.  Sporules  developing  on  the  surface  of  an  apple,  after  three  days  .         .  807 

468.  The  same,  after  four  daj-s 807 

469.  The  same,  more  fully  developed  on  the  human  arm,  after  inoculation  807 

470.  Thalli,  mycelia,  and  sporidia,  of  the  Achorion  Schcenkini      .         .         .  808 

471.  Portion  of  clot  from  the  vena  cava  in  leucocytliemia     .         .         .         .  816 

472.  Posterior  surface  of  the  aorta  and  vena  cava  in  leucocytliemia      .         .  816 

473.  Appearance  of  the  cerebral  hemispheres  in  a  ca.se  of  leucocythemia      .  817 

474.  Colourless  corpuscles,  mingled  with  a  few  coloured  ones      .         .         .  818 

475.  The  same  bodies,  mingled  with  a  larger  number  of  yellow  blood  corpuscles  818 

476.  Change  produced  on  the  colourless  corpuscles  on  the  addition  of  acetic  acid  818 

477.  Cells  in  the  fluid  squeezed  from  the  lymphatic  glands  ....  818 

478.  Blood-vessels  giving  off  a  capillary  from  the  pia  mater          .         .         .  818 

479.  Appearance  of  a  drop  of  blood  in  leucocythemia  .         ....  821 

480.  The  same  after  the  addition  of  acetic  acid     ......  821 

481.  The  same  after  the  blood  has  stood  for  twenty-four  hours     .         .         .  822 

482.  Colourless  corpuscles  slighth^  increased  in  number        ....  828 

483.  The  same  after  the  addition  of  acetic  acid 828 

484.  Colourless  corpuscles  increased  in  number,  and  of  small  size         .         .  829 

485.  The  same  after  the  addition  of  acetic  acid     ......  829 

486.  Colourless  blood-cells  observed  in  leucocythemia          ....  830 

487.  Developement  of  the  nucleus  in  colourless  blood  cells           .         .         .  830 

488.  Cells  of  various  sizes  in  the  blood  of  a  haddock,  frog,  and  turkey          .  831 

489.  The  nuclei  of  the  blood-cells  of  the  haddock,  frog,  and  turkey     .         .  831 

490.  Fluid  chyle,  mingled  with  water 832 

491.  The  same  after  the  addition  of  acetic  acid 832 

492.  Numerous  naked  nuclei  of  the  colourless  corpuscles  in  the  blood          .  834 

493.  The  same  after  the  addition  of  acetic  acid 834 

494.  Cells  with  single  and  multiple  nuclei  .......  837 

495.  Structure  of  a  decolorized  mass  in  spleen 873 

496.  The  same  after  the  addition  of  acetic  acid 873 

497.  Appearance  of  exudation  and  epithelial  cells  in  the  typhoid  lung          .  874 

498.  Another  portion  of  the  same  lung,  after  the  addition  of  acetic  acid       .  874 

499.  Portions  of  normal  epithelium  separated  from  the  air  vesicles        .         .  874 

500.  A  clinical  ward  of  the  Royal  Infirmarj'-,  with  fever  beds,  in  1817          .  876 

501.  Clinical  ward,  No.  XI.,  1858,  with  present  arrangement  of  fever  beds  876 

502.  Dr.  "Weir's  scarificator  for  vaccuiatiou 897 


CLINICAL    LECTURES. 


INTRODUCTION. 

Gentlemen— Medicine,  as  a  subject  of  study,  must  be  regarded  in  a 
two-fold  aspect,  as  a  science  and  as  an  art — It  has  its  theory  and  its 
practice  ;  its  principles  and  their  application.  We  can  trace  the  germs 
of  theory  and  practice  in  medicine  to  a  very  early  period.  At  first,  in- 
deed, the  art  must  necessarily  have  been  founded  upon  experience  and 
observation  alone.  Hippocrates  first  added  philosophy  and  reasoning  to 
experience,  and  introduced  those  discussions  which  led  to  the  overthrow 
of  empiricism,  and  the  final  triumph  of  dogmatism,  six  hundred  years 
later,  in  the  time  of  Galen.  Since  then,  although  the  medical  profession 
has  uniformly  conjoined  the  results  both  of  reasoning  and  experience, 
each  of  these  two 'methods  has  had  its  special  supporters.  Even  at  the 
present  day  you  will  find  persons  who  complacently  call  themselves  prac- 
tical men,  and  who  sneer  at  all  modern  advances  in  pathology.  Others 
are  apt  to  attribute  too  much  importance  to  theory,  and  regard  with 
feelings  approaching  to  contempt,  him  whom  they  denominate  a  routine 
practitioner.  Hence,  unfortunately,  it  too  often  happens  that  practical 
men  are  comparatively  unacquainted  with  physiology  and  pathology ; 
while  those  who  dedicate  themselves  to  the  latter  studies  are  very  scepti- 
cal as  to  empirical  remedies.  On  this  subject  Cullen  made  a  remark 
eighty  years  ago,  which  applies  at  present: — "Everyone  now-a-days 
pretends  to  neglect  theory,  and  to  stick  to  observation.  But  the  first  is 
in  talk  only,  for  every  man  has  hisrtheory,  good  or  bad,  which  he  occa- 
sionally employs ;  and  the  only  difterence  is,  that  weak  men  who  have 
little  extent  of  ability  for,  or  who  have  had  little  experience  in,  reason- 
ing, are  most  liable  to  be  attached  to  frivolous  theories ;  but  the  truly 
judicious  practitioners  and  good  observers  are  such  as  have  the  most 
extensive  views  of  the  animal  economy,  and  know  best  the  true  account 
of  the  present  state  of  theory,  and,  therefore,  know  best  where  to  stop  in 
the  application  of  it." 

If  these  observations  were  correct  when  Cullen  wrote,  they  are  far 
more  applicable  now,  when  almost  every  advance  that  has  been  made  in 
the  art  of  medicine  since  his  day  has  been  owing  to  the  result  of  scientific 

1 


2  INTRODUCTION. 

investigation.     But  in  order  to  make  this  proposition  clear,  allow  me,  in 
the  first  place,  to  point  out  what  I  conceive  to  be 

The  Relation  of  the  Science  to  the  Art  of  Medicine. 

If  we  regard  the  whole  field  of  human  knowledge,  and  reflect  on  the 
differences  which  exist  among  the  various  sciences,  we  must  insensibly 
be  led  to  classify  them  into  two  great  divisions,  viz.  the  exact  and  the  in- 
exact. All  the  sciences  belonging  to  the  first  class  are  characterised  by 
the  possession  of  a  primitive  fact  or  law,  which,  being  applicable  to  the 
whole  range  of  phenomena  of  which  the  science  consists,  renders  its  dif- 
ferent parts  harmonious,  and  the  deductions  of  its  cultivators  conclusive. 
Thus,  the  physical  sciences  possess  a  primitive  fact,  in  what  is  called  the 
law  of  gravity.  It  was  Sir  Isaac  Xewton  who  demonstrated,  by  a  happy 
effort  of  genius,  that  all  the  planets  in  our  system  gravitate  towards  the 
sun,  by  the  same  law,  and  in  consequence  of  the  same  principle,  as  that 
by  which  bodies  on  the  earth  gravitate  towards  its  centre.  This  theory 
was  subsequently  found  applicable  to  avast  number  of  circumstances,  and 
by  it  the  philosopher  now  explains  many  of  the  material  phenomena  of 
the  universe,  and  the  astronomer  calculates  the  movements  of  the  hea- 
venly bodies.  This  law  applies  to  all  the  facts  of  which  physical  science 
is  made  up.  In  the  same  manner,  chemistry  possesses  a  primitive  fact 
in  what  is  called  the  law  of  aflinity,  discovered  later  by  Lavoisier.  If 
we  mix  two  salts,  which  mutually  decompose  each  other,  a  third  salt  is 
formed  by  the  union  in  definite  proportions  of  their  constituent  elements. 
This,  in  the  language  of  chemists,  is  brought  about  by  chemical  afiinity. 
If  we  repeat  the  experiment  a  thousand  times,  the  same  result  takes 
place,  and  the  law,  which  applies  in  one  case,  is  found  universally  appli- 
cable to  every  phenomenon  in  chemical  science.  The  possession  of  this 
primitive  fact,  then,  communicates  the  greatest  accuracy  and  precision 
to  the  sciences  which  possess  it,  and  on  this  account  they  are  called  the 
exact  sciences. 

But  there  are  other  sciences  which  arc  altogether  destitute  of  a  primi- 
tive fact;  which  consist  of  groups  of  phenomena,  each  of  which  may  or 
may  not  be  governed  by  a  particular  law.  Such  a  one  is  agriculture. 
Xo  man,  however  skilful,  can  till  the  ground  or  cultivate  the  soil,  and  be 
certain  of  the  same  result  on  every  occasion.  Numerous  circumstances, 
over  which  he  has  no  control,  may  destroy  his  anticipations  and  show 
the  fallacy  of  his  calculations,  and  this  after  every  known  condition 
has  been  fulfilled,  and  every  possible  degree  of  prudence  and  saga- 
city has  been  exercised  to  ensure  success.  The  same  means,  apparently, 
which  operate  at  one  time  fail  to  do  so  at  another.  Such  sciences,  then, 
are  denominated  inexact  sciences,  and  it  is  to  this  class  that  medicine 
belongs. 

Now  the  cultivators  of  medicine  always  have  been,  and  are  still 
endeavouring  to  render  the  science  exact,  and  hence  at  various  times 
individuals  have  brought  forward  what  they  conceived  to  be  a  law  or 
primitive  fact,  and  have  tried  to  show  that  it  was  applicable  to  all  vital 
phenomena.  Some  have  placed  the  law  in  the  physical  condition  of  the 
solids,  and  others  in  the  physical  condition  of  the  fluids.  Hence  the 
terms  solidists  and  fuidists. '  A  third  party  have  sought  it  in  the  func- 


RELATION  OF  THE   SCIENCE   TO   THE   ART  OF   MEDICINE.       3 

tional  conditions  of  the  bod}-,  viz.,  an  alteration  in  the  living  force.  They 
have  been  called  vitalists.  If,  for  instance,  we  could  constitute  the  vital 
property,  excitability,  a  primitive  fact,  it  would  serve  the  same  purpose  in 
physiology  that  gravitation  does  in  physics.  But  we  cannot  do  this.  It 
is  "true  that  the  stomach  is  excited  by  the  food,  in  order  that  digestion 
may  be  produced,  and  that  the  lungs  are  excited  by  the  air  during  the 
process  of  aeration.  But,  in  the  performance  of  these  functions,  excita- 
bility plays  a  secondary  part ;  it  is  only  one  of  the  elementary  properties 
necessary  for  their  completion,  and  is  utterly  insufficient  to  account  for 
their  production.  In  the  same  manner,  neither  the  mechanism  of  the 
solids  nor  of  the  fluids  can  explain  every  known  fact;  so  that  it  becomes 
necessary  to  take  all  three  doctrines, — solidism,  humoralism,  and  vital- 
ism,— into  consideration,  if  we  wish  to  escape  fallacy. 

Of  late  years  it  has  been  contended  that,  as  far  as  structure  and 
development  are  concerned,  we  do  possess  a  law  in  the  doctrine  of  cyto- 
genesis,  that  is,  of  the  growth  of  those  minute  vesicles  or  cells,  of  which 
we  find  all  plants  and  animals,  at  one  period  of  their  existence,  to  be 
composed.  It  has  been  argued  that  if  a  theoiy  of  organization  can  be 
shown  to  apply  to  all  animated  nature,  to  the  vegetable  as  well  as  to  the 
animal  kingdom  ;  if  it  can  be  demonstrated  that  the  humblest  and  minu- 
test tribes  of  plants  possess  the  same  original  structure  as  is  to  be  found 
in  the  most  gigantic  trees  of  the  forest ;  if  it  become  evident  that  the 
same  principle  of  formation  is  discoverable  in  animals,  whether  so  raimite 
that  thousands  may  be  contained  in  a  drop  of  water,  or,  on  the  other 
hand,  so  enormous  as  the  elephant  or  whale ;  nay,  more,  if  it  admit  of 
demonstration,  that  the  organic  diseases  to  which  they  are  subject,  that 
the  formation  of  new  growths,  and  the  reparation  of  tissues,  are  explicable 
by  the  same  theory  as  applies  to  the  development  of  healthy  structure, 
— then,  it  is  contended,  we  are  surely  approaching  to  something  like  a 
great  primitive  fact,  which  may  ultimately  communicate  exactitude  to 
physiological  science.  And  yet,  notwithstanding  the  flood  of  light  which 
has  been  thrown  upon  all  departments  of  our  science  by  the  beautiful 
generalization  of  Schleiden  and  Schwann,  recent  researches  have  exhi- 
bited its  insufliciency  to  explain  all  known  phenomena  of  growth. 

Medicine,  then,  in  its  present  state,  possesses  no  primitive  fact.  But 
is  it  not  very  possible  that  it  may  do  so  at  some  future  time  ?  During 
the  many  ages  that  existed  before  Newton,  physical  science  was  as  inex- 
act as  that  of  physiology  is  now.  Before  the  time  of  Lavoisier,  chemis- 
try, like  physiology,  consisted  of  nothing  but  groups  of  phenomena. 
These  sciences  went  on  gradually  advancing,  however,  and  accumulating 
facts,  until  at  length  philosophers  appeared,  who  united  these  together 
under  one  law.  So  medicine,  we  trust,  is  destined  to  advance,  and  one 
day  another  Newton,  another  Lavoisier,  may  arise,  whose  genius  will 
furnish  our  science  with  its  primitive  fact,  and  stamp  upon  it  the  charac- 
ter of  precision  and  exactitude. 

Although  it  must  be  confessed  that  we  have  not  yet  arrived  at  such 
a  happy  consummation,  it  caimot  be  denied  that  we  are  making  rapid 
strides  towards  it.  Notwithstanding  those  principles  which  Bacon 
introduced  into  the  study  of  Science,  it  is  only  lately,  from  the  advance 
of  collateral  branches  of  knowledge,  that  we  have  been  enabled  to 
catch  glimpses  of  a  correct  philosophy  as  applied  to  physiology.     A 


4  INTEODUCTION". 

truly  scientific  medicine  is  yet  to  be  created — for  all  the  processes  of 
life,  both  in  its  healthy  and  diseased  conditions,  are  really  owing  to  the 
structures  which  have  been  only  lately  raade  visible  by  the  improvement 
in  optical  instruments.  We  know  also,  that  these  processes  are  con- 
nected with  physical  and  chemical  changes,  the  importance  of  which  we 
are  just  commencing  to  estimate.  But  now,  assured  of  what  is  really 
necessary,  and  guided  by  rigid  observation  and  experiment,  rather  than 
by  a  vague  hypothesis,  physiology  and  pathology  are  advancing  with 
such  rapidity,  that  every  year  improves  or  modifies  the  ideas  which 
sprang  up  in  the  one  which  preceded  it.  Moreover,  it  has  been  satis- 
factorily shown  that  the  branch  of  science,  which  refers  to  vital  pheno- 
mena, bears  such  a  relation  or  correlation  to  various  branches  of  j9/;//s/co7 
science,  that  the  whole  is  gradually  becoming  more  simple,  instead  of 
more  complex.  Instead  of  physiology  being  isolated  under  the  idea 
that  its  laws  are  peculiar,  it  is  every  day  becoming  more  evident,  that 
vegetable  and  animal  life  are  dependent  on  conditions  which,  strictly 
speaking,  are  elucidated  by  the  geologist,  botanist,  zoologist,  chemist, 
and  natural  philosopher.  In  short,  the  intimate  union  of  the  natural 
sciences  seems  to  be  near  at  hand. 

But  you  do  not  cultivate  these  sciences  as  barren,  however  interest- 
ing, subjects  of  medical  study.  With  you,  I  apprehend,  as  with  myself, 
the  knowledge  so  acquired,  constitutes  a  groundwork  for  the  practice  of 
an  art.  It  is  in  this  point  of  view  I  am  especially  anxious  you  should 
consider  physiology  and  pathology.  For,  gentlemen,  I  trust  that,  in 
studying  these  subjects,  you  will  never  lose  sight  of  the  important  fact, 
that  you  are  medical  students,  and  that  as  such  your  ultimate  object  is 
to  acquire  an  art ;  in  other  words,  skill  in  the  employment  of  all  those 
means  which  are  directed  to  the  prolongation  of  life  and  the  cure  of 
diseases.  Now,  in  order  that  you  may  successfully  accomplish  this  great 
object,  it  is  necessary  that  you  should  appreciate  properly  the  impor- 
tance of  theory  in  its  bearings  on  practice,  so  that,  when  you  are  called 
upon  to  treat  the  sick,  you  may  be  ready  to  take  advantage  of  all  the 
knowledge  which  you  may  have  obtained.  Hence  the  importance  of 
knowing  how  to  distinguish  between  the  nature  and  object  of  science 
and  art  respectively. 

We  may  consider  science,  then,  to  be  a  collection  of  theories;  art, 
a  body  of  rules.  Science  says,  this  is,  or  is  not;  this  is  probable  or 
improbable.  Art  says,  do  this,  avoid  that.  The  object  of  science  is  to 
discover  facts  and  determine  laws ;  the  object  of  art  is  to  accomplish  an 
end,  and  determine  the  means  of  eflPecting  it.  Science  is  inductive,  and 
reasons ;  art  is  imitative,  and  exemplifies.  Science  is  steady,  certain, 
and  progressive ;  art  is  vacillating,  doubtful,  and  limited. 

Hitherto  it  has  been  imagined  that  the  chief,  if  not  the  only  method 
of  obtaining  skill  in  art,  is  by  practising  it ;  that  is,  obtaining  expe- 
rience. In  medicine  this  is  proverbial,  and  every  practitioner  is  more 
apt  to  boast  of  his  experience  than  of  his  scientific  knowledge.  In  the 
infancy  of  science,  indeed,  we  can  readily  understand  that  its  hasty  gene 
ralizations  must  have  been  continually  overthrown  and  rendered  ridicu- 
lous the  moment  they  were  applied  to  practice.  Hence  the  reason  why 
art  for  many  ages  preceded  science — why  dogmatic  rules  were  more 
attended  to  than  ingenious  theories — and  why  the  accomplishment  of 


RELATION   OF   THE   SCIENCE   TO   THE   ART   OF   MEDICINE.       5 

an  end,  even  when  that  end  was  limited,  was  more  regarded  than  the 
discovery  of  a  new  fact,  or  tlie  determination  of  a  law  capable  of  exten- 
sive application.  But,  in  recent  times,  this  state  of  things  is  gradually 
becominor  reversed.  Science,  in  numberless  instances,  has  advanced 
bevond  art ;  nay  more,  science  herself  has  worked  out  all  the  details, 
and  made  art  obedient  to  her  commands.  Thus  it  was  that  the  theory 
of  achromatism,  worked  out  by  Euler,  led  opticians  to  make  perfect 
telescopes  and  microscopes.  Thus  it  was  that  Le  Verrier  and  Adams, 
by  calculations  in  their  observatories  in  Paris  and  London,  discovered  a 
planet  which  they  had  never  seen,  but  which,  when  looked  for,  accord- 
ing to  their  directions,  fi'om  Stockholm  and  St.  Petersburg,  was  imme- 
diately proved  to  exist  in  fact,  as  it  had  prenously  been  proved  to  exist 
in  theory.  Thus  it  was  that  the  electric  telegraph,  perfected  in  the 
closet  of  a  man  of  science,  flashed  ready  made  on  the  astonished 
gaze  of  an  admiring  world  ;  and  thus  it  is  that  at  the  present  moment 
we  see  the  artizan  in  his  workshop,  the  explorer  in  the  mine,  the  agri- 
culturist in  his  farm,  nay,  even  the  sculptor  in  his  studio,  abandoning 
the  rules  and  wise  saws  handed  down  to  him  from  ancient  tradition, 
and  accommodating  himself  to  the  revolutions  which  science  has  dic- 
tated, and  those  laws  whereby  blind  experience  is  made  to  yield  to  an 
enlightened  knowledge. 

We  may,  therefore,  receive  it  as  an  established  law,  that,  the  more 
any  particular  science  is  advanced,  the  more  is  the  art  to  which  it  leads 
rendered  perfect,  and  that  true  theory  in  the  one  produces  never-failing 
rules  in  the  other.  The  art  of  navigation,  for  instance,  is  certain, 
because  the  science  of  astronomy  on  which  it  is  based,  admits  of  exact 
calculation.  In  like  manner,  the  only  way  of  improving  the  art  of 
medicine  is  to  advance  the  science  of  physiology,  and  all  that  has  been 
accomplished  during  the  last  fifty  years  has  been  brought  about  in  this 
manner.  In  that  short  time  have  been  discovered  the  independent 
properties  of  the  nerves,  the  reflex  functions  of  the  nervous  centres,  the 
chemical  balance  of  organic  nature,  the  functions  of  cells,  and  their 
influence  on  nutrition  and  secretion,  the  laws  regulating  the  develop- 
ment of  the  ovum,  the  significance  of  the  sounds  produced  by  the  heart 
and  lungs,  and  numerous  other  doctrines,  which  have  tended  to  improve 
the  art  of  medicine. 

But  while  the  modern  cultivator  of  medicine  loses  no  opportunity, 
and  employs  all  the  means  with  which  the  improved  state  of  science 
furnishes  him,  for  investigating  morbid  anatomy  and  the  causes  of  dis- 
ease, he  carefully  corrects  the  theoretical  conclusions  to  which  these 
alone  might  lead  him,  by  practical  experience  and  observation.  Our 
active  and  our  speculative  powers  should  go  hand  in  hand,  so  that,  by  a 
union  of  theoretical  knowledge  and  practical  skill,  we  may  advance 
both  to  their  farthest  limits.  It  is  by  cultivating  medicine  in  this  spirit 
that  the  clinical  school  of  Edinburgh  has  rendered  itself  so  famous. 
Those  who  taught  the  theoretical  branches  of  medicine  from  their 
chairs  in  the  Vnivei'sitv,  were  those  who  taught  the  practice  in  the 
wards  of  this  Infirmary.  They  were  thus  enabled  to  demonstrate  how, 
on  the  one  hand,  correct  observation  leads  to  just  deduction,  and  on  the 
other,  how  a  knowledge  of  general  principles  causes  accuracy  and  acute- 
ness  in  observation.     Indeed,  it  is  impossible  to  estimate  too  highly  the 


6  INTRODUCTION, 

advantacres  "which  liave  resulted  from  such  a  system,  which  has  been 
carried  on  uninterruptedly  by  the  Professors  of  this  University,  for  one 
hundred  and  ten  years.     This  leads  me  to  speak  of 

The  Mode  of  Conducting  the  Clinical  Course. 

Tour  principal  object,  gentlemen,  in  coming  into  this  Hospital,  is,  I 
presume,  to  observe  disease  for  yourselves.  Xow,  to  observe  with 
advantage,  two  things  are  necessary ;  1st,  The  correct  appreciation  of 
actual  facts,  as  communicated  to  the  senses  of  the  practitioner  or  of  his 
patient;  2d,  The  deduction  from  these  of  a  correct  judgment  as  to  the 
nature  of  the  disease,  and  the  proper  mode  of  its  treatment.  Both  these 
processes  are  very  difficult  of  attainment,  and  some  men  have  a  natural 
aptitude  for  the  one,  and  some  for  the  other.  They  are  also  frequently 
confounded  together,  some  observers  considering  those  to  be  facts  which 
are  only  theories,  and  others  imagining  that  to  be  theoretical  which  is 
trulv  fact.  Thus  the  assertion  that  a  man  is  labouring  under  apoplexy, 
pneumonia,  pericarditis,  and  so  on,  is  only  stating  the  opinion  or  theory 
the  practitioner  holds  with  regard  to  his  case,  although  such  assertion  is 
SCenerally  received  as  a  fact.  Again,  when  it  is  said  that  porrigo  favosa 
consists  of  vegetable  fungi,  growing  on  the  scalp,  the  statement,  though 
generally  received  as  mere  theory,  is  truly  a  fact,  inasmuch  as  the  vege- 
tations may  actually  be  demonstrated,  and  rendered  as  visible  to  the  eye 
as  trees  growing  in  a  plantation.  Indeed,  the  just  distinction  between 
theory  and  fact  is  a  matter  which  has  excited  lively  discussion,  and 
hence  the  celebrated  saying  of  Cullen,  that  there  are  more  false  facts 
than  false  theories  in  medicine. 

If,  in  the  field  of  medical  observation,  we  define  a  fact  to  be  any- 
thing which  is  obvious  to  the  well-cultivated  senses  of  the  observer,  we 
perhaps  approach  as  near  accuracy  as  is  possible.  Remark,  I  say  tvell 
cultivated^  because  the  senses  require  to  be  educated  before  they  can 
receive  proper  impressions.  In  this  lies  the  great  difficulty  in  teaching 
practical  medicine,  for  what  is  obvious  to  the  sight  of  an  experienced 
practitioner  is  overlooked  by  the  student ;  the  sound  which  is  heard  by 
the  one  is  inaudible  to  the  other ;  what  the  first  feels  distinctly  is  not  per- 
ceived by  the  second.  Now  this  instruction  of  the  senses  constitutes  a 
kind  of  information  which  cannot  be  obtained  from  others ;  you  must 
acquire  it  for  yourselves.  Of  late  years,  however,  the  detection  of 
facts  has  been  greatly  facilitated  by  the  appropriate  use  of  instruments, 
wherebv  what  at  one  time  was  conjectural  is  now  rendered  certain. 
Thus,  the  existence  of  many  diseases,  which  could  formerly  be  detected 
only  by  a  happy  speculation,  or  by  a  rare  sagacity,  is  easily  demon- 
strated by  those  who  know  how  to  employ,  judiciously,  chemical  tests, 
microscopes,  stethoscopes,  pleximeters,  specula,  etc.  To  carry  observa- 
tion, then,  to  its  utmost  extent,  we  must  learn  how  to  avail  ourselves  of 
all  these  means  in  the  examination  of  the  signs  and  symptoms  of  dis- 
ease. 

On  the  other  hand,  gentlemen,  a  sound  and  correct  judgment  is  equally 
necessary,  in  order  that  the  cultivation  of  the  senses  may  lead  to  a  pro- 
per end,  and  indicate  the  direction  in  which  you  must  act  for  the  benefit 
of  the  patient.     For  this  purpose  a  certain  degree  of  preliminary  instruc- 


MODE   OF   CONDUCTING  THE   CLINICAL   COUKSE,  7 

tion  is  absolutely  essential  before  you  can  be  qualified  to  attend  an  hos- 
pital with  advantage.  Indeed,  I  must  take  it  for  granted,  that  before 
comino-  here  you  are  tolerably  well  acquainted  with  anatomy  and  che- 
mistry ;  that  you  have  studied  the  institutes  of  medicine,  that  is,  the 
present  state  of  histology,  physiology,  and  pathology,  and  that  you  have 
a  knowledge  of  the  materia  medica,  and  of  the  effects  of  remedies  on 
the  economy.  Thus  prepared,  you  commence  a  series  of  visits  to  the 
bedsides  of  those  who  are  labouring  under  disease,  in  other  words,  you 
enter  upon  a  course  of  clinical  instruction.  What  should  we  understand 
by  clinical  instruction  ?  It  is  not  attendance  on  the  lectures  only — it  is 
not  merely  learning  the  opinions  of  your  teacher — it  is  not  simply  de- 
riving knowledge  from  others.  It  is  acquiring  medical  information  for 
yourselves — it  is  the  learning  how  to  observe — it  is  that  education  of 
the  senses  to  which  I  have  alluded ;  and,  in  addition,  the  formation 
of  that  sound  judgment  which  will  enable  you  to  act  for  the  benefit  of 
your  patients.  This  can  only  be  learned  by  continual  practice  and  ex- 
perience ;  and  it  has  always  appeared  to  me  that  the  great  aim  of  clini- 
cal instruction  should  be  to  teach  the  student  to  acquire  that  kind  of 
tact  and  readiness  to  do^  which  we  have  seen  constitutes  art. 

How  are  all  arts  acquired  ?  A  young  mechanic,  when  he  makes  a 
chair,  follows  exactly  the  same  process  as  those  who  study  what  are 
called  the  fine  arts.  That  is,  he  learns  how  to  do  what  his  master  does 
before  him.  He  imitates  his  plan  of  proceeding.  His  first  attempts 
are  rude  and  uncouth  ;  his  subsequent  ones  are  more  perfect,  until,  at 
length,  by  continual  practice,  he  is  enabled  to  equal,  or  surpass,  his  in- 
structor. In  painting,  sculpture,  and  music,  there  are  principles  which 
must  be  attended  to,  and  which  are  learnt  from  others  ;  but  no  man  can 
become  a  painter,  a  sculptor,  or  a  musician,  without  obtaining  practical 
skill  as  an  artist,  in  the  way  now  alluded  to.  It  is  thus,  and  thus  only, 
that  art  descends  from  the  old  to  the  young.  And  so  in  medicine  ;  it  is  not 
enough  to  obtain  general  views  of  health  and  disease,  or  to  study  what 
is  known  of  the  nature  and  treatment  of  individual  maladies.  It  is  ab- 
solutely essential  to  watch  diseases  for  yourselves,  to  see  the  altered 
countenance  and  form,  to  feel  the  variations  in  the  pulse  and  temperature 
of  the  surface,  to  hear  the  changes  which  the  sounds  of  the  heart  and 
lungs  undergo,  to  learn  the  employment  of  stethoscopes,  microscopes, 
and  other  mechanical  aids  in  investigation,  and  to  adapt  those  remedies 
which  are  in  use,  to  the  special  case  before  you.  It  is  only  by  a  combi- 
nation of  such  training  in  a  hospital  for  the  sick,  with  the  varied  scienti- 
fic knowledge  you  have  obtained  elsewhere,  that  you  can  hope  to  pre- 
pare yourselves  conscientiously  for  the  responsible  duties  of  a  medical 
practitioner. 

Considering,  then,  that  a  too  exclusive  attention  either  to  theory  or 
practice,  tends  to  circumscribe  the  usefulness  of  the  physician,  it  will  be 
my  endeavour  to  aS'ord  you  every  facility  for  learning  medicine  both  as 
a  science  and  as  an  art.  For  this  purpose  the  course  will  consist  of  two 
kinds  of  instruction.  1st,  Lectures;  2d,  The  examination  of  patients, 
and  prescribing  for  them  by  the  student  in  my  presence.  In  the  lecture 
I  shall  direct  your  attention  to  the  histories  of  the  cases  we  have  pre- 
viously examined,  notice  the  difficulties  in  diagnosis,  or  the  peculiarities 
they  may  have  presented — speak  of  the  treatment  which  has  been  em- 


O  INTRODUCTION. 

ployed,  or  of  the  recorded  experience  of  those  who  are  actnowledged 
to  be  worthy  guides  for  our  imitation — and  especially  dwell  upon  such 
points  of  doctrine  or  speculation  as  may  be  serviceable  to  us  in  our 
eftbrts  at  cure.  At  the  bedside  I  shall  call  upon  such  of  you  as  wish 
to  exercise  yourselves  in  observation,  to  examine  the  patient,  according 
to  a  plan  which  I  shall  subsequently  communicate  to  you :  then,  hav- 
ing elicited  the  facts,  to  form  a  judgment  as  to  the  nature  of  the  case ; 
and  lastly,  to  suggest  a  plan  of  treatment,  and  prescribe  for  the  patient. 
In  doing  this,  numerous  opportunities  will  present  themselves  for  the 
communication  of  practical  instruction  in  the  use  of  various  instruments, 
for  improving  the  observing  and  reflecting  powers,  and  for  obtaining  a 
familiarity  with  the  method  of  combining  medicines  in  extempore  pre- 
scriptions. 

This  plan  of  clinical  instruction  has  been  for  a  long  time  practised 
on  the  Continent,  and  especially  in  Germany.  It  was  also  followed 
by  Dr.  Graves,  in  Dublin.  I  have  myself  taught  in  this  way  for  the 
last  sixteen  years,  to  classes  at  the  Royal  Dispensary,  and  in  this  Infir- 
mary. I  have  never  found  that  it  produced  the  smallest  inconvenience 
to  teacher,  student,  or  patient,  or  was  open  to  the  slightest  objection ; 
but,  on  the  contrary,  that  it  has  been  productive  of  good  to  all  parties. 
It  has  given  me  much  pleasure  to  observe  the  readiness  with  which  the 
students,  during  the  last  ten  years,  have  entered  into  this  plan,  and  the 
evident  advantage  they  derive  from  it. 

I  am  satisfied  that  you  Avill  not  cultivate  practical  medicine  very- 
long  in  this  way  without  noticing  a  fact,  which  is  every  year  becom- 
ing more  and  more  evident,  viz. — that  the  art  has  of  late  years  been 
undergoing  a  great  revolution.  It  is  daily  becoming  apparent  to  those, 
who  observe  in  a  spirit  of  sincerity  and  of  truth,  that  much  of  the 
practice  of  our  profession,  which  has  resulted  from  what  is  called  expe- 
rience, is  altogether  incompatible  with  the  existing  state  of  our  know- 
ledge— that  in  consequence  it  requires  a  thorough  revision — that  the 
systems  and  nosologies  of  our  forefathers,  though  useftil  in  their  day, 
no  longer  apply — and  that  a  new  field  of  labour  is  now  open  to  the 
cultivation  of  those  zealous  clinical  students,  who  are  anxious  to  identify 
themselves  with  the  progress  of  medicine. 

It  cannot  fail  to  strike  all  those  Avho  have  paid  any  attention  to 
modern  medical  education  that,  whilst  phj'siology  and  pathology  have 
been  making  rapid  advances,  our  previous  impressions  of  the  action  of 
drugs,  and  of  various  modes  of  treatment,  have  become  altogether 
changed.  Whilst  we  were  ignorant  of  the  structure  and  functions  of  an 
organ  or  tissue — so  long  as  we  confounded  together  causes  and  results 
— so  long  we  were  especially  apt  to  be  led  astray  by  tentative  eftbrts  at 
cure.  But  once  that  we  have  established  on  indisputable  data  what  is 
really  fact — what  is  the  true  law  governing  the  progress  of  a  disease — 
in  how  many  instances  does  it  then  become  evident,  that  the  means 
employed  for  its  removal  are  feeble  or  altogether  inert.  This  has  now 
occurred  so  extensively — systematic  works  on  medicine  are  so  at  vari- 
ance with  books  on  physiology  and  pathology — the  practice  of  the 
profession  is  so  discordant  with  its  theory — that  many  intellectual  inqui- 
rers among  us  take  refuge  in  a  universal  scepticism  as  to  the  action  of 
drugs,  leave  everything  to  nature,  and  merely  adopt  what  is  called  in 


POLITICAL  STATE   OF  THE   MEDICAL   PROFESSION.  9 

France  an  expectant  treatment,  and  in  Germany  the  practice  of  "  Nibil- 
ismus."  Nay,  it  has  been  even  contended  that  our  remedies,  so  far 
from  doing  good,  in  many  instances  do  positive  injury,  and  that  it  is 
safer  to  trust  to  nature  than  to  tlie  physician. 

The  only  method  of  escape  from  this  state  of  things,  it  appears  to 
me,  is  bv  an  earnest  effort  on  the  part  of  those  who  sincerely  desire  the 
improvement  of  our  art,  to  establish  the  science  of  medicine  upon 
something  like  a  solid  foundation.  Let  us,  at  all  events,  endeavour  to 
realize  our  position,  and  to  separate  what  is  known  from  what  is 
unknown.  Among  the  known,  let  us  determine  what  we  have  derived 
from  scientific  generalization,  and  what  from  blind  experience  ;  and  in 
the  vast  field  of  the  unknown,  let  us,  if  possible,  agree  as  to  the  direc- 
tion and  manner  in  which  we  ought  to  work,  in  order  to  explore  its 
extent,  and  contract  its  boundaries. 

The  proprietv  of  this  procedure  is  admitted.  ^Vhy,  then,  is  it  not 
carried  out  ^ — why  cannot  we  co-operate  in  the  resolve  to  prosecute  our 
noble  profession  with  a  simple  desire  to  advance  it  towards  its  true  end 
— the  cure  of  disease  ?  I  will  answer  these  questions  by  endeavouring 
to  show  what  are,  as  I  think,  the  circumstances  which,  at  the  outset  of 
every  honest  attempt,  discourage  our  endeavours  to  improve  medical 
practice.  Thev  seem  to  me  to  be  connected,  as  far  as  this  country  is 
concerned — 1st,  "With  the  political ;  2d,  "With  the  social ;  and,  3d, 
With  the  practical  status  of  our  profession.  On  each  of  these  subjects 
a  volume  might  be  written,  but  I  shall  endeavour  to  place  their  leading 
aspects  before  you  in  a  few  words. 

The  Political  State  of  the  Medical  Profession. 

"When  we  regard  all  the  other  professions  and  pursuits  of  life  in  this 
great  country,  we  find  there  are  none  of  them,  except  medicine,  whose 
cultivators  are  excluded  from  the  high  offices  of  state,  or  forbidden  to 
aspire  to  any  rank  below  that  of  royalty.  The  eminent  lawyer  or 
divine,  the  successful  admiral  or  general,  the  popular  author,  or  the 
heads  of  our  great  commercial  houses,  may  become  peers  of  the  realm, 
are  commonly  seen  taking  an  active  part  in  the  Legislature,  and  fre- 
quentlv  receive  reward  or  distinction,  conferred  upon  them  by  a  nation 
grateful  for  their  services.  It  is  a  fact  well  calculated  to  excite  astonish- 
ment, that  a  class  of  men  who  have  dedicated  themselves  to  the  well- 
being  of  the  public  health,  should  be  comparatively  neglected.  In  this 
respect,  we  suffer  with  men  of  science  in  general,  who,  however  much 
they  may  be  respected  individually,  are  but  slightly  encouraged  by  the 
state.  The  hackneyed  phrase  of  our  legislators  Avith  regard  to  all  men 
of  science,  including  medical  men,  is,  in  the  words  of  Sir  Robert  Peel, 
that  "  science  is  its  own  reward  ;"  or  in  the  words  of  the  Duke  of  Argyle, 
"  that  in  the  main  it  must  depend  for  its  advancement  on  its  own  in- 
exhaustible attractions,  and  on  the  delight  which  it  affords  us  to  study 
the  constitution  of  the  world  around  us."  But  in  every  civilized  country 
except  Great  Britain,  it  has  been  thought  a  matter  of  good  policy  to 
encourage,  by  marks  of  honour,  those  who,  by  their  scientific  labours, 
have  contributed  to  the  public  weal.  The  French  reproach  the  profes- 
sion in  this  country  for  having  achieved  for  itself  no  adequate  honour 


10  INTRODUCTION. 

or  reputation.  It  has  been  said  that  "in  France,  during  tte  last 
half-century,  there  is  no  council-board,  no  administration,  no  society, 
in  which  the  medical  profession  has  not  found  itself  represented, 
whether  at  the  court  of  the  sovereign,  or  among  the  peerage,  or  in 
the  legislature.  Physicians  of  the  Institute  take  their  place  naturally 
among  the  first  of  the  land.  Their  views,  their  discoveries,  their 
cures,  their  professional  ideas  and  suggestions  must  be  listened  to, 
cannot  be  neglected,  and  may  never  be  treated  as  intrusion  ;  nor  had 
Napoleon  fewer  physicians  and  surgeons  for  friends,  councillors,  and 
dignitaries  of  state,  than  he  had  of  any  other  profession.  But  in  Eng- 
land, all  such  interests  find  themselves  either  misrepresented,  or  not 
represented  worthily ;  and  the  best  of  their  physicians  is  good  only  to 
amass  money,  or,  at  the  highest,  get  a  baronetcy." — [Examiner) 

All  this,  gentlemen,  would  be  of  little  importance,  did  it  not,  as  I 
shall  point  out  immediately,  greatly  affect  our  social  position,  and  through 
it  lower  the  true  objects  for  which  medicine  ought  to  be  cultivated. 

Much  of  the  evil  arises  from  the  fjxct,  that  the  medical  profession  in 
this  country  possesses  no  national  organization.  Unlike  the  other  pro- 
fessions, so  tar  from  there  being  a  bond  of  union  among  its  members, 
they  are  irreconcilably  divided  by  chartered  medical  institutions.  These 
amount  to  about  thirty  in  number,  each  having  diflerent  powers  con- 
ferred upon  them  by  past  sovereigns  or  governments,  and  an  interest 
in  aggrandising  itself  at  the  expense  of  its  neighbours.  These  various 
institutions,  though  they  were  all  established  professedly  to  support 
the  honour  and  dignity  of  medicine  and  its  cultivators,  are  so  discre- 
pant in  power,  and  so  conflicting  in  interest,  that  they  have  led  to  little 
but  confusion  and  disunion  among  the  members  of  the  profession  at  large. 

Such,  of  late  years,  have  been  the  clashing  interests,  the  conflicting 
privileges,  the  injuries  inflicted  on  the  student  and  on  medical  education, 
the  discreditable  prosecutions  in  our  courts  of  law  of  well-educated 
medical  men,  whilst  the  ignorant  pretender  is  allowed  to  escape,  and  a 
host  of  other  evils,  that  a  universal  cry  has  been  raised  for  what  is  called 
medical  reform — that  is,  a  re-arrangement  of  the  affairs  of  the  profession, 
by  an  act  of  the  legislature.  It  would  be  curious  to  analyse  thVj  dif- 
ferent measures  which  have  been  proposed  for  this  purpose.  But  it  was 
to  be  anticipated  that  our  medical  corporations  Avould  look  after  their 
own  interests — oppose  everything  that  encroached  upon  them — and  in 
cases  where  there  existed  few  or  no  privileges,  that  efforts  would  be 
made  to  obtain  them,  even  at  the  expense  of  sister  institutions.^  The 
endeavours  of  the  profession,  during  the  last  twenty  years,  on  this  sub- 
ject, have  ended  in  nothing,  nay,  worse  than  nothing,  as  they  have 
engendered  every  species  of  rancour  and  jealousy  among  parties  who 
ought  to  have  been  united,  in  order  to  attain  the  object  sought. 

The  course  which  for  a  long  time  government  took  with  regard  to 
this  matter  was  quite  inefficient.  "  Ag'ree,"  it  said,  "  among  yourselves, 
as  to  a  measure  of  medical  reform,  and  we  will  give  it  consideration." 
But  this  agreement  was  as  improbable  as  would  be  the  union  of  the 
most  opposing  elements.  What  the  profession  required  was  a  states- 
man, who,  after  mastering  the  subject,  would  cause  a  bill  to  be  passed, 
which  should  secure  equality  of  education  and  of  privilege  throughout 
the  whole  empire,  with  a  marked  protection  and  encouragement  for 


POLITICAL  STATE   OF  THE   MEDICAL  PKOFESSION,  11 

the  educated,  as  distinguished  from  the  uneducated,  in  practice.  The 
means  for  accomplishing  this,  it  was  clear,  could  only  be  settled  by  the 
legislature,  as  the  medical  corporations  were  never  likely  to  agree  as  to 
details. 

At  length,  however  (1858),  an  act  has  passed  the  legislature  which 
empowers  the  formation  of  a  general  council,  to  be  constituted  of  dele- 
gates sent  from  the  various  Universities  and  medical  corporations, 
to  whom  the  settlement  of  all  vexed  questions  is  referred.  It  is 
intrusted  with  the  task  of  regulating  medical  education  throughout  the 
country,  of  preparing  a  correct  register  of  legally  qualified  practitioners, 
and  of  publishing  a  national  pharmacopeia.  The  result  of  their 
deliberations  is  anxiously  looked  for  by  the  profession,  and  it  Avill  be  a 
matter  of  sincere  congratulation,  if,  disregarding  party  influences  and 
the  interests  of  their  individual  institutions,  they  shall  show  themselves 
to  be  animated  with  the  desire  of  founding  a  national  instead  of  several 
local  systems  of  education.  If,  with  a  view  to  temporary  expediency 
or  in  okler  to  neutralize  partial  oppositions,  the  different  grades  of  the 
profession  are  not  alike  and  equally  respected  throughout  the  country, 
little  benefit  can  reasonably  be  expected  to  result  from  the  recent  legis- 
lative act. 

About  the  same  time  (1858)  another  bill  passed  the  legislature,  under 
the  auspices  of  the  then  Lord-Advocate  (Inglis),  having  for  its  object 
the  improvement  of  the  Scotch  Universities.  By  this  bill  the  University 
of  Edinburgh  more  especially  obtains  important  privileges,  and  its  con- 
stitution is  for  the  first  time  assimilated  to  that  of  the  other  Universities. 
In  future,  the  Senatus-  Academicus  is  to  superintend  and  regulate  the 
teaching  and  discipline  of  the  University,  and  administer  its  property  and 
revenues.  There  is  to  be  a  general  council,  consisting  of  a  chancellor, 
the  professors,  and  graduates  who  have  been  matricufated  students  for 
four  years,  which  is  to  meet  twice  a  year  to  consider  all  questions  affect- 
ing the  well-being  and  prosperity  of  the  University.  There  is  also  to 
be  a  University  Court,  composed  of  a  rector  (to  be  elected  by  the  matri- 
culated students),  the  principal,  the  Lord  Provost  of  Edinburgh,  and 
assessors  nominated  by  the  chancellor,  the  rector,  the  Town  Council, 
and  the  General  Council.  The  duties  of  this  court  are  to  be  as  follows : 
— 1.  To  review  all  decisions  of  the  Senatus  Academicus,  and  to  be 
a  court  of  appeal  from  the  Senatus  in  every  case  except  as  herein 
otherwise  provided  for  ;  2.  To  effect  improvements  in  the  internal 
arrangements  of  the  University,  after  due  communication  with  the 
Senatus  Academicus,  and  with  the  sanction  of  the  chancellor ;  provided 
that  all  such  proposed  improvements  shall  be  submitted  to  the  University 
Council  for  their  consideration  ;  3.  To  require  due  attention  on  the  part 
of  the  professors  to  regulations  as  to  the  mode  of  teaching  and  other 
duties  imposed  on  the  professors ;  4.  To  fix  and  regulate  from  time  to 
time  the  fees  in  the  sevei'al  classes ;  5.  Upon  sufficient  cause  shown,  and 
after  due  investigation,  to  censure  a  principal  or  professor,  or  to  suspend 
him  from  his  office  and  from  the  emoluments  thereof,  in  whole  or  in 
part,  for  any  period  not  exceeding  one  year,  or  to  require  him  to  retire 
fi'om  his  office  on  a  retiring  allowance,  or  to  deprive  him  of  his  office; 
and  during  the  suspension  of  any  professor  to  make  due  provision  for 
the  teaching  of  his  class ;  provided  always,  that  no  such  sentence  of 


12  INTRODUCTION". 

censure,  suspension,  or  deprivation,  or  requisition  on  a  professor  to  retire 
from  office,  shall  have  nny  effect  until  it  has  been  approved  by  her 
Majesty  in  Council;  6.  To  inquire  into  and  control  the  administration 
by  the  Senatus  Academicus  or  principal  and  professors  of  the  revenue, 
expenditure,  and  all  the  pecuniary  concerns  of  the  University,  including 
funds  mortified  for  bursaries  and  otber  purposes.  Lastly,  a  commission 
is  appointed  with  ample  powers  to  found  new  professorships,  endow  chairs, 
etc.,  and  a  grant  of  public  money  has  been  made  for  that  purpose. 

In  this  manner  the  students,  graduates,  and  professors  of  the  Uni- 
versity are  henceforth  to  form  a  body  corporate,  and  are  all  united  in 
the  election  of  office-bearers  for  its  government,  a  circumstance  that  can- 
not fail  to  connect  more  strongly  than  heretofore  those  who  teach  and 
those  who  learn.  This  act  has  emancipated  the  University  from  the 
control  of  the  Town  Council  of  Edinburgh,  a  body  of  men  which,  in 
different  important  respects,  was  ill  fitted  to  exercise  such  a  power.  For 
a  long  series  of  years,  indeed,  this  council  had  the  good  sense  to  be 
guided,  in  regard  to  the  arrangements  subject  to  their  regulation,  by 
the  advice  of  the  professors,  but  latterly  serious  differences  of  opinion 
occurred  between  the  two  bodies.  Expensive  law-suits  ensued,  widening 
the  breach  and  increasing  the  ill  feeling.  In  1854,  the  House  of  Lords, 
interpreting  an  ancient  statute,  decreed  that  the  Town  Council  of  the 
city  possessed  the  sole,  absolute,  and  imcontrolled  power  of  regulating 
the  education  necessary  for  the  degree  of  doctor  of  medicine,  and  that  in 
every  other  respect  it  possessed  unlimited  jurisdiction  over  the  Uni- 
versity. Thereupon  the  Town  Council  commenced  a  series  of  inter- 
ferences with  medical  instruction,  and  among  others,  in  1857,  suppressed, 
without  reason,  and  without  even  investigating  into  the  subject,  most 
necessary  changes  required  for  the  teaching  of  Clinical  Medicine,  which 
had  received  the  long  and  anxious  consideration  of  the  Medical  Faculty, 
Avhich  were  approved  of  by  the  Senatus  Academicus,  and  consented  to 
by  the  Managers  of  the  Royal  Infirmary.  These  changes  we  now  hope 
will  be  authorised  by  the  University  Court,  so  that  clinical  instruction 
may  be  improved  and  extended  in  proportion  to  the  advanced  develop- 
ment of  the  study. 

The  Social  State  of  the  Medical  Profession. 

The  evils,  resulting  from  the  political  condition  of  the  medical  pro- 
fession, have  led  to  still  greater  ones  in  its  social  state.  In  consequence 
of  the  complete  absence  of  public  positions,  with  emoluments  sufficient 
to  satisfy  the  reasonable  desire  and  ambition  of  scientific  men — as  the 
most  skilful  physician,  or  most  successful  discoverer,  does  not,  in  conse- 
quence, receive  any  dignity  or  honour  from  the  state — and  as  the  offices 
of  our  medical  corporations,  as  they  are  at  present  managed,  are  utterly 
incapable  of  supplying  the  deficiency — it  follows  that  the  only  prize 
open  to  the  aspiring  and  ambitious  is  the  wealth  to  be  derived  from  an 
enormous  practice. 

If,  indeed,  there  were  any  necessary  relation  between  the  popularity 
of  a  physician  and  his  real  professional  merit,  we  might  recognise  this 
as,  so  far,  a  reward  and  encouragement.  But  it  is  notorious  that  this  is 
not  the  case,  and  that  in  many  instances  large  practices  are  acquired  by 


PRESENT  STATE   OF  PRACTICAL   MEDICINE.  13 

the  most  unblushing  charlatanism.  St.  John  Long  was  supposed  to 
have  received  about  twelve  thousand  pounds  a-year  for  pretending  to 
cure  consumption  by  rubbing  an  escharotic  liniment  into  the  chest; 
and  when  at  length  he  was  tried  for  the  manslaughter  of  Miss  Cashin, 
evidence  in  his  favour  was  given  by  half  the  aristocracy  of  the  metro- 
polis. In  all  ages,  indeed,  the  successful  pretender  has  succeeded  in 
collecting  more  gold  than  could  be  accomplished  by  honourable  mem- 
bers of  the  profession ;  formerly,  however,  the  imposture  was  manifest, 
and  carried  its  own  shame  with  it.  But  the  bane  of  the  profession  at 
this  moment  is  the  existence  of  a  class  of  medical  practitioners,  who,  in 
arduous  competition  with  their  fellows,  and  pressed,  perhaps,  by  the 
necessity,  if  not  the  desire  of  making  money,  have  come  to  the  con- 
clusion, that  what  they  really  know  and  can  pei-form  professionally  is  of 
much  less  consequence  than  what  the  public  gives  them  credit  for.  The 
ultimate  influence  of  this  state  of  things,  on  their  own  morals,  and  on 
the  welfare  of  the  profession,  must  be  obvious. 

But  let  us  suppose  that  a  really  able  man,  after  years  of  toil  and 
anxiety,  at  length  reaches  the  full  career  of  a  metropolitan  practice.  Is 
this,  after  all,  a  suitable  reward  for  his  labours  ?  Is  this  position  really 
a  desirable  one,  with  regard  to  its  results  either  on  his  own  mind  or  on 
the  honour  and  higher  interests  of  his  profession  ?  On  this  head  I  pre- 
fer reading  the  statement  of  another.  "  Many  years'  attention  to  all 
subjects  atfecting  the  profession  of  physic," 'says  an  anonymous  writer, 
"  has  led  us  to  the  conclusion  that  large  practices,  the  only  prizes 
which  the  profession  offers  at  present  to  its  members,  are  in  many  ways 
its  bane.  By  them  the  high  scientific  tone  of  the  profession  is  de- 
pressed ;  its  independence  sunk ;  a  low  standard  of  effort  is  fostered  ; 
the  individual  who  succeeds  is  rendered  worthless  ;  the  public  cheated  ; 
false  practice  authorised  ;  quackery  promoted ;  and  sterling  merit  often 
deprived  of  its  just  reward."  * 

Occasionally,  also,  this  excessive  practice  leads  to  such  a  love  of 
money,  or  desire  to  be  thought  important,  distinguished,  or  influential, 
that  in  order  to  obtain  it,  the  proper  etiquette  of  the  profession  is 
abandoned,  and  every  feeling  of  gentlemanly  propriety  and  honour  is 
first  blunted,  then  destroyed.  The  great  position  a  person  of  this  kind 
fancies  he  has  attained  leads  him  to  overlook  the  interests  and  just 
claims  of  his  fellow-practitioners,  and  to  tempt  away  their  patients, 
Avho,  after  all,  among  the  croAvd  of  those  he  attends,  are  often  sadly 
neglected. 

By  watching  the  progress,  and  mingling  in  the  society  of  men  of  this 
class,  the  professional  mind  is  in  danger  of  being  rendered  unsound,  and 
actuated  more  by  a  desire  of  attaining  what  is  conventionally  received 
as  "  success  in  life,"  which  simply  means  the  obtaining  of  a  large  income, 
than  by  the  higher  incentive  of  public  usefulness. 

Tlie  Present  State  of  Practical  Medicine. 

If  the  political  state  of  the  medical  profession  leads  to  the  deteriora- 
tion of  the  social  one,  so  does  the  latter  lead  to  the  greatest  confusion  in, 

*  Azygos  on  Medical  Reform,  London,  1853.  The  author  of  this  pamphlet  will 
see  that  I  have  adopted  some  of  his  arguments  and  a  little  of  his  phraseology. 


14  INTRODUCTION. 

and  distrust  ot^  the  power  of  cure.  "What,  indeed,  is  to  be  expected  of 
men  whose  highest  aim  and  boast  are  to  have  a  large  practice?  Are 
the  statements  of  their  wonderful  cures,  of  their  practical  knowledge, 
and  the  success  of  remedies  in  their  hands,  and  so  on,  to  be  trusted — 
statements  which,  for  the  most  part,  so  far  from  promoting,  tend  only  to 
retard  and  obstruct  the  advancement  of  the  medical  art  ?  On  the 
other  hand,  those  of  this  class  who  act  conscientiously  (and  many  such, 
to  the  honour  of  medicine,  exist)  are  too  busy  in  the  active  duties  of 
their  calling,  and  have  too  little  time  to  follow  the  rapid  progress  of  the 
science.  Hence,  what  they  have  acquired  by  long  experience,  is  seldom 
seen  by  them  to  harmonise  (though  truth  in  practice  always  must  in  the 
end  harmonise)  with  truth  in  theory. 

Although  eighteen  years  have  elapsed  since  the  cell  doctrine  of  growth 
has  been  admitted  into  physiology  and  pathology,  medical  men  have 
not  yet  realised  to  themselves  its  vast  importance  in  a  practical  point  of 
view.  The  morbid  processes  of  inflammation,  of  tuberculization,  and  of 
various  morbid  growths,  are  now  for  the  most  part  elucidated  by  this 
theory.  But  a  cell  pathology  is  no  more  universally  applicable  to  the 
phenomena  of  disease  than  is  humoralism  or  solidism.  Indeed,  we  may 
more  correctly  speak  of  a  molecular  pathology,  for  a  molecule,  and  not 
a  cell,  is  the  first  and  last  form  of  organization.  ^Yhat,  however,  it  is 
important  to  remember  here  is,  that  if  there  be  a  molecular  or  a  cell 
physiology  and  pathology, 'so  is  there  a  molecular  and  a  cell  therapeu- 
tics. For,  it  is  evident,  that  those  diseases  which  depend  on  an  increase 
or  diminution  of  cells,  can  only  be  reached  scientifically  through  a 
knowledge  of  those  laws  which  govern  their  evolution  and  disintegration. 

Thus,  growth  (that  is,  the  multiplication  of  cells)  is  favoured  by 
increased  warmth,  by  room  for  expansion  and  by  moisture  ; — and  it  is 
checked  by  cold,  by  pressure,  and  by  dryness.  If,  then,  an  exudation  be 
poured  out  and  coagulated  near  the  surtace,  as  it  can  only  disappear  by 
its  passing  through  the  stages  of  cell  growth,  we  favour  suppuration, 
that  is,  the  growth  of  pus  cells,  by  warm  poultices  or  fomentations,  and 
retard  it  by  cold  and  pressure. 

Pneumonia  consists  of  an  exudation  into  the  vesicles  and  tissues  of 
the  lung,  which  coagulates  and  excludes  the  air.  It  is  very  doubtful 
whether  a  large  bleeding  ft-om  the  arm  can  operate  upon  the  stagnant 
blood  in  the  inflamed  part,  or  the  congested  capillaries  in  its  neighbour- 
hood— that  it  can  directly  afl"ect  the  coagulated  exudation  is  impossible. 
But  by  lowering  the  strength  and  vital  power  of  the  individual,  venesec- 
tion is  directly  opposed  to  the  necessary  vital  changes  which  the  exuda- 
tion must  undergo  in  order  to  be  removed  by  cell  growth  and  dis- 
integration. Hence  it  is,  in  my  opinion,  that  the  mortality  from  pneu- 
monia has  diminished  since  large  bleedings  have  been  abandoned,  and 
not  because,  as  has  been  suggested  by  an  eminent  authority,  inflamma- 
tions, like  fevers,  have  changed  their  types  since  the  days  of  Cullen  and 
Gregory. 

The  absorption  of  a  pleuritic  eifusion  depends  on  the  formation  of 
new  blood-vessels  in  the  coagulated  exudation,  which  is  adherent  to  the 
pleursB.  These  in  their  turn  are  the  results  of  cell  formation.  Such 
formations,  so  far  from  being  encouraged,  can  only  be  retarded  or  pre- 
vented by  large  bleedings  and  antiphlogistics. 


PRESENT  STATE   OF   PRACTICAL   MEDICINE.  15 

Tlie  c:rowtb  of  tumours  may  be  encourasied  or  retarded  by  the  same 
means  which  influence  all  other  kinds  of  cell  development.  But  if  they 
assume  a  parasitic  character,  as  in  cancerous  growths,  that  is,  if  the  cells 
possess  a  power  of  multiplication  in  themselves,  then  the  only  chance  of 
cure  is  in  tlieir  complete  destruction  or  extirpation.  But  the  surgeon 
who  trusts  to  his  naked  sight,  forgets  that  germs  are  infiltrated  among 
the  surrounding  tissues,  and  are  so  minute  that  he  cannot  see  them  ; 
vet  he  emplovs  no  microscope  to  discover  them.  He  cuts  out  a  tumour, 
but  only  cuts  through  the  disease.  Xeed  we  wonder,  therefore,  that 
cancer  should  frequently  return,  or  rather  continue  to  grow,  when  in 
fact  it  had  never  been  removed. 

The  beneficial  changes  which  have  taken  place  in  our  treatment  of 
apoplexv,  syphilis,  small-pox,  phthisis,  Bright's  disease,  favus,  and  many 
other  diseases,  might  in  like  manner  be  shown  either  to  have  originated 
from,  or  to  be  capable  of  being  satisfactorily  explained  by  an  advanced 
knowledge  of  physiology. 

Again,  notwithstanding  the  universality  with  which  the  stethoscope 
and  auscultation  are  now  received  as  necessary  means  of  diagnosis,  how 
few  of  our  medical  men,  comparatively,  are  really  skilful  in  detecting  by 
them  the  morbid  changes  going  on  in  the  lieart  and  lungs.  The  stetho- 
scope, indeed,  was  as  much  sneered  at  when  it  was  first  introduced  as 
the  microscope  is  now.  Physicians  then  existed,  who  taught  that  a 
piece  of  stick  was  not  likely  to  make  us  discern  what  was  going  on  in 
the  lungs,  and  who  cautioned  students  against  losing  their  time  in 
learning  auscultation,  just  as  some  now-  do  in  reference  to  histology. 
But  the  philosophic  practitioner  must  see  the  necessity  of  using  every 
means  in  his  power  for  detecting  disease,  whether  stethoscopical, 
microscopical,  or  chemical. 

I  cannot  too  strongly  advise  you  not  to  be  influenced  by  the  opinion 
of  those  who,  educated  before  these  means  of  research  came  into  general 
use,  speak  of  them  as  worthless,  especially  in  the  investigation  and 
diagnosis  of  disease.  It  is  because  they  are  ignorant  of  their  value,  that 
they  hold  them  out  as  of  little  benefit.  I  need  scarcely  remark,  that 
this  kind  of  reasoning  is  altogether  unsound,  and  is  directly  opposed  to 
the  introduction  of  all  improvement  in  either  science  or  art.  What 
shoulil  we  think  of  a  modern  astronomer  who  sneered  at  telescopes,  and 
boasted  that  it  was  enough  for  him  to  examine  the  heavens  with  his 
naked  eye  ?  or  how  should  we  like  to  trust  ourselves  at  sea  with  the 
navigator  who,  as  in  ancient  times,  steered  by  the  sun  and  stars,  and 
who  abused  sextants  and  other  instruments  by  which  alone  exact  calcu- 
lations can  be  made  of  his  course  ?  Such,  however,  is  precisely  what 
those  medical  men  do  who  underrate  stethoscopes  and  microscopes, 
betraying  an  unacquaintance  with  the  present  state  of  their  own  art. 

At  all  events,  in  this  Clinic,  you  will  find  that  we  seize  eagerly  on 
every  means  that  science  places  in  our  hands,  for  detecting  the  true 
nature  of  disease — that  percussion,  auscultation,  histology,  and  chemis- 
try, are  all  pressed  into  our  ser\4ce — that,  whilst  we  spare  no  pains  to 
make  ourselves  masters  of  observation,  cultivate  our  senses  to  the  utmost, 
study  spnptoms,  and  thus  endeavour  to  unite  the  knowledge  of  the  pre- 
sent day  with  the  experience  of  the  past — we  never  forget  that  the 
Medical  Art   is  founded  on   science,  the  only  guarantee   of  its   ele- 


16  INTKODUCTIOX. 

vated  and  ennobling  cliaracter,  and  the  only  secure  means  for  its  future 
advancement. 

What,  then,  is  required,  in  the  present  condition  of  medicine,  is  an 
attempt  to  bring  our  advanced  knowledge  of  physiology  and  pathology 
to  bear  upon  tlie  treatment  of  disease,  and  by  renewed  observation,  with 
all  the  aids  which  modern  diagnosis  gives  us,  to  reinvestigate  the  action 
of  our  more  important  remedies.  In  so  doing  we  should  not  neglect 
past  experience,  but  endeavour  to  make  the  truths  it  has  taught  us  har- 
monise with  scientific  laws. 

So  far  from  believing  in  the  propriety  of  a  pure  expectant  system,  or 
a  "  Xihilismus,"  I  am  con\'inccd  that  experience  has  furnished  us  -with 
some  most  precious  results.  No  one  can  doubt,  for  instance,  that  qui- 
nine cures  ague,  and  that  lemon-juice  cures  scurvy.  Why  they  do  so 
we  are  ignorant,  and  hence  those  remedies  are  given  empirically — that 
is,  as  a  result  of  blind  experience.  It  has  also  been  distinctly  shown 
that  sulphur  ointment  cures  scabies.  But  here,  I  think,  false  reasoning 
has  stepped  in,  and  declared  sulphur  to  be  as  much  a  specific  for  sca- 
bies as  quinine  is  for  ague.  But  scabies  depends  upon  the  presence  of 
insects  which  lay  their  eggs  in  the  skin  ;  and  the  greasy  matter  of 
the  ointment  is  brought,  by  means  of  friction,  into  contact  with,  and 
asphyxiates  them,  just  as  well  without  as  with  sulphur.  But  to  dis- 
cover these  insects,  and  to  determine  their  habits,  patient  and  long  con- 
tinued scientific  research  was  necessary,  and  practice  now  reaps  the  bene- 
fit of  it. 

It  is  true  that  the  contradictory  opinions  concerning  medical  doctrine 
and  practice  have,  in  all  times,  excited  the  ridicule  of  the  weak-minded, 
and  still  constitute  the  ground  on  which  Medicine  is  attacked  by  the 
ignorant  and  superficial.  Yet  the  differences  which  exist,  no  more 
prove  that  there  is  no  foundation  for  Medicine  as  a  science,  than  the 
varieties  of  religious  sects  show  that  there  is  no  truth  in  religion,  or  than 
the  opposing  decisions  of  our  courts  of  law  prove  jurisprudence  to  be  a 
farce.  All  these  contradictions  depend  upon  imperfect  attempts  at  cor- 
rect theory ;  and,  this  latter  once  rendered  perfect,  it  will  be  seen  that 
both  health  and  disease  are  governed  by  laws  as  determinate  as  the 
motion  of  the  planets  and  the  currents  of  the  ocean. 

But  notwithstanding  the  discouragements  which  knowledge  has 
received  and  will  ever  sufler  from  the  indolent  or  narrow-minded,  at  no 
period  has  the  tendency  to  cultivate  scientific  medicine  been  more 
strongly  manifested  than  it  is  at  this  moment.  Everywhere  in  Europe 
do  we  observe  a  noble  etfort  to  enlarge  the  foundations  on  which  its 
practice  is  based.  Everywhere  we  see  Natural  Philosophy  advancing 
— enthusiastic  chemists  pushing  forward  organic  analyses — anatomists 
unwearied  in  their  researches  concerning  development  and  the  structure 
of  tissues — Physiologists  experimenting  and  concentrating  all  the 
resources  of  modern  science  in  order  to  elucidate  organic  laws — and 
pathologists  busy  in  connecting  the  symptoms  observed  in  the  living, 
with  alterations  in  the  minutest  tissues  and  atoms  of  the  dead.  At  this 
time  Medicine  is  undergoing  a  great  revolution,  and  to  you,  gentlemen, 
to  the  rising  generation,  do  we  look,  as  to  the  agents  who  will  accom- 
plish it.  Amidst  the  wreck  of  ancient  systems,  and  the  approaching 
downfall  of  empirical  practice,  you  will,  I  trust,  adhere  to  that  plan  of 


PRESENT  STATE   OF  PRACTICAL  MEDICINE.  17 

medical  education  which  is  based  on  Anatomy  and  Physiology.  If  you 
resolve  to  follow  in  the  legitimate  path  of  improvement  to  which  all 
reason  and  experience  invite  you,  be  assured  that  the  toil  of  mastering 
what  is  now  known  of  correct  generalization,  will  not  be  in  vain.  Every- 
thing promises,  that  before  long,  a  law  of  true  harmony  will  be  formed 
out  of  the  discordant  materials  which  surround  us ;  and  if  we,  your 
predecessors,  have  failed,  to  yoii,  I  trust,  Avill  belong  the  honour  of 
building  up  a  system  of  Medicine  which,  from  its  consistency,  simplicity, 
and  truth,  may,  at  the  same  time,  attract  the  confidence  of  the  public, 
and  command  the  respect  of  the  scientific  world. 


SECTION  I. 


EXAMINATION  OF  THE  PATIENT. 

It  is  absolutely  necessary  that  an  examination  of  patients  at  the  bed- 
side should  be  conducted  with  order,  and  according  to  a  well  understood 
plan,  I  have  observed  that  some  students,  on  being  called  upon,  in  their 
turn,  to  interrogate  a  case,  feel  great  embarrassment,  and  are  unable  to 
proceed.  Others  put  their  questions,  as  it  were,  at  random,  without  any 
apparent  object,  and  wander  from  one  system  of  the  economy  to  another, 
vainly  searching  for  a  precise  diagnosis,  and  a  rational  indication  of  cure. 
But  continual  practice,  and  the  adoption  of  a  certain  method,  will  re- 
move all  difficulty.  No  doubt,  questioning  a  patient,  to  arrive  at  a 
knowledge  of  his  condition,  requires  as  much  still  in  the  medical  practi- 
tioner, as  examining  a  witness  does  in  counsel  at  the  bar.  They  make 
it  an  especial  study,  and  you  must  do  so  likewise.  You  should  remem- 
ber that,  in  proportion  as  this  duty  is  performed  well  or  ill,  is  the  proba- 
bility of  your  opinion  of  the  case  being  correct  or  incorrect;  and,  not 
only  will  the  reputation  you  hold  among  your  colleagues  greatly 
depend  on  your  ability  in  this  matter,  but  the  public  also  will  promptly 
give  its  confidence  to  him,  whose  interrogations  reveal  sagacity  and 
talent. 

The  method  of  examination  differs  greatly  among  practitioners,  and 
must  necessarily  vary  in  particular  cases.  Men  of  experience  gradually 
form  a  certain  plan  of  their  own,  which  enables  them  to  arrive  at  their 
object  more  rapidly  and  securely  than  that  adopted  with,  perhaps,  an 
equally  good  result,  by  others.  In  a  clinical  class,  however,  and  in  order 
that  every  one  present  may  follow  and  understand  what  is  going  forward, 
the  method  adopted  must  be  uniform.  1  hold  it  to  be  a  matter  of  great 
importance,  that  every  one  standing  round  the  bed  should  take  an  equal 
interest  in  what  is  proceeding,  and  this  he  cannot  do  unless  he  is  fully 
aware  of  the  manner  and  object  of  the  examination.  The  plan  which 
appears  to  me  the  best,  and  which  we  shall  follow,  is  the  one  I  learnt 
when  myself  a  clinical  student  in  the  wards  of  Pi'ofessor  Rostan  of 
Paris.  Its  object  is  to  arrive,  as  quickly  as  possible,  at  a  knowledge  of 
the   existing    condition  of  the   patient,  in  a  way  that  will  insure  the 


EXAMINATION   OF  THE  PATIENT.  19 

examiner  that  no  important  organ  has  been  overlooked  or  has  escaped 
notice. 

For  this  purpose  we  search  out,  in  the  first  instance,  the  organ  princi- 
pally affected,  and  ascertain  the  duration  of  the  disease,  by  asking  two 
questions,  "  Where  do  you  feel  pain  ?"  and,  "  How  long  have  you  been 
ill  ?"  Let  us  suppose  that  the  patient  feels  pain  in  the  cardiac  region, 
we  immediately  proceed  to  examine  the  heart  functionally  and  physically, 
and  then  the  circulatory  system  generally.  We  next  proceed  to  those 
organs  which  usually  bear  the  nearest  relation  to  the  one  principally 
affected — say,  the  respiratory  organs — and  Ave  then  examine  the  lungs 
functionally  "and  physically."  W^e  subsequently  interrogate  the  nervous, 
digestive,  genito-urinary,  and  integumentary  systems.  It  is  a  matter  of 
little  importance  in  what  order  these  are  examined — the  chief  point  is, 
not  to  neglect  any  of  them.  Lastly,  we  inquire  into  the  past  history  of 
the  case,  and  thus' we  arrive  at  all  the  information  necessary  for  the  form- 
ation of  a  diagnosis. 

The  following  is  the  arrangement  of  symptoms  and  circumstances 
demanding  attention  under  each  of  the  seven  heads  into  which  the  exami- 
nation is  divided : — 

I.  Circulatory  System. — Heart — Uneasiness  or  pain  ;  its  action  and 
rhythm  ;  situation  where  the  apex  beats ;  extent  of  dulness  determined 
by  percussion ;  its  impulse  ;  sounds — if  abnormal,  their  character,  and 
the  position  and  direction  in  which  they  are  heard  loudest.  Arterial 
pulse — Number  of  beats  in  a  minute  ;  large  or  small,  strong  or  feeble, 
hard  or  soft,  equal  or  unequal,  regular  or  irregular,  intermittent,  confused, 
imperceptible,  etc.  If  an  aneurismal  swelling  exist,  its  situation,  pulsa- 
tions, symptoms,  extent,  and  sounds,  must  be  carefully  examined.  Ve- 
nous pulse — If  perceptible,  observe  position,  force,  etc. 

II.  Respiratory  System. — J^ares — Discharges;  sneezing.  Larynx 
and  Trachea — Voice,  natural  or  altered  in  quality,  hoarseness,  difficulty 
of  speech,  aphonia,  etc.;  if  affected,  observe  condition  of  epiglottis, 
tonsils,  and  pharynx,  by  means  of  a  spatula.  Lungs — State  of  respira- 
tion ;  easy  or  difficult,  quick  or  slow,  equal  or  unequal,  laboured,  painful, 
dyspnoea,  etc.;  odour  of  breath.  Expectoration,  trilling  or  profuse,  easy 
or  difficult ;  its  character,  thin  or  inspissated,  frothy,  mucous,  purulent 
or  muco-purulent,  rusty,  bloody ;  microscopical  examination.  Hemopty- 
sis ;  colour,  appearance,  and  amount  of  blood  discharged.  Cough,  rare 
or  frequent,  short  or  long,  painful  or  not,  moist  or  dry.  External  form  of 
the  chest,  unusually  rounded  or  flattened,  symmetrical  or  not,  etc.  Move- 
ments— regular,  equal,  their  amount,  etc.  Resonance,  as  determined 
by  percussion,  increased  or  diminished,  dulness,  cracked-pot  sound,  etc. 
Sounds  determined  by  auscultation;  if  abnormal,  their  character  and 
position. 

III.  Nervous  System. — Brain — Intelligence — augmented,  perverted, 
or  diminished  ;  cephalalgia  ;  hallucinations  ;  delirium,  stupidity,  mono- 
mania, idiocy ;  sleep,  dreams,  vertigo,  stupor,  coma.  Sp>inal  cord  and 
nerves — Pain  in  back ;  general  sensibility,  increased,  diminished,  or 
absent;    special   sensibility — sight,    hearing,  smell,  taste,   touch,  their 


20  EXAMINATION   OF  THE   PATIENT. 

increase,  perversion,  or  diminution  ;  spinal  irritation,  as  determined  by 
percussion  ;  motion,  natural  or  perverted,  fatigue,  pain  on  movement ; 
trembling,  convulsions,  contractions,  rigidity,  paralysis. 

IV.  Digestive  System. — Mouth — Lips,  teeth,  and  gums;  taste  in 
tbe  mouth.  Tongue — Mode  of  protrusion,  colour,  furred,  coated,  fis- 
sured, condition  of  papillae,  moist  or  dry.  Fauces,  tonsils,  jyharynx 
and  oesophagus — Deglutition — if  impeded,  examine  the  pharynx  with  a 
spatula,  the  cervical  glands,  neck,  etc.;  regurgitation.  Stomach — 
Appetite,  thirst,  epigastric  uneasiness  or  pain,  swelling,  nausea,  vomit- 
ing, character  of  matters  vomited,  flatulence,  eructations.  Abdomen — 
Its  measurement  and  palpation  ;  pain,  distension  or  collapse,  borborygmi, 
tumours,  constipation,  diarrhciea,  character  of  dejections,  hemorrhoids. 
Liver — Size,  as  determined  by  percussion,  pain,  jaundice,  results  of  pal- 
pation, etc.  Spleen — Size,  as  determined  by  percussion.  If  enlarged, 
examine  blood  microscopically. 

V.  Genito-Urinary  System. —  Uterus — Condition  of  menstrual  dis- 
charge, amenorrhoea,  dysmenorrhoea,  menorrhagia,  leucorrhcea,  etc.  If 
pain,  or  much  leucorrhoeal  discharge,  examine  os  uteri  and  vagina  with 
speculum ;  uterine  or  ovarian  tumours ;  pain  in  back ;  difficulty  in 
walking,  or  in  defoecation ;  functions  of  mammae.  Kidney — Lumbar 
pain ;  micturition ;  quantity  and  quality  of  urine,  colour,  specific  gra- 
vity ;  precipitates,  as  determined  by  the  microscope,  and  by  chemical 
tests ;  action  of  heat,  nitric  acid,  etc. ;  action  on  test  papers  ;  strictures ; 
discharges  from  urethra;  spermatorrhoea,  etc. 

"VI.  Integumentary  System. — General  posture;  external  surface; 
expression  of  countenance ;  obesity ;  emaciation  ;  colour ;  rough  or 
smooth ;  dry  or  moist ;  perspiration ;  marks  or  cicatrices ;  eruptions 
(see  diagnosis  of  skin  diseases)  ;  temperature  ;  morbid  growths  or  swell- 
ing ;  anasarca ;  oedema  ;  emphysema ;  etc, 

VII.  Antecedent  History. — Age;  parentage;  constitution;  here- 
ditary disposition  ;  trade  or  profession ;  place  of  residence ;  mode  of 
living  as  regards  food  and  drink ;  habits ;  epidemics  and  endemics ; 
contagion  and  infection ;  exposure  to  heat,  cold,  or  moisture  ;  irregu- 
larities in  diet ;  excesses  of  any  kind  :  fatigue ;  commencement  and 
progress  of  the  disease;  date  of  rigor  or  seizure;  mode  of  invasion; 
previous  treatment :  in  female  cases  whether  married  or  single — have 
had  children  and  miscarriages,  previous  diseases,  etc. 

Such  are  the  principal  points  to  which  your  attention  should  be 
directed  during  the  examination  of  a  case.  A  little  practice  will  soon 
impress  them  on  your  memory,  and  in  this  manner  habit  will  insure 
that  no  very  important  circumstance  shall  be  overlooked.  At  first, 
indeed,  it  inay  appear  to  you  that  such  a  minute  examination  is  unne- 
cessary;  but  we  shall  have  abundant  opportunities  of  proving,  that, 
whilst  a  little  extra  trouble  never  does  harm,  ignorance  of  a  fact  fre- 
quently leads  to  error.  It  is  surprising,  also,  how  rapidly  one  thoroughly 
conversant  with  the  plan,  is  able  to  examine  a  patient  so  as  to  satisfy 


EXAMINATION   OF  THE   PATIENT.  21 

himself  that  all  the  organs  and  functions  have  been  carefully  interro- 
gated. Remember  that  the  importance  of  particular  symptoms  is  not 
known  to  the  patient,  and  that,  consequently,  it  is  not  in  his  power 
voluntarily  to  inform  you  of  the  necessary  particulars.  It  is  always 
your  duty  to  discover  them. 

In  carrying  out  the  examination,  the  following  hints  may  be  attended 

to:— 

1.  It  sliould  never  be  forgotten  that  you  are  examining  a  fellow- 
creature,  who  possesses  the  same  sensitiveness  to  pain,  and  the  same  . 
feelings  as  you  do,  and  that  everything  that  can  increase  the  one  or 
wound  the  other  should  be  most  carefully  avoided.     Prudence,  kindness, 
and  delicacy,  are  especially  enjoined  upon  those  who  treat  the  sick. 

2.  The  questions  should  be  precise,  simple,  and  readily  compre- 
hended. When  an  individual  has  a  limited  intelligence,  or  is  accus- 
tomed to  a  particular  dialect,  you  will  not  arrive  at  your  object  by 
becoming  impatient,  or  talking  in  a  loud  voice,  but  by  putting  your 
interrogations  in  a  clear  manner,  and  in  language  proportioned  to  the 
inteUigence  of  the  individual. 

3.  it  is  often  necessary,  after  asking  the  first  question,  "Where  do 
you  feel  pain?"  to  tell  the  patient  to  put  his  or  her  hand  on  the  part. 
An  Irish  peasant  applies  the  term  "heart"  to  an  indefinite  region, 
extending  over  great  part  of  the  chest  and  abdomen ;  and  a  woman, 
in  speaking  of  pain  in  the  stomach,  often  means  the  lower  part  of  the 
abdomen. 

4.  When  pain  is  referred  to  any  circumscribed  part  of  the  surface, 
the  place  should  always  be  examined  by  palpation,  and,  if  possible, 
seen.  Rostan  relates  very  instructive  cases  where  the  omission  of  one 
or  the  other  of  these  rules  has  led  to  curious  errors  in  diagnosis.^ 

5.  Although  the  question,  "How  long  have  you  been  ill?"  is  suffi- 
ciently plain,  it  is  often  difficult  to  determine  the  period  of  commence- 
ment of  many  diseases.  In  acute  inflammatory  or  febrile  disorders,  we 
generally  count  from  the  first  rigor.  In  chronic  affections,  a  lengthened 
cross-examination  is  frequently  necessary  to  arrive  at  the  truth. 

6.  A  state  of  fever  may  be  said  to  exist  when  we  find  the  pulse 
accelerated,  the  skin  hot,  the  tongue  furred,  unusual  thirst,  and  head- 
ache. These  symptoms  are  commonly  preceded  by  a  period  of  indis- 
position, varying  in  duration,  and  ushered  in  by  a  rigor  or  sensation  of 
cold.  Such  a  febrile  state  may  be  idiopathic,  when  the  case  is  called 
one  of  fever,  or  symptomatic  of  some  local  disease,  when  the  nature  of 
the  case  is  determined  by  the  organ  affected  and  lesion  present. 

1.  In  endeavouring  to  ascertain  the  cause  of  the  disease,  great  tact 
and  skill  in  examination  are  necessary.  We  must  guard  ourselves 
against  the  preconceived  views  of  the  patient  on  the  one  hand,  and  be 
aUve  to  the  possibility  of  imposition  on  the  other.  Sometimes,  with  all 
our  endeavours,  no  appreciable  cause  can  be  discovered,  and  at  others 
we  find  a  variety  of  circumstances,  any  one  of  which  would  be  sufficient 
to  occasion  the  malady. 

8.  In  forming  our  diagnosis — that  is,  in  framing  a  theory  deduced 
from  the  facts  elicited  by  examination — we  should  be  guided  by  all  the 
circumstances  of  the  case,  and  be  very  careful  that  these  are  fully  knowui 
before  we  hazard  an  opinion.     Even  then  it  is  not  always  possible  to 


22  EXAMINATIOX   OF   THE   PATIENT. 

come  to  a  satisfactory  conclusion,  and  in  sucli  cases  the  diagnosis  should 
be  deferred  until  further  observation  has  thrown  new  light  upon  the 
nature  of  the  disease. 

9.  In  recording  a  case,  it  is,  for  the  most  part,  only  necessary  to  put 
down,  under  each  head,  the  symptoms  or  signs  present.  If  any  system 
be  quite  health}-,  it  should  be  said  that  it  is  normal.  In  many  cases, 
however,  it  is  necessary  to  state  what  are  called  negative  symptoms. 
This  demands  great  tact,  and  exhibits  a  high  degree  of  medical  informa- 
tion. For  instance,  an  attack  of  epilepsy  generally  commences  with  a 
cry  or  scream ;  but  sometimes  there  is  none — in  which  case  this  should 
be  stated.  Again,  no  expectoration  is  a  rare  negative  symptom  in  pneu- 
monia. Symptoms  which  are  usually  present  in  the  disease,  but  are 
absent  in  the  particular  case,  constitute  negative  symptoms. 

10.  All  mention  of  size  should  be,  according  to  its  exact  measure- 
ment, in  feet  and  inches.  Situation  is  often  referrred  to  certain  regions, 
into  which  the  surface  has  been  arbitrarily  divided,  such  as  subscapular, 
cardiac,  epigastric,  etc.,  but  it  is  always  better  to  refer  at  once  to  ana- 
tomical parts,  such  as  the  clavicle,  particular  rib,  nipple,  umbilicus,  angle 
of  scapula,  and  so  on.  Extent  should  also  be  determined  by  proximity 
to  well-known  fixed  points.  All  vague  statements,  such  as  large,  great, 
small,  little,  etc.,  should  be  carefully  avoided ;  and  in  recording  cases, 
dates  and  references  should  always  be  given  in  the  day  of  the  month  or 
of  the  disease,  and  not  in  the  day  of  the  week. 

11.  In  conversing  on,  or  discussing,  the  circumstances  of  the  case  at 
the  bed-side,  we  should  always  use  technical  language.  Thus  instead  of 
saying,  a  man  has  a  cavern  at  the  top  of  the  lung,  we  should  speak  of  a 
vomica  under  the  clavicle  ;  instead  of  saying,  a  man  has  diseased  heart, 
we  should  speak  of  cardiac  hypertrophy,  or  of  insufficiency  of  the  mitral 
or  aortic  valves,  etc. 

Having  formed  a  diagnosis,  and  prescribed  for  the  patient,  the  further 
examination  should  be  conducted  at  intervals,  varying,  as  regards  time, 
according  to  the  gravity  of  the  case.  In  addition  to  the  changes  which 
may  occur  in  the  signs  and  symptoms  previously  noticed,  the  effects  of 
remedies  should  be  carefully  inquired  into,  and  care  taken  to  ascertain 
whether  the  medicine  and  diet  ordered  have  been  administered.  If  the 
case  prove  fatal,  the  symptoms  ushering  in  death,  and  the  manner  in 
which  it  occurs,  should  be  especially  observed.  "Whenever  a  record  of  the 
case  is  to  be  kept,  I  cannot  too  strongly  impress  upon  you  the  impor- 
tance of  noting  these  down  in  a  book  at  the  time,  rather  than  trusting  to 
the  memory.  For  a  long  series  of  years  the  reports  of  cases,  dictated 
aloud  by  the  professor,  and  written  down  at  the  bed-side  by  the  clerk,  have 
formed  a  leading  feature  of  the  Edinburgh  system  of  clinical  instruction, 
and  such  is  the  only  trustworthy  method  of  recording  cases  with  accuracy. 

When  a  patient  dies,  the  examination  is  not  completed.  The  time 
has  now  arrived  when  an  inspection  of  the  dead  body  confirms  or  nulli- 
fies the  diagnosis  of  the  observer.  You  should  consider  this  as  a  most 
important  part  of  the  clinical  course.  It  is  invariably  regarded  with  the 
greatest  interest  by  those  who  practise  their  profession  with  skill.  It  is 
only  in  this  manner,  that  any  errors  they  may  have  committed  can  be 
corrected  ;    that  the  value  of  physical  diagnosis  can  be  demonstiated 


EXAMINATION  OF  THE   PATIENT.  23 

and  properly  appreciated,  and  the  true  nature  or  pathology  of  diseases, 
and  the  mode  of  treating  them  rationally,  can  ever  be  discovered. 

But  here,  again,  method  and  order  are  as  necessary  in  the  examina- 
tion of  the  dead  as  of  the  living,  and  it  is  of  equal  importance  that  no 
viscus  be  overlooked.  The  three  great  cavities  should  always  be  inves- 
tigated. Nothing  is  more  injurious  to  the  scientific  progress  of  medicine 
than  the  habit  of  inspecting  only  one  of  them,  to  satisfy  the  curiosity  of 
the  practitioner,  or  to  determine  his  doubts  on  this  or  that  point.  Many 
medical  men  direct  their  attention  to  a  certain  class  of  diseases,  and  are 
apt  to  attribute  too  much  importance  to  a  particular  lesion.  It  fre- 
quently happened  to  me,  -when  pathologist  to  this  institution,  after  the 
physician  had  examined  this  or  that  organ,  to  which  he  attributed  the 
death  of  his  patient,  and  had  left  the  theatre,  that  further  examination, 
according  to  the  routine  I  always  practised,  revealed  important  lesions 
that  were  never  suspected.  Thus,  a  person  supposed  to  have  died  of 
Bright's  disease  of  the  kidney,  may  have  had  a  pneumonia  latent  and 
overlooked.  Large  caverns  and  tubercular  deposits  in  the  lungs  may 
satisfy  the  physician,  and  he  may  leave  the  body,  when  intense  peritoni- 
tis may  be  subsequently  found,  arising  from  intestinal  perforation.  A 
man  has  hypertrophy,  with  valvular  disease  of  the  heart ;  he  dies  sud- 
denly, and  everything  is  referred  to  the  cai'diac  lesion.  On  opening  the 
head,  an  apoplectic  extravasation  or  yellow  softening  may  be  discovered. 
I  cannot  too  strongly,  therefore,  impress  upon  you  the  necessity  of 
always  making  a  thorough  jmst-mortem  examination,  and  for  this  pur- 
pose you  should,  if  possible,  obtain  permission  to  inspect  the  whole 
body,  and  not  any  particular  cavity. 

The  object  of  a  post-mortem  examination  is  threefold, — 1st,  To  ascer- 
tain the  cause  of  death  ;  2d,  To  obtain  a  just  appreciation  of  the  signs 
and  symptoms  ;  3d,  To  learn  the  nature  of  the  disease.  These  inquiries 
are  very  distinct,  but  practitioners  generally  have  only  in  view  the  two 
first.  It  frequently  happens  that,  on  the  discovery  of  a  lesion  that 
seems  to  explain  the  fatal  termination,  they  feel  satistied,  and  there  is  an 
end  to  the  investigation.  In  medico-legal  cases,  this  is  the  only  object. 
But  even  here  it  is  necessary  to  examine  all  the  organs,  to  avoid  a  pos- 
sibility of  error,  for  how  can  any  conscientious  man  form  an  opinion, 
that  an  abdominal  disease  has  been  fatal,  if  he  be  not  satistied  by 
inspection  that  the  chest  and  brain  are  healthy  ?  Again,  it  often  occurs 
during  life  that  a  particular  sign  or  symptom  is  unusual  or  mysterious, 
and  that  this,  if  explained  by  the  examination,  too  often  satisfies  the 
practitioner.  But  it  must  be  obvious  that  this  throws  no  light  upon  the 
nature  of  the  disease  or  its  mode  of  cure.  To  do  this,  morbid  changes 
must  be  sought  for,  not  in  that  advanced  stage  where  they  cause  death, 
or  occasion  prominent  symptoms,  but  at  the  ver\'  earliest  period  that 
can  be  detected.  Hence  we  must  call  in  the  microscope  to  our  assist- 
ance, and  with  its  aid  follow  the  lesion  into  the  ultimate  tissue  of 
organs ;  we  must  observe  the  circumstances  which  produced  it,  as  well 
as  the  symptoms  and  physical  signs  to  which  it  gave  rise,  the  secondary 
disorders,  and  the  order  of  their  sequence  ;  their  duration  and  mode  of 
termination.  This  is  the  kind  of  extended  investigation  which  can  alone 
be  serviceable  to  the  advancement  of  medicine,  and  such,  I  trust,  will 
be  the  object  all  of  you  will  have  in  view  in  examining  dead  bodies. 


24  EXAMESTATION   OF  THE   PATIENT. 

At  all  events,  sucli  are  the  views  that  I  shall  constantly  endeavour  to 
place  before  you  during  this  course  of  clinical  instruction. 

The  following  is  an  arrangement  of  the  organs,  textures,  etc.,  which 
demand  your  attention  : — 

I.  External  Appearances. — Number  of  hours  after  death.  Gene- 
ral aspect  and  condition  of  the  body ;  peculiarities  of  person  ;  marks  on 
the  surface;  sugillation;  amount  of  decomposition.  In  cases  of  sus- 
pected death  by  "violence,  great  minuteness  in  the  external  examination 
is  necessary. 

II.  Head. — Scalp;  calvaria ;  meninges;  sinuses;  choroid  plexus; 
brain,  its  form  and  weight ;  cerebellum,  its  weight ;  cortical  and  medul- 
lary substance  of  brain ;  ventricles,  exact  quantity  of  fluid  in  each, 
which  should  be  removed  with  a  pipette — its  character;  medulla 
oblongata  ;  nerves,  and  arteries  at  the  base  of  the  brain  ;  base  of  cranium  ; 
sinuses. 

HI.  Spinal  Column. — Integuments  over  spine;  vertebrae;  meninges; 
cord ;  nerves. 

IV.  Xeck. — Thyroid  gland;  larynx  and  its  appendages;  trachsea ; 
tongue  ;  tonsils  ;  pharynx  ;  oesophagus. 

V.  Chest. — Thymus  gland  ;  lining  membrane  of  bronchi ;  bronchial 
glands ;  pleurae  ;  contents  of  pleural  cavity  ;  parenchyma  of  lungs  ;  large 
thoracic  veins ;  pericardium,  its  contents ;  general  aspect  and  position 
of  the  heart;  its  weight;  amount  of  blood  in  its  various  cavities;  right 
auricle  ;  coronary  veins ;  auricular  septum  ;  right  ventricle,  size  of  its 
cavity  ;  thickness  and  degree  of  firmness  of  its  walls ;  endocardium ; 
tricuspid  valve ;  pulmonary  artery,  its  calibre ;  pulmonary  veins ;  left 
auricle;  mitral  valve;  left  ventricle;  thickness  and  condition  of  its 
muscular  tissue  ;  size  of  its  cavity ;  sigmoid  valves ;  coronary  arteries ; 
aortic  opening  and  arch  ;  large  arteries  of  the  neck ;  thoracic  aorta,  its 
structure  and  calibre. 

VI.  Abdomen. — Peritoneum  and  peritoneal  cavity ;  omentum ;  posi- 
tion of  abdominal  viscera  ;  stomach  ;  duodenum  ;  small  and  large  intes- 
tines ;  liver,  its  weight,  form,  and  structure — its  artery,  veins,  and  ducts ; 
o-all-bladder  and  its  contents ;  portal  system ;  pancreas  and  its  duct ; 
mesenteric  and  other  absorbent  glands ;  spleen ;  its  weight,  size,  and 
structure  ;  supra-renal  capsules  ;  kidneys,  weight  of  each  ;  secreting  and 
excreting  portions;  pelvis;  ureters;  bladder;  with  the  prostate  and 
urethra  in  the  male ;  in  the  female,  uterus,  ovaries,  Fallopian  tubes, 
vao-ina ;  abdominal  aorta  and  vena  cava ;  large  abdominal  arteries  and 
veins  ;  ganglia  of  the  sympathetic  system. 

VII.  Blood. — Appearance  in  the  cavities  of  the  heart,  in  aorta,  vena 
cava,  vena  portse,  etc. ;  coagulated  and  fluid  portions — adhesion  or  not 
of  the  former. 

VIII. — Microscopic  Examination  of  all  the  morbid  structures  and 
fluids,  the  blood,  etc.  etc. 

In  carrying  out  the  post-mortem  examination,  the  following  hints 
may  be  attended  to  : — 

i.  As  I  have  already  said,  the  head,  chest,  and  abdomen,  should 
always  be  examined,  but  the  spinal  cord  and  neck  need  not  be  disturbed 


EXAMINATION  OF  THE   PATIENT.  25 

unless  the  symptoms  indicate  some  lesion  there.  In  special  cases,  par- 
ticularly judicial  ones,  however,  every  part  should  be  carefully  inspected, 
and  it  may  be  also  necessary  to  investigate  a  variety  of  circumstances 
connected  with  external  and  surgical  lesions,  such  as  fractures,  wounds, 
and  burns;  injury  to  the  large  vessels;  alterations,  of  the  organs  of 
sense,  etc.  etc. 

2.  Great  care  should  be  taken  not  to  disfigure  the  body.  Incisions 
through  the  skin,  therefore,  should  be  made  in  such  directions  that 
when^the  edges  are  afterwards  sewn  together,  the  necessary  dissections 
below  may  not  be  visible.  Neither  should  the  body  be  exposed  more 
than  is  needful,  and  delicacy  demands  that  the  genitals  should  always 
be  kept  covered.  The  wishes  and  feelings  of  friends  and  relations  should 
invariably  be  held  in  consideration. 

3.  Before  removing  the  stomach,  or  any  portion  of  the  intestines,  a 
ligature  should  be  placed  above  and  below  the  tube,  which  should  after- 
wards be  opened  with  the  greatest  care,  and  the  character  of  the  con- 
tents, whether  gaseous,  Huid,  mucous,  bloody,  fcecal,  or  containing 
foreign  substances,  should  be  observed  before  washing  and  inspecting 
the  mucous  surface.  This  rule  should  be  especially  followed  in  all 
medico-legal  investigations,  in  which,  from  neglect  of  it,  the  ends  of  jus- 
tice have  been  frequently  defeated. 

4.  You  should  seize  every  opportunity  of  opening  dead  bodies  with 
your  own  hands,  and  acquiring  dexterity  in  exposing  the  cavities,  taking 
out  the  viscera,  etc.  Nothing  is  more  annoying  than  to  see  the  brain 
cut  into  or  contused,  in  removing  the  calvarium  ;  or  the  large  vessels  at 
the  root  of  the  neck  wounded  in  disarticulating  the  sternum,  whereby 
the  surrounding  parts  are  deluged  with  blood  ;  or  the  cardiac  valves  cut 
through,  instea^l  of  being  simply  exposed ;  or  awkward  incisions  made 
into  the  intestines,  permitting  the  foecesto  escape  ;  slipping  of  ligatures, 
etc.  etc.  Coolness,  method,  knowledge  of  anatomy,  and  skilfulness  in  dis- 
section, are  as  necessary  when  operating  on  the  dead  as  on  the  living 
body. 

5.  In  examinations  made  at  private  houses,  it  is  not  always  neces- 
sary to  remove  the  viscera.  The  heart,  lungs,  liver,  kidneys, etc.,  maybe 
readily  examined  in  situ.  But  in  this  Infirmary,  where  every  facility 
exists,' the  viscera  are  invariably  taken  out,  and  after  describing  the  mor- 
bid alterations  they  present,  I  shall  always  pass  them  round,  so  that 
every  one  present  may  examine  them. 

6.  It  is  a  good  rule  never  to  omit  the  examination  of  a  morbid  tex- 
ture or  product  miscroscopically,  until  experience  has  made  you  perfectly 
familiar  with  its  minute  structure. 

7.  Notes  of  the  examination  should  always  be  made  at  the  time. 
If  organs  are  healthy,  this  should  be  distinctly  stated,  so  that  hereafter 
all  doubt  as  to  their  having  been  carefully  examined  may  be  removed. 
Here  negative  appearances  are  often  of  as  much  consequence  as  negative 
symptoms. 

8.  In  describing  morbid  appearances,  we  should  be  careful  to  state 
the  physical  properties  of  an  organ  or  texture,  such  as  the  size,  form, 
weight',  density,  colour,  position,  etc. ;  and  avoid  all  theoretical  language, 
such  as  its  being  inflamed,  tubercular,  or  cancerous,  as  well  as  such  inde- 
finite description  as  small  and  large,  narrow  and  wide,  increased  or  dimi- 


26 


EXAMIISrATION   OF  THE   PATIENT. 


nislied,  etc.  etc.     Size  should  always  be  stated  in  feet  and  inches,  and 
the  amount  of  fluid  in  quarts,  pints,  or  ounces. 

9.  The  amount  of  care  and  time  bestowed  on  the  examination  of  an 
individual  body  will  vary  according  to  circumstances.  In  some  cases  it 
may  require  continued  investigation,  involving  microscopical  and  chemi- 
cal research  for  several  days.  I  have  never  heard  of  a  student  regretting 
the  employment  of  too  much  care  in  post-mortem  investigation,  although 
the  occurrence  of  omissions  from  carelessness  and  unacquaintance  with 
morbid  anatomy,  are  unfortunately  too  often  exhibited  by  medical  men 
in  courts  of  justice,  to  the  detriment  of  our  profession  in  the  eyes  of  the 
public,  and  not  unfrequently  to  the  perversion  or  suppression  of  justice.* 

For  the  correct  examination  of  the  patient  in  the  manner  described,  it 
will  be  found  necessaiy  to  possess  an  accurate  knowledge  of  the  relative 
position  of  the  various  internal  organs.  This  subject  is  not  placed  so 
carefully  before  the  student  as  it  deserves — a  circumstance  which  may 
probably  be  attributed  to  the  fact,  that  anatomy  is  for  the  most  part 
taught  by  surgeons.  But  now  that  physical  diagnosis  constitutes  so 
necessary  a  part  of  medical  education,  topographical,  as  distinguished 
from  surgical  anatomy,  is  every  day  felt  to  be  more  necessary.     I  would 


Fig.  1. 


*  For  an  excellent  guide  to  the  examination  of  the  dead  body,  I  would  recoiumend 
the  practitioner  and  student  to  a  work  entitled,  "  "What  to  observe,"  published  under 
the  authority  of  the  London  Medical  Society  of  Observation. 

Fig.  1.  Superficial  view  of  internal  organs  after  the  removal  of  the  thoracic  and 
abdominal  parietes.     Fig.  2.  Deep  view. — Sihson.) 


EXAMINATION  OF  THE   PATIENT. 


27 


earnestly  therefore  recommend  the  student  of  Clinical  Medicine  to  study 
the  excellent  work  of  Dr.  Sibson  on  Medical  Anatomy,  in  which  this 
subject  is  admirably  treated  and  illustrated.  From  his  work  I  have  bor- 
rowed the  two  accompanving  figures,  which  exhibit  at  a  glance  the  posi- 
tion of  the  internal  organs  in  a  healthy  adult  male  after  death.  They 
also  indicate  the  general  relation  of  the  viscera  to  the  fixed  parts  of  the 
trunk  and  thoracic  walls,  the  study  of  which  is  far  more  useful  than 
learning  the  contents  of  various  artificial  regions  marked  out  by  lines  on 
the  surface  of  the  body. 

In  studying  all  such  relations  of  the  viscera  after  death,  it  should  be 
remembered  that  the  organs  do  not  occupy  exactly  the  same  position  in 
the  living  body.  "  Expiration  is  the  last  act  of  life,  and  this  last  expira- 
tion is  usually  more  extensive  and  forced  than  the  expiration  of  tranquil 
life.  In  the  dead  body,  the  lungs  shrink  up  within  the  position  that 
they  usually  occupy  during  life ;  at  the  same  time  the  heart  and  its  ves- 
sels retract,  and  the  abdominal  organs  follow  the  diaphragm  somewhat 
upwards." —  ( Sibson.) 

The  remaikable  changes  which  occasionally  occur  in  the  natural  posi- 
tion of  the  internal  viscera  may  be  judged  of  from  a  case  which  occurred 
to  Professor  Easton  of  Glasgow,  in  a  pregnant  female,  aged  twenty-seven. 
The  enlargement  of  the  uterus,  co-operating  with  a  gradually  increasing 
tendency  to  accumulation  of  foeces  in  the  lower  end  of  the  colon,  at 


ifl    -c 


Fic  8 


length  produced  enormous  distension  of  the  sigmoid  flexure,  the  ascend- 
ing portion  of  which  measured  thirteen,  and  the  descending  twenty-five 

Fig.  3.  Remarkable  displacement  of  organs,  in  consequence  of  intestinal  obstruc- 
tion, a,  Caput  coli ;  b,  ascending  portion  of  sigmoid  flexure ;  c,  descending  portion  ; 
d,  gravid  uterus  turned  a  little  down. — {Eastmi.) 


28  EXAMINATION   OF  THE   PATIENT 

inches  in  circumfei'ence.  The  spleen  and  diaphragm  were  forced  high  up 
on  the  left  side,  compressing  the  hing,  and  displacing  all  the  neighbour- 
ing organs,  so  that,  on  elevating  the  sternum  and  removing  the  ribs  after 
death,  the  appearances  represented  Fig.  3  were  exhibited.* 

Besides  the  method  of  general  examination  previously  detailed,  it  is 
further  essential  to  employ  various  special  modes  of  investigation.  These 
are  inspection,  palpation,  mensuration,  percussion,  auscultation,  the  use 
of  the  microscope,  and  of  chemical  tests.  To  them  we  are  indebted  for 
that  precision  and  certainty  which  characterise  the  results  of  physical 
science.  Up  to  a  comparatively  recent  period  medical  men  formed  their 
diagnosis  and  prognosis  of  internal  diseases  from  an  observation  of  func- 
tional symptoms.  But  as  these — being  often  only  the  sensations  of  the 
patient — may  vary  from  hour  to  hour  according  to  accidental  circum- 
stances, while  the  pathological  lesions  which  occasion  them  remain  the 
same,  they  are  most  uncertain.  Formerly  it  was  imagined  that  every 
morbid  organic  change  gave  rise  to  a  certain  train  of  symptoms,  and 
that  a  knowledge  of  these  was  all-sufficient  to  determine  the  structural 
malady.  But  this  idea  is  negatived  by  clinical  observation,  which 
teaches  us  that  many  ditferent  lesions  have  the  same  symptoms ;  and 
that,  occasionally,  most  important  and  even  fatal  organic  diseases  have 
no  symptoms  at  all.  (See  Cases  LXXXIIL,  LXXXVIL,  OXX., 
CXXIII.)  Cases  of  fatty  heait,  and  atheromatous  degeneration  of  the 
cerebral  blood-vessels,  often  give  rise  to  no  symptoms  whatever  until 
death  suddenly  supervenes  by  syncope  or  coma.  Hence,  whenever  phy- 
sical exploration  is  applicable,  it  should  be  had  recourse  to,  in  addition 
to  an  investigation  of  the  symptoms.  It  is  in  a  great  measure  owing  to 
our  superior  knowledge  in  this  respect  that  medicine  has  made  such  great 
advancement  during  the  present  century. 


INSPECTION. 

Inspection  of  a  part  or  of  the  w^hole  surface  of  the  body  in  various  posi- 
tions is  often  of  the  utmost  importance.  The  latter  is  necessary  in  the 
examination  of  army  recruits,  but  can  seldom  be  carried  out  rigorously 
in  hospital,  and  still  less  in  private  practice.  Delicacy  forbids  it  in 
females.  The  part  affected,  however,  ought  always  to  be  seen,  a  neglect 
of  which  rule  has  led  to  numerous  errors.  The  various  eruptions  which 
appear  on  the  surface  of  the  body  are  spoken  of  in  another  place.  Here 
I  shall  only  shortly  allude  to  the  inspection  of  the  general  posture, 
of  the  countenance,  of  the  thorax,  and  of  the  abdomen. 

Inspection  of  the  general  jJosture  of  the  patient  in  repose  and  in  mo- 
tion is  often  highly  diagnostic.  Thus  the  position  and  attitude  assumed 
by  the  body  in  cases  of  fever,  in  acute  inflammations,  in  hemiplegia  or 
paraplegia,  in  hydrothorax  and  asthma,  in  colic  or  spasmodic  diseases, 
even  in  various  forms  of  insanity,  are  very  characteristic.  The 
description  of  these,  however,  belongs  to  the  consideration  of  individual 
diseases.  As  a  general  rule,  the  supine  position  denotes  muscular  de- 
bility— quick  and  forcible  changes  of  position  indicate  excitement  of  the 

*  Monthly  Journal  of  Medical  Science,  Dec.  1850,  p.  494. 


BY  INSPECTION.  29 

nervous  system  or  spasm, — whilst  fixed  and  restrained  movements  are 
dependent  on  paralysis  or  inflammatory  pain. 

Inspection  of  the  countenance  is  a  matter  of  such  importance  as  to 
be  instinctively  practised,  with  a  view-  of  determining  the  amount  of 
pain,  disturbance  of  the  feelings,  or  general  mental  and  bodily  con- 
dition of  the  patient.  A  thorough  knowledge  of  the  indications  so 
presented  to  the  physician  is  only  to  be  attained  by  long  experience  in 
the  observation  of  "^disease.  The  cuticular  surface  may  be  so  altered 
as  to  give  a  peculiar  appearance  to  the  complexion,  especially  in 
chronic  diseases  of  the  digestive  system.  The  changes  in  the  blood- 
vessels and  blood  occasion  pallor  or  flushing ;  the  sallow  and  yellow^ 
hue  observed  in  some  disorders ;  the  state  of  tumidity  or  shrinking,  of 
heat  or  coldness,  and  of  dryness  or  moisture.  Alterations  in  the  sub- 
cutaneous and  muscular  tissues  produce  emaciation,  or  oedema,  languor, 
and  various  kinds  of  convulsion  or  paralysis.  The  individual  features 
also  require  to  be  studied,  especially  the  eye  and  mouth.  Pain,  if  in  the 
head,  causes  the  brow  to  corrugate  ;  if  in  the  chest,  the  nostrils  to  be 
drawn  upwards ;  if  in  the  abdomen,  the  lips  to  be  raised  and  stretched 
over  the  gums  and  teeth.  These  changes  are  more  readily  observed  in 
children  m  whom  they  are  not  under  the  control  of  the  will. 

Inspection  of  the  Chest. — This  refers  to  the  form  and  confignration 
of  the  entire  thorax,  or  its  various  parts,  and  to  a  careful  comparison 
of  the  two  sides  wdaen  at  rest  and  when  in  motion.  It  is  often  difiicult, 
in  cases  where  changes  are  not  well  marked,  to  determine  thera  by 
mere  inspection.  To  "do  so,  a  good  light,  and  a  proper  position,  both 
of  the  observer  and  of  the  patient,  are  necessary.  The  observer  should, 
if  possible,  be  directly  in  front  of  the  patient,  and  whenever  the  case 
admits  of  it,  the  latter  should  be  in  the  sitting  posture.  The  chest 
may  be  so  altered  in  disease  as  to  be  irregular  or  unsymmetrical,  from 
distortions,  congenital  or  acquired,  in  the  bones  of  the  vertebral  column 
or  of  the  thoracic  w^alls.  Various  portions  of  it  may  be  expanded  or 
bulge  out,  as  in  cases  of  empyema  or  thoracic  tumours;  or  it  may  be 
retracted  and  depressed,  as  occurs  in  chronic  phthisis.  A  case  pre- 
sented jtself  to  the  late  Dr.  Spittal  at  the  Royal  Dispensary  of  this 
city,  where  the  retraction  was  so  great  on  one  side,  that  the  student 
in  charge  of  it  had  placed  compresses  on  the  sound  side,  in  the  belief 
that  the  healthy  prominence  there  was  indicative  of  a  tumour.  The 
motions  of  the  chest  bear  reference  to  inspiration  and  expiration,*  which 

*  "  During  inspiration,  the  clavicles,  first  ribs,  and  through  them  the  sternum  and 
all  the  annexed  ribs,  are  raised ;  the  upper  ribs  converge,  the  lower  diverge ;  the 
upper  cartilages  form  a  right  angle  with  the  sternum,  and  the  lower  cartilages  of 
opposite  sides,  from  the  seventh  downwards,  move  further  asunder,  so  as  to  widen 
the  abdominal  space  between  them,  just  below  the  ziphoid  cartilage :  the  effect  being 
to  raise,  widen,  and  deepen  the  whole  chest,  to  shorten  the  neck,  and  apparently  to 
lengthen  the  abdomen.  During  expiration,  the  position  of  the  ribs  and  cartilages  is 
reversed ;  the  sternum  and  ribs  descend ;  the  upper  ribs  diverge,  the  lower  con- 
verge ;  the  upper  cartilages  form  a  more  obtuse  angle  with  the  sternum,  and  the 
lower  cartilages  of  opposite  sides  approximate,  so  as  to  narrow  the  abdominal 
space  between  them,  just  below  the  ziphoid :  the  effect  being  to  lower,  narrow,  and 
flatten  the  whole  chest,  to  lengthen  the  neck,  and  apparently-  to  shorten  the  abdo- 
men. It  is  to  be  observed,  that  during  inspiration,  while  the  ribs  and  sternum  are 
moving  upwards,  the  lungs  and  heart,  and  the.  abdominal  organs,  are  moving  down- 
wards, and  that,  consequently,  viewed  in  relation  to  the  ribs,  the  descent  of  the 
internal  organs  appears  to  be  greater  than  it  really  is." — {Sibson.) 


80  EXAMINATION   OF  THE   PATIENT 

pass  imperceptibly  into  one  another,  and  can  be  made  more  rapid  or 
prolonged  voluntarily.  A  forced  inspiration  gives  rise  to  more  thoracic 
movement  in  the  female  than  in  the  male,  in  whom  it  is  more  abdo- 
minal. In  disease  these  motions  are  altered  in  various  ways — 1st,  By 
general  excess  or  diminution,  as  in  cases  of  spasmodic  asthma  or 
laryngeal  obstruction.  2d,  By  partial  immobility,  as  in  pleurisy ;  or 
by  augmented  expansion,  as  in  the  side  not  affected  in  a  pneumonia  or 
pleurisy.  3d,  By  increased  rapidity,  as  in  pericarditis ;  or  unusual 
slowness,  as  in  coma. 

Insjyectioti  of  the  Abdomen. — The  abdomen  in  health  is  slightly 
convex,  and  marked  by  elevations  and  depressions,  corresponding  to 
the  muscles  in  its  walls,  the  umbilicus,  and  prominences  of  the  viscera 
below.  It  varies  according  to  age  and  sex — in  youth  being  smoother 
and  flatter  than  in  the  adult,  and  in  females  being  broader  inferiorly 
than  in  males,  from  the  greater  width  of  the  pelvis.  In  disease  it 
may  be,  1st,  enlarged  generally  and  symmetrically,  as  in  dropsies,  or 
partially .  and  irregularly,  from  ovarian,  hepatic,  splenic,  and  other 
tumours  ;  2d,  it  may  be  retracted — generally  fi'om  extreme  emaciation, 
or  partially,  from  local  intestinal  obstruction.  The  superficial  abdo- 
minal veins  are  sometimes  greatly  enlarged,  and  at  others  distinct 
pulsations  are  visible,  dependent  on  deep-seated  cardiac,  or  arterial 
disease.  The  abdomen,  like  the  chest,  is  in  constant  movement  in 
connection  with  the  act  of  respiration,  being  more  prominent  during 
inspiration,  and  flattened  during  expiration.  These  respiratory  move- 
ments of  the  abdomen  bear  a  certain  relation  to  those  of  the  chest, 
being  often  increased  when  the  latter  are  arrested,  and  vice  versa. 
Thus,  in  pleui'isy,  the  respiratory  movements  are  mostly  abdominal, 
whereas,  in  peritonitis,  they  are  altogether  thoracic.  The  variations 
observable  in  the  disturbed  relations  of  the  respiratory  movements  in  the 
thorax  and  abdomen  are  often  highly  instructive,  especially  in  cases  of 
dyspnoea  from  hydrothorax,  spasmodic  asthma,  anaemia,  ascites,  abdo- 
minal tumours,  etc. 


PALPATIOX. 

Palpation  also  is  a  necessary  mode  of  examination,  and  is  some- 
times practised  by  simply  applying  the  tips  of  the  fingers,  at  others,  by 
placing  the  hand  on  the  part  affected,  and  not  unfrequently  by  employ- 
ing both  hands,  and  pressing  with  them  alternately.  This  latter  method 
is  most  applicable  in  endeavouring  to  judge  of  tumours,  especially  when 
large  or  deep  seated,  and  situated  in  the  abdomen.  The  position  of  the 
patient  during  palpation  must  be  varied  according  to  the  part  examined. 
Tlie  horizontal  posture  is  best  to  judge  of  deep-seated  pulsations  and 
vibrations,  but  sometimes  the  erect  posture,  or  even  leaning  forward, 
becomes  necessary,  as  when  the  heart  is  being  examined.  When  feel- 
ing the  abdominal  organs  through  the  integuments,  these  last  should 
be  relaxed,  by  causing  some  one  to  flex  the  inferior  extremities  on  the 
abdomen,  and  push  tlie  head  and  neck  forwards.  In  this  manner  palpa- 
tion aftbrds  information — 1st,  As  to  the  increased  or  diminished  sensi- 
bility of  various  parts ;    2d,  Of  their  altered  form,  size,  density,  and 


BY  PALPATION.  31 

elasticity ;  and,  3d,  Of  tlie  different  kinds  of  movement  to  which  they 
may  be  subjected. 

1.  When  pain  is  experienced  in  any  part,  it  is  generally  increased  by 
pressure  and  movement,  if  inflammatory,  but  relieved  if  neuralgic.  Not 
unfrequently  pressure  causes  pain  or  tenderness  where  otherwise  neither 
are  experienced.  Thus  deep  pressure  in  the  right  iliac  region  causes 
pain  in  typhoid  fever,  which,  however,  must  be  judged  of  from  the  ex- 
pression of  the  countenance,  rather  than  the  statement  of  the  patient. 
Again,  over  the  vertebral  column  pressure  or  percussion  may  induce 
pain  that  is  otherwise  not  felt.  In  paralytic  cases  the  diminution  of  sen- 
sibility can  only  be  ascertained  by  feeling  or  pinching  the  part,  and  the 
limitation  of  anaesthesia  is  best  arrived  at  by  pricking  the  surface  with 
some  pointed  hard  substance. 

2.  Alterations  in  external  form  and  size  may  be  judged  of  by  inspec- 
tion, but  with  regard  to  internal  organs,  especially  abdominal  ones,  we 
derive  more  exact  information  from  palpation  conjoined  with  percus- 
sion, as  in  cases  of  hypertrophied  liver  and  spleen,  or  when  some  tumour 
exists.  In  such  cases  we  can  feel  from  the  increased  density  and  resist- 
ance the  size  and  outline  of  the  morbid  growths,  which  will  be  more  or 
less  distinct,  in  proportion  as  they  are  near  the  surface,  and  circumscribed 
in  form.  Occasionallv  organs  are  diminished  in  size,  and  cannot  be  felt 
in  their  normal  positions,  as  when  the  inferior  margin  of  the  liver  can- 
not be  detected  in  this  way,  from  atrophy.  The  natural  elasticity  of 
parts  mav  also  be  increased  or  diminished.  Thus  the  abdomen  is  more 
elastic  when  air  is  in  excess  in  the  intestines,  and  less  so  when  the  peri- 
toneum contains  liquid.  The  integuments  also  may  be  more  rigid  and 
indurated,  as  in  chronic  skin  diseases,  or,  on  the  other  hand,  soft  and 
doughy,  as  in  oedema,  when  they  pit  on  pressure,  from  diminished  elas- 
ticity. 

3.  Certain  motions  in  the  thoracic  and  abdominal  ca\-ities,  as  well  as 
in  other  parts  of  the  body,  are  best  judged  of  by  palpation.  It  is  in  this 
way  that  the  character  and  situation  of  pulsation  at  the  heart,  root  of 
the'  neck,  or  elsewhere,  are  determined.  The  expansive  motion  of  the 
thorax  and  abdomen  during  respiration  is  also  thus  ascertained.  If  we 
place  the  two  hands,  with  the  fingers  spread  out  like  a  fan  in  the  axillae 
or  flanks,  and  bring  the  two  thumbs  towards  each  other,  near  the  ster- 
num or  umbilicus,  we  can  judge  by  their  approach  and  separation,  of  the 
amount  of  expansion  or  retraction  that  takes  place.  Application  of  the 
hand  also  allows  us  to  detect  undulatory  motions  below  the  integument, 
and  to  determine  the  existence  of  vibrations,  frictions,  gratings,  and  cre- 
pitations. Rostan  relates  a  case  where  all  the  symptoms  of  acute  inter- 
costal rheumatism  were  present  (which  disease  was  diagnosed),  caused 
by  a  broken  rib,  that  was  overlooked  from  the  diseased  part  not  having 
been  examined  by  palpation.  There  is  a  natural  fremitus  or  thrill  per- 
ceptible on  placing  the  hand  on  the  chest,  when  a  person  is  speaking, 
which  is  increased  in  some  diseases  of  the  chest,  and  lessened  in  others. 
This  sensation  is  also  sometimes  felt  over  the  large  blood-vessels.  It 
resembles  more  or  less  the  %nbration  felt  on  placing  the  hand  on  the 
back  of  a  cat  while  purring.  Fluctuation  is  another  sensation,  caused 
by  pressing  on  or  percussing  parts  in  such  a  way  as  to  cause  displace- 
ment of  their  contained  fluids.     A  modification  of  it  is  known  under 


32 


EXAMINATION"   OF  THE   PATIENT 


the  name  of  succussion,  whicli  is  effected  by  shaking  the  patient- 
ceeding,  however,  which  is  seldom  necessary. 


-apro- 


MEXSURATION. 

Tlie  simplest  way  of  measuring  the  circumference  of  parts,  or  the 
distance  between  any  two  fixed  points,  is  by  means  of  a  graduated  tape. 
In  ascertaining  the  circular  measurement  of  the  chest  or  abdomen,  that 
moment  should  be  chosen  when  the  patient  holds  his  breath  at  the  end 
of  an  ordinary  expiration,  great  care  being  taken  that  the  tape  is  carried 
evenly  round  the  body.  The  relative  mensuration  of  the  two  sides  of 
the  chest  or  abdomen,  is  best  accomplished  by  choosing  the  spinous  pro- 
cesses of  the  vertebrae  as  fixed  points  on  the  one  hand,  and  a  line  drawn 
through  the  centre  of  the  sternum  and  umbilicus  on  the  other.  The 
exact  levels  of  the  measurements  should  always  be  noted,  such  as  at  the 
nipples,  margin  of  the  lower  ribs  or  umbilicus,  which  are  those  most 
deserving  of  observation.  The  diameter  of  the  trunk  in  various  direc- 
tions is  best  ascertained  by  means  of  a  pair  of  callipers. 

The  amount  of  motion  in  the  chest  and  abdomen,  and  of  its  various 
parts,  is  capable  of  being  accurately  determined  by  means  of  the  chest- 
measurer  of  Dr.  Sibson  ^Fig.  6),  or  the  stethometer  of  Dr.  Quain  (Fig. 
4).     Both  instruments  are  composed  of  a  brass  box,  having  a  dial  and 


Fl?.4 


Fis.  6. 


an  index,  which  is  moved  by  a  rack  attached  to  a  prolonged  pinion  or  a 
string.  One  revolution  of  the  index  indicates  an  inch  of  motion  in  the 
chest ;  the  intervening  space  being  graduated.  It  has  been  found  neces- 
sary, when  making  observations  on  the  respiratory  movements,  whether 
of  the  chest  or  the  abdomen,  to  divert  the  patient's  attention,  and  make 
him  look  straight  forwards,  otherwise  these  movements  become  so 
affected  as  to  vitiate  the  results.  The  instruments  may  be  applied  in  the 
sitting  or  recumbent  posture.  The  method  of  applying  them  with  a 
string  attached  is  shewn  (Fig.  o),  and  the  mode  of  using  Dr.  Sibson's 


Fig.  4.  The  stethometer  of  Dr.  Quain,  half  the  real  size. 

Fig.  5.  Mode  of  applying  the  instrument  when  the  string  is  used. — {R.  Quain.) 


BY   MENSURATION. 


83 


chest-measurer  by  placing  the  pinion  on  the  nail  of  the  observer's  finger, 
mo'v-ing  with  the  chest,  is  seen  (Fig.  V),  If  held  in  the  hand,  as  in  Fio-s, 
5  anil  7,  great  steadiness  and  care  are  requisite  to  arrive  at  exact  results. 
Dr.  Sibson's  instrument  may  be  attached  to  brass  rods,  -which  are  bent 
at  right  angles,  so  as  to  present  the  form  of  3.  The  upper  arm  is  move- 
able, and  admits  of  elongation  by  means  of  a  split  tube,  so  tbat  iu  this 
way  great  steadiness  is  arrived  at,  while  the  instrument  itself  can  be  car- 
ried to  any  part  of  the  chest  or  abdomen,  without  disturbing  the  position 
of  the  patient,  as  seen  in  Fig.  8. 


There  is,  however,  considerable  variation  even  in  health  in  difi"erent 
persons.  Some,  for  instance,  can  cause  the  second  rib  to  advance  two 
and  a  quarter  inches  during  forced  inspiration,  whilst  others  can  only 
cause  it  to  advance  three  quarters  of  an  inch.  The  motion  of  the  whole 
left  side,  excepting  that  of  the  second  rib,  is  somewhat  less  than  on  the 
right  side.     It  should  also  be  remembered  that  the  motion  of  the  tenth 


Fig.  6.  The  chest-measurer  of  Dr.  Sibson,  natural  size. 
Fig.  7.  Mode  of  applying  the  chest-measurer. — {Sibson.) 

3 


84 


EXAMINATION  OF  THE   PATIENT 


ribs  indicates  that  of  the  diaphragm.     Tlie  pressure  of  the  stars  in  the 
female  exaggerates  the  thoracic  and  diminishes  the  abdominal  movements. 


Fi2.  S. 


According  to  the  observations  of  Dr.  Sibson,  made  with  this  instru- 
ment, the  respiratory  movements  in  health  may  be  thus  represented  in 
lOOth's  of  an  inch. 


Instrument  applied  to 


Side. 


Centre  of  sternum  between  2d  costal 
cartilages ! 

2d  Rib  near  the  costal  cartilage .... 

Lower  end  of  sternum 

5th  Costal  cartilages  near  the  rib . . 


ight 
left 


6th  Rib  at  the  side. 
10th  Rib 


(rio 
{let 

(rig 
|lef 

r 


Abdomen . 


ght 
left 
right 
left 

(  right 

j  left 

centre 

;  i  right 
i  [left 


(boy 
I  man 


Involuntary 

tranquil 
respiration. 

Voluntary 
forced 

respiration 
about 

3    to  6 

100 

3    "  7 

110 

3    "   7 

110 

2    "   6 

95 

3     "    6 

95 

2     '^    5 

85 

5 

70 

3 

60 

10 

65 

9 

60 

25 

90 

25  to   30 

100 

9 

In  disease  it  may  be  observed  as  a  general  rule,  that  if  the  respiratory 
movements  are  restrained  in  one  place,  they  are  increased  elsewhere. 
We  have  already  alluded  to  the  relation  existing  between  thoracic  and 
abdominal  movements  (see  Inspection).  The  amount  of  these  may  be 
exactly  ascertained  by  the  chest-measurer.  In  the  same  manner  the 
diminished  movements  on  one  side  of  the  chest  in  pleuritis,  pneumonia, 
and  incipient  phthisis,  can  be  determined  and  compared  with  the  exag- 
gerated motion  on  the  opposite.  Thus  in  phthisis,  instead  of  the  indi- 
cator of  the  instrument  placed  over  the  second  rib,  on  the  affected  side, 
moving  between  1  and  110  on  forced  inspiration,  as  in  health,  it  may 
only  move  between  1  and  30.  In  making  observations  with  the  chest- 
measurer,  considerable  practice  and  skill  are  necessary,  as  in  the  employ- 
ment of  all  other  instruments.     It  enables  us  to  arrive  at  great  accuracy, 


Fig.  8.  Mode  of  application  of  the  cliest-measurer,  attached  to  brass  rods,  bent  at 
right  angles,  when  the  patient  is  in  the  horizontal  posture. — (Sibsoa.) 


BY  PERCUSSION. 


85 


and  constitutes  an  extra  means  of  exploration,  without,  however,  being 
absolutely  necessary  for  arriving  at  a  correct  diagnosis  in  every  case. 

The  expansibility  of  the  lungs,  and  the  amount  of  air  expelled  from 
the  chest  after  full  inspiration,  may  also  be  measured  by  the  spirometer 
of  Mr.  Hutchinson.  But  the  necessity  of  determining  the  height  and 
weight  of  the  individual,  of  teaching  him  how  to  inspire  and  expire,  of  pay- 
ing attention  to  the  muscular  force  and  other  circumstances,  so  interferes 
with  the  correct  conclusions  to  be  derived  from  this  mode  of  explora- 
tion, as  to  render  it  valueless  in  the  examination  of  cases  generally.  As 
a  means  of  physiological  research  in  determining  the  vital  capacity  of 
the  chest,  Mr.  Hutchinson's  investigations  are  of  the  utmost  importance. 

Dr.  Scott  Alison  has  lately  invented  an  instrument  for  measuring  the 
angles  of  the  chest.  It  will  also  enable  us  to  judge  approximatively  of 
the  curves  under  various  altered  conditions.  He  calls  it  stetho-gonio- 
meter,  a  term  derived  from  three  Greek  words,  signifying  chest,  angle, 
and  measure.     Dr.  S.  Alison  believes  that  it  will  afford  data  not  to  be 


Fi2.  9. 


obtained  by  other  means,  and  assist  in  the  diagnosis  of  disease  in  its 
earlv  as  well  as  in  its  later  stages.* 


PERCUSSION. 

The  object  of  percussion  is  to  ascertain  the  resistance  and  size  of 
organs.  It  may  be  practised  directly,  or  through  the  medium  of  an 
interposed  body  (mediate  percussion) — the  last  being  the  only  satisfac- 
tory way.  Without  knowing  how  to  strike,  and  to  produce  clear  tones, 
we  can  never  educate  the  ear,  or  the  sense  of  resistance.     This  prelimi- 


Fig.  10. 
*  Beale's  Archives  of  Medicine,  Vol.  I.,  p.  60. 


Fig.  9.  Stetho-goniometer,  for  measuring  the  incHnation  of  different  parts  of  the 
walls  of  the  thorax  in  cases  of  disease,  aa,  The  arms;  b,  the  arc  of  a  circle  gra- 
duated ;  c,  the  vernier,  with  an  arrow,  also  graduated ;  d,  vernier  arm ;  e,  joint. — 
{Scott  Alison.) 


86 


EXAMINATION   OF  THE   PATIENT 


nary  education  in  the  art  of  percussion  requires  a  certain  dexterity,  -which 
some  find  it  very  difficult  to  obtain.     The  difficulty  seems  to  depend,  in 

some  cases,  on  an  alteration  in 
the  proportions  usually  exist- 
ing between  the  length  of  the 
fingers.      Thus,  I  have   seen 
more  than  one  person  who  had 
the  index  finger  nearly  an  inch 
shorter  than  the  middle  one,  and  -who,  consequently, 
found   it    impossible  to    strike  the  pleximeter  fairly 
with  the  tips  of  two  fingers  at  once.     By  far  the  most 
common  cause  of  failure,  however,  is  want  of  patience 
and  perseverance  in  overcoming  the  first  mechanical 
difficulties;  and  there  is  every  reason  to  believe  that 
could  this  be  surmounted,  accurate  percussion  would 
become  more  universal  and  better  appreciated.    With- 
out entering  into  the  numerous  discussions  which  have 
arisen  as  to  the  superior  advantages  of  one  plan  as 
compared  with  another,  or  of  using  this  or  that  instru- 
ment, I  may  mention,  that  for  the  last  sixteen  years  I 
have  employed  a  pleximeter  and  a  hammer.     These 
instruments    I    can    confidently   recommend    to    you 
as  the  readiest  means  of  obtaining  accurate  results 
at  the  bed-side  by  means  of  percussion. 

The  ivory  pleximeter  I  use  is  that  of  M.  Piorry,  as 
modified  by  M.  Mailliot.  Its  length  is  two  inches,  and 
breadth  one.  It  possesses  two  handles,  and  an  inch 
and  half  scale  drawn  upon  the  surface.  It  may  be 
applied  with  great  precision  to  every  part  of  the  chest, 
even  in  emaciated  subjects  (Fig.  10). 

The  hammer  is  the  invention  of  Dr.  Winterich  of 
"Wurzburgh.  The  advantages  it  possesses  are, — 1st, 
That  the  tone  produced  by  it,  in  clearness,  penetra- 
tiveness,  and  quality,  far  surpasses  that  which  the  most 
practised  percussor  is  able  to  occasion  by  other  means. 
2d,  It  is  especially  useful  in  clinical  instraction,  as  the 
student  most  distant  from  the  patient  is  enabled  to 
distinguish  the  varieties  of  tone  with  the  greatest  ease. 
3d,  It  at  once  enables  those  to  percuss,  who,  from 
peculiar  formation  of  the  fingers,  want  of  opportunity, 
time,  practice,  etc.,  are  deficient  in  the  necessary  dex- 
terity (Fig.  11). 

"With  Ae  assistance  of  the  instruments  I  now 
recommend  to  you,  every  student  acquainted  with  the 
relative  situations  of  the  difterent  thoracic  and  abdo- 
minal organs,  is  himself  enabled,  without  other  pre- 
liminary education,  to  detect  the  difterent  degrees  of 
sonoriety  they  possess  in  a  state  of  health  and  disease. 
Yi2.  11.  I  may  say,  that  by  means  of  these  instruments,  after 

one  hour's  practice  on  a  dead  body,  he  is  placed  on  a  par  (as  regards  the 
art  of  percussion)  with  the  generality  of  experienced  practitioners  in 


BY  PERCUSSION".  37 

this  country ;  and  any  of  you,  after  one  mouth's  employment  of  them, 
will  be  enabled  to  mark  out  accurately  on  the  surface  of  the  body,  the 
size  and  form  of  the  heart,  liver,  spleen,  etc. 


Of  the  Diffkrent  Sounds  pkoduced  by  Percussion. 

The  sounds  produced  by  percussion  arise  from  the  vibrations  occa- 
sioned in  the  solid  textures  of  the  organ  percussed.  The  different 
density  and  elasticity  of  these  textures  will  of  course  more  or  less  modify 
the  number  and  continuance  of  the  vibrations,  and  give  rise  to  different 
sounds. 

M.  Piorry  considers  that  nine  elementary  sounds  are  thus  formed, 
which  he  has  designated,  from  the  organ  or  part  which  originates  them, 
'■'■femoral,  jecoral,  cardial,  2}uli)ional,  intestinal,  stomacal,  osteal,  hiimo- 
rique,  and  hydatiquer  I  consider  that  all  these  sounds  may  be  reduced 
to  three  elementary  ones;  that,  in  point  of  fact,  there  are  only  three 
tones  occasioned  by  percussion,  and  that  all  the  others  are  intermediate. 
These  three  tones  are  respectively  dependent, — let.  On  the  organ  con- 
taining air  ;  2d,  On  its  containing  fluid ;  and  3d,  On  its  being  formed  of 
a  dense  uniform  parenchymatous  tissue  throughout.  These  tones,  there- 
fore, may  be  termed  the  tympanitic,  the  humoral,  and  the  jMrcnchytna- 
tous.  Percussion  over  the  empty  stomach  gives  the  best  example  of  the 
first  kind  of  sound ;  over  the  distended  bladder,  of  the  second  ;  and 
over  the  liver,  of  the  third.  Certain  modifications  of  these  sounds  occa- 
sion the  metallic  and  the  cracked-pot  sound.  The  latter  is  made  audible 
over  the  chest  under  a  variety  of  circumstances,  by  percussing  with  the 
mouth  open.  The  terms  jecoral,  cardial,  pulmonal,  intestinal,  and 
stomacal,  however,  may  be  used  to  express  those  modifications  of  sound 
produced  in  percussing  respectively  the  liver,  heart,  lungs,  intestines, 
and  stomach. 

No  description  will  suffice  to  convey  proper  ideas  of  the  various  altera- 
tions of  tone  occasioned  by  percussing  over  the  difterent  thoracic  and 
abdominal  viscera.  To  become  acquainted  with  these,  it  is  absolutely 
necessary  to  apply  the  pleximeter  to  the  body,  and  then  half  an  hour's 
practice  with  this  instrument  and  the  hammer  will  be  sufiicient  to  render 
any  one  conversant  with  those,  which  may  be  heard  in  a  normal  state. 

It  must  be  remembered,  however,  that  the  tones  even  then  may  vary 
according  to  circumstances.  Thus,  immediately  after  a  deep  inspiration, 
the  pulmonal  sound  will  be  rendered  more  tympanitic,  and,  after  expira- 
tion, more  parenchymatous.  In  the  same  manner  the  stomach  and 
intestines  may  give  out  difterent  sounds  according  to  the  nature  of  its 
contents.  In  the  left  or  right  iliac  fossa  a  clear  tympanitic  sound  will 
be  heard  when  the  intestine  below  is  empty,  and  a  dull  parenchymatous 
sound  when  it  is  full  of  foeces. 

A  study  of  the  difterent  modifications  of  sound,  which  various  organs 
thus  produce  in  a  state  of  health,  readily  leads  to  the  comprehension  of 
the  sounds  which  may  be  elicited  in  a  morbid  state.  Thus,  the  lungs 
may  occasion  a  dull  or  parenchymatous  sound,  from  solidification,  the 
result  of  exudation,  or,  on  the  other  hand,  become  more  tympanitic, 
from  the  presence  of  emphysema.    The  abdomen  may  give  out  a  paren- 


38  EXAMINATION   OF  THE   PATIENT 

chTmatous  sound,  from  enlargement  of  the  uterus  or  an  ovarian  tumour  ; 
or  "a  dull  humoral  sound,  from  the  effusion  of  fluid  into  the  cavity  of  the 
peritoneum. 


Of  the  Sense  of  Resistaxce  pkoduced  by  Percussion. 

By  the  sense  of  resistance  is  understood  the  peculiar  sensation 
resulting  from  those  impressions  which  are  communicated  to  the  fingers 
on  striking  hard,  soft,  or  elastic  bodies.  It  is  of  the  greatest  service  in 
determining  the  physical  condition  of  the  organ  percussed.  The  sense 
of  resistance  bears  relation  to  the  density  of  the  object  struck, — hence, 
firm  and  solid  textures  offer  more  resistance  than  those  which  are  soft 
or  elastic.  The  thorax  of  the  child  is  elastic,  whilst  that  of  the  adult 
is  unvielding.  Of  all  the  thoracic  and  abdominal  organs,  the  liver  pre- 
sents the  greatest  degree  of  resistance,  and  the  stomach  the  least.  The 
presence  of  fluid  in  the  hollow  viscera  offers  an  amount  of  resistance 
between  the  parenchymatous  organs  on  the  one  hand,  and  those  con- 
tainino-  air  on  the  other.  But  air  much  condensed,  or  fluid  contained 
within  the  rigid  walls  of  the  thorax,  may  oft'er  a  considerable  degree  of 
resistance. 

The  sense  of  resistance  should  be  as  much  educated  by  the  physician 
as  the  sense  of  hearing,  and  it  would  be  difficult  for  an  indix^idual,  prac- 
tised in  the  art  of  percussion,  to  say  which  of  these  two  points  is  the 
more  valuable  to  him.  Both  are  only  to  be  learnt  by  practice,  and  con- 
sidering it  perfectly  useless  to  describe  that  in  words  which  may  be 
learnt  in  half  an  hour,  by  the  use  of  the  plexi meter  and  hammer  on  a 
dead  body,  or  the  liWng  subject,  I  shall  now  proceed  to  describe  the 


General  Ecles  to  be  followed  ix  the  Practice  of  Mediate 
Pekcussion, 

1.  Tlie  pleximeter  should  be  held  by  the  projecting  handles  between 
the  thumb  and  index  finger  of  the  left  baud,  and  pressed  firmly  down 
upon  the  organ  to  be  percussed.  Much  depends  upon  this  rule  being- 
followed,  as  the  sound  and  sense  of  resistance  are  considerably  modified 
according  to  the  pressure  made  by  the  pleximeter.  A  very  easy  experi- 
ment will  prove  this.  If,  for  instance,  the  pleximeter  be  struck  while  it 
rests  lightly  on  the  abdomen  over  the  umbilicus,  and  again,  when  it  is 
pressed  firmly  down  amongst  the  viscera,  the  change  in  tone  will  be  at 
once  perceived.  In  the  first  case,  a  dull  sound  is  produced,  from  the 
muscles  and  integuments  being  alone  influenced  by  the  force  of  the 
blow ;  in  the  second  case,  a  clear  tympanitic  sound  is  occasioned  from 
the  vibration  of  the  walls  of  the  intestine.  In  every  instance,  therefore, 
the  pleximeter  should  be  so  held  and  pressed  down,  as  to  render  it,  so 
to  speak,  a  part  of  the  organ  we  wish  to  percuss. 

2,  Great  care  must  be  taken  that  no  inequality  exist  between  the 
inferior  surface  of  the  pleximeter  and  the  skin.  Firmly  pressing  it 
down  will  always  obviate  this  when  the  abdomen  is  examined.  As 
regards  the  thorax,  the  groove  over  the  antenor  mediastinum,  the  pro- 


BY  PERCUSSION.  39 

minence  of  the  clavicles  and  of  the  ribs,  in  emaciated  siibjects,  may 
allow  a  hollow  to  exist  iinder  the  instrument,  by  which  a  deceptive 
tympanitic  sound  is  occasioned.  By  a  little  management,  however,  with 
the  small  and  oval  pleximeter  I  have  recommended,  this  may  readily 
be  avoided. 

3.  The  hammer  should  be  held,  as  advised  by  Dr.  Winterich,  between 
the  thumb  and  the  first  and  third  fingers,  the  extremities  of  which  are 
to  be  placed  in  hollows  prepared  for  "them  in  the  handle  of  the  instru- 
ment. By  some  these  are  considered  useless ;  but  in  all  cases  where 
slight  differences  in  tone  are  to  be  appreciated,  I  have  found  this  the 
best  mode  of  employing  it.  Ordinarily,  however,  it  will  be  sufiicient  to 
hold  it  by  the  extremity  of  the  handle,  merely  in  such  a  manner  as  will 
enable  the  practitioner  to  strike  the  pleximeter  lightly,  or  with  force,  as 
occasion  may  require. 

4.  Care  must  be  taken  to  strike  the  pleximeter  fairly  and  perpen- 
dicularly. Unless  this  be  done,  vibrations  are  communicated  to  tex- 
tures in  the  neighbourhood  of  the  organ  to  be  percussed,  and  fallacious 
results  are  the  consequence.  If  in  percussing  the  lungs,  for  example, 
the  blow  be  made  obliquely,  we  obtain  the  dull  sound  produced  by  the 
rib,  and  I  have  seen  considerable  error  in  the  diagnosis  thus  occasioned. 

5.  A  strong  or  gentle  stroke  with  the  hammer  will  modify  the  tone 
and  sense  of  resistance,  inasmuch  as  the  impulse  may  be  communicated 
by  one  or  the  other  to  a  deep-seated  or  a  superficial  organ.  Thus  a 
gentle  stroke  will  elicit  a  pulmonal  tympanitic  sound  just  below  the 
fourth  rib,  where  a  thin  layer  of  lung  covers  the  liver,  but  a  strong  one 
will  cause  a  jecoral  parenchymatous  sound.  At  the  inferior  margin  of 
the  liver,  on  the  other  hand,  where  a  thin  layer  of  the  organ  covers  the 
intestines,  the  reverse  of  this  takes  place,  a  gentle  stroke  occasioning  a 
dull,  and  a  strong  one  a  clear  sound. 

6.  By  withdrawing  the  hammer  immediately  after  the  blow,  we  are 
better  able  to  judge  of  the  sound ;  by  allowing  it  to  remain  a  moment, 
we  can  judge  better  of  the  sense  of  resistance. 

7.  The  integuments  should  not  be  stretched  over  the  part  percussed, 
as  when  the  stethoscope  is  employed,  for  an  unnatural  degree  of  re- 
sistance is  thus  communicated  to  the  hand  of  the  operator  from  the 
muscular  tension.  In  every  case,  especially  where  the  abdomen  is 
examined,  the  integuments  and  superficial  muscles  should  be  rendered 
as  flaccid  as  possible. 

8.  It  is  always  best  to  percuss  on  the  naked  skin.  It  is  not  absolutely 
essential,  however ;  and  in  cases  where,  from  motives  of  delicacy,  it  is 
desirable  that  the  chest  or  abdomen  be  not  exposed,  it  only  becomes 
necessary  that  the  covering  of  linen  or  flannel  be  of  equal  thickness 
throughout,  and  not  thrown  into  folds. 

9.  The  position,  in  which  the  individual  examined  should  be  placed, 
will  vary  according  to  the  organ  explored.  In  percussing  the  tlioracic 
organs  and  the  liver,  a  sitting  position  is  most  convenient.  The  stomach, 
intestines,  uterus,  bladder,  and  abdominal  tumours  or  effusions,  are  best 
examined  when  the  patient  is  lying  on  the  back,  with  the  knees  flexed 
so  as  to  relax  the  abdominal  walls,  and,  if  necessary,  the  head  and  neck 
bent  forward,  and  supported  by  pillows.  In  percussing  the  spleen, 
the  individual  should  lie  on  the  right  side ;  and  when  the  kidneys  are 


40  EXAMINATION   OF  THE   PATIENT 

examined,  lie  should  lie  on  the  breast  and  abdomen.  In  cases  of  effu- 
sion into  the  serous  cavities,  a  change  of  position  furnishes  most  valu- 
able indications. 

10.  In  percussing  any  particular  organ,  the  pleximeter  should  be 
first  applied  over  its  centre,  where  the  sound  and  sense  of  resistance  it 
mav  furnish  are  most  characteristic.  Two  blows  with  the  hammer  are 
generally  sufficient  to  determine  this.  From  the  centre,  the  pleximeter 
should  be  moved  gradually  towards  the  periphery,  or  margin  of  the 
organ,  and  struck  as  it  proceeds  with  the  hammer,  now  forcibly,  now 
lio-htly,  until  the  characteristic  sound  of  the  next  organ  be  elicited. 
The  pleximeter  is  then  gradually  to  be  returned  towards  the  organ 
under  examination,  until  the  diiference  of  tone  and  sense  of  resistance 
become  manifest.  In  this  manner  having  first  heard  the  two  distinct 
sounds  well  characterised,  we  shall  be  better  enabled  to  determine  with 
accuracy  the  limit  between  the  one  and  the  other.  This  may  be  done 
exactlv,  after  having  determined  whereabouts  the  line  of  separation  is,  by 
placing  the  long  diameter  of  the  pleximeter  transversely  across  it,  and 
strikino-,  first  one  end  of  the  instrument,  and  then  the  other,  till  the  pre- 
cise spot  is  determined.  This  spot  should  now  be  marked,  by  placing 
with  a  pen  a  dot  of  ink  on  the  skin.  The  opposite  and  then  other 
portions  of  the  margin  of  the  organ  sliould  be  limited  in  the  same  man- 
ner, and  these  in  turn  should  be  marked  with  dots  of  ink,  until  the 
wdiole  organ  be  completely  examined.  Then  by  uniting  all  these  dots 
with  a  line  of  ink,  we  have  the  exact  form  of  the  organ  drawn  upon 
the  skin.  When  it  is  thought  necessary  to  render  the  first  mark  per- 
manent, in  order  to  see  if  any  subsequent  change  take  place  in  the  size 
of  the  organ,  or  extent  of  the  dulness,  it  may  be  rendered  so,  by  carry- 
ino-  lightly  a  stick  of  nitrate  of  silver  over  the  ink  line,  while  it  is  still 
moist. 


Special  Rules  to  be  followed  in  Percussing  Particular  Organs. 

Before  proceeding  to  percuss  individual  organs  in  persons  labouring 
imder  disease,  you  should  obtain  a  general  knowledge  of  the  limits  and 
intensity  of  dulness  on  percussing  the  thoracic  and  abdominal  viscera  in 
health.  The  accompanying  figures  convey  this  information  with  great 
accuracy,  the  depth  of  tint  corresponding  to  the  dulness  of  tone  and 
amount'of  resistance.  The  normal  sonoriety  and  dulness  exhibited  (Figs. 
12  and  13),  will  enable  you  to  compare  with  readiness  the  alterations 
revealed  by  percussion  under  a  variety  of  diseased  conditions. 

Lungs. — Percussion  of  the  lungs  generally  bears  reference  to  a  change 
in  density,  which  is  only  to  be  detected  by  comparing  the  healthy  with 
the  morbid  portions.  The  great  practical  rule  here  to  be  followed  is,  to 
apply  the  pleximeter  with  the  same  firmness,  and  exactly  in  the  same 
situation,  to  each  side  of  the  chest  in  succession,  and  to  let  the  blow 
with  the  hammer  be  given  with  an  equal  force.  Care  must  be  taken 
that  the  position  of  both  arms  be  alike,  as  the  contraction  of  the  pectoral 
muscles  on  one  side  more  than  on  the  other  may  induce  error.  In 
short,  every  circumstance  must  be  the  same  before  it  is  possible  to  deter- 
mine, in  delicate  cases,  either  from  the  tone  or  sense  of  resistance, 


BY  PERCUSSION. 


41 


wlietlier  change  of  density  exist  in  the   hings.     AVhen  circumscribed 
alterations  are  discovered  in  the  pulmonary  tissue,  their  limits  may  be 


Fig.  12. 


Fig.  13. 


marked  out  on  the  surface  of  the  skin,  in  the  manner  previously  indi- 
cated. In  this  way  I  have  frequently  succeeded  in  determining  with 
accuracy  the  size  and  form  of  circumscribed  indurations,  arising  from 
partial  pneumonia  and  pulmonary  apoplexy.  Under  the  clavicles,  the 
pleximeter  must  be  applied  with  great  firmness.  Inferiorly,  a  thin 
layer  of  lung  lies  over  the  superior  surface  of  the  liver ;  and  to  deter- 
mine the  exact  place  where  its  inferior  border  terminates,  the  blows  with 
the  hammer  should  be  very  slight.  Posteriorly,  also,  the  pleximeter 
must  be  firmly  applied,  and  the  force  of  the  blows  considerable ;  but 
they  should  decrease  in  force  inferiorly,  where  a  thin  layer  of  lung 
descends  over  the  liver  much  deeper  than  anteriorly. 

In  a  healthy  state,  a  distinct  difference  may  be  observed  in  the 
sonoriety  of  the  lungs  immediately  after  a  full  expiration  and  a  full  inspi- 
ration. This  does  not  take  place  when  the  tissue  becomes  indurated 
from  any  cause;  and  thus  we  are  furnished  with  a  valuable  diagnostic 
sign.  Congestion  of  the  lung,  and  pneumonia  in  its  first  stage,  cause 
only  slight  dulness  and  increased  resistance,  which,  however,  may 
occasionally  be  detected  by  the  practised  percussor.  In  the  second 
and  third  stage  of  pneumonia,  and  in  apoplexy  of  the  lung,  this  dulness 
and  resistance  are  well  marked,  and  even  an  impression  of  hardness  and 

Fig.  12,  anterior,  and  Fig.  13,  posterior  view  of  the  nonnal  limits  and  intensity 
of  dulness  on  percussion.  P,  pulmonal  sound ;  C,  cardiac  sound  ;  H,  hepatic  sound  ; 
S,  splenic  sound ;  G-,  gastric  sound  (here  the  stomach  is  moderately  distended  with 
air) ;  E,  enteric  sound.  In  the  anterior  view  the  intestines  are  tolerabh'  free  from 
air,  except  CO,  colic  sound,  from  distended  colon.  The  descending  colon  and  rectum 
are  filled,  and  sound  dull.  HU,  humoral  sound,  over  a  distended  bladder;  M,  mus- 
cular, and  0,  osteal  sounds. — i^P lorry.) 


42 


EXAMrS'ATIOX   OF   THE   PATIENT 


Fis.  14. 


solidity  communicated  to  the  hand.  "When,  however,  the  lung  is  infil- 
trated with  tubercle,  the  induration 
is  most  intense,  and  the  greatest 
degree  of  resistance  communicated. 
Partial  indurations  Irom  apoplexy 
or  simple  cancerous  and  tubercular 
exudation,  may  be  detected  by  per- 
cussion, even  when  deep-seated,  and 
covered  by  healthy  portions  of  the 
lungs.  In  this  case,  by  pressing 
with  the  pleximeter,  and  striking 
lightly,  a  tympanitic  sound  only  is 
heard ;  but  by  pressing  the  plexi- 
meter down  firmly,  and  striking  with 
force,  the  dull  sound  may  be  elicited 
and  circumscribed.  When  indura- 
tions, however,  exist  inferiorly  in 
those  portions  of  the  lungs  which 
overlap  the  liver,  it  requires  great 
practice  to  detect  them  with  cer- 
tainty. Caverns  in  the  lungs,  when 
large  and  filled  with  air,  induce  a 
tympanic  sound  (Fig.  14,  3);  but 
ther  are  generally  more  or  less  full  of  viscous  and  fluid  matters,  and  give 
rise  to  duiness. 

Two  or  three  ounces  of  fluid  may  be  detected  in  the  pleural  cavity, 
bv  causing  the  patient  to  sit  up.  The  height  or  level  of  the  fluid  is 
readily  determined,  and  should  be  marked  daily  by  a  line  made  with 
nitrate  of  silver.  If  the  eff"usion  be  only  on  one  side,  the  increased 
duiness  is  more  easily  detected.  It  disappears  on  placing  the  patient 
in  such  a  position  as  will  cause  the  fluid  to  accumulate  in  another  part 
of  the  pleural  cavitv,  when  the  space  which  was  previously  dull  becomes 
clear  (Fig.  15).  When  the  eftusion  entirely  fills  the  pleural  cavity,  no 
limit,  of  course,  can  be  detected ;  but,  even  then,  the  duiness  is  distin- 
guished from  that  of  the  liver  by  the  diminished  feeling  of  resistance. 

When  the  lung  is  emphysematous,  or  if  air  be  present  in  the  pleura, 
the  sound  becomes  unusually  tympanitic ;  this  tympanitic  note  on  per- 
cussion, however,  may  exist  under  a  variety  of  circumstances,  which 
it  is  of  great  importance  to  be  acquainted  with.  Thus,  condensation 
from  pneumonia  at  the  posterior  part  of  the  lung,  or  partial  pleurisy, 
by  causing  the  anterior  portion  of  the  organ  to  be  over  distended  with  air, 
or  compressed  and  pushed  forward,  may  give  origin  to  this  sound.  The 
same  occurs  in  chronic  phthisis,  over  parts  which  were  once  dull,  either 
from  large  dry  cavities  filled  with  air,  or  from  the  emphysema  which 
accompanies  cicatrices  and  partial  condensation  of  pulmonary  texture. 

On  percussing  the  chest  with  the  mouth  open,  there  may  fre- 
quently be   elicited  a  sound,   which   Laennec   first   likened  to  gently 

Fig.  14.  Phthisis — Atrophied  heart  and  liver — Prolonged  abstinence.  1,  Atrophied 
hear?;  2,  Infiltrated  tubercle  on  left  side ;  3,  The  same  on  right  side  with  a  cavity ; 
4,  Atrophied  liver ;  5,  Spleen :  6,  Unusual  duiness  over  abdomen,  from  prolonged 
aiistinence. — {Piarry.) 


BY  PERCUSSIOlSr. 


•iS 


striking   a  cracked  pot.     It  may  be  very  closely  imitated  by  crossing 
tlie  palms  of  both  hands,  so  as  to 
leave  a  hollow  between  them,  and 
then  striking  the  knuckles  of  the 
inferior  hand  against  the  knee,  so 
as  to   produce    a   clinking    sound. 
I  have  produced  it  by  percussing 
the  chest  in  cases  of  pleurisy,  pneu- 
monia, and  phthisis ;  of    congest- 
ed, apoplectic,  and  emphysematous 
luncrs,  and  even  when  these  organs 
were  quite  healthy,  if,  as  in  young 
subjects,  the  ribs  are  very  elastic. 
The  conditions  which  seem  favour- 
able  for   the   production   of    this 
sound,  are,  1st,  A  certain  amount 
of  confined  air  rendering  the  tissue 
of  the  lung  tense  ;  2d,  The  sudden 
compression  of  this  air  by  a  solid 
body   in  its  neighbourhood ;     3d, 
Communication  of  this  air  with  the 
external  atmosphere.     Hence  it  is 
not  diagnostic  of  any  particular  dis- 
order, or  pathological  state,  such  as  a  Fig- 15. 
pulmonary  cavity,  so  much  as  of  a  physical  condition,  which,  however,  if 
rightly  interpreted,  is  likely  to  be  of                      '  ' 
the  utmost  advantage  in  our  efforts  at 
detecting  the  nature  of  disease.* 

Heart, — To  mark  out  the  precise 
limits  of  the  heart  constitutes  the 
first  difiicult  lesson  in  the  art  of  per- 
cussion. M.  Piorry  commences  by 
determining  the  clear  sound  at  the 
upper  end  of  the  sternum,  and  bring- 
ing the  pleximeter  gradually  down- 
wards till  the  dull  sound  of  the  heart 
be  heard.  I  have  found  it  best  to 
place  the  instrument  first  under  and 
a  little  inside  the  left  nipple,  where 
the  cardiac  dulness  is  most  intense ; 
then  to  carry  it  upwards,  striking  it 
continually  with  the  hammer  until  the 
clear  sound  of  the  lung  be  elicited ; 
then,  by  bringing  it  down  again  to- 
wards the  heart,  we  shall  readily  distinguish  the  line  where  cardial  dulness 

*  See  the  author's  "Clinical  Investigation  into  the  diagnostic  value  of  the 
cracked-pot-sound." — Edinburgh  Medical  Journal  for  March  1856. 

Fig.  15.  Pleurisy.  1,  On  the  right  side  when  in  the  erect  position ;  2,  On  the  left 
side,  when  lying  on  the  right:  3,  Kidneys,  the  left  enlarged;  4,  Spleen. — (Piorry.) ^ 

Fig.  16.  Pericarditis,  pmuinonia,  and  loaded  rectum.  1,  Pericarditis;  2,  Pneumonia 
separable  from  the  extreme  dulness  of  the  Uver;  3,  Loaded  rectum.— (Picwr;/.) 


u 


EXAillXATIOX   OF   THE   PATIENT 


commeBces,  and  thus  limit  the  superior  margin  of  the  organ.  Tlie  same 
method  is  to  be  followed  in  determining  the  situation  of  the  lateral  margins, 
only  carrying  the  pleximeter  outwards  or  inwards,  striking  more  and  more 
forcibly  with  the  hammer,  until  the  clear  tympanitic  sound  of  the  lung 
only  be  heard.  It  is  more  difBcult  to  determine  the  situation  of  the  apex 
of  the  heart ;  for  as  this  rests  on  the  diaphragm,  and  this  again  upon  the 
left  lobe  of  the  liver,  it  cannot  readily  be  distinguished  fi-om  them.  The 
size  of  the  heart,  however,  may  be  pretty  accurately  estimated,  by  limit- 
ing its  superior  and  lateral  margins.  In  females,  the  left  mammary  gland 
should  be  drawn  upwards  and  outwards  by  an  assistant.  In  the  natural 
position  of  the  organ  (Figs.  1  and  2)  it  is  well  to  remember  that  the 
auricles  are  on  the  right,  and  the  ventricles  on  the  left  side. 

The  normal  size  of  the  heart  differs  in  different  persons.  As  a  gene- 
ral rule,  however,  it  may  be  considered  that,  if  the  transverse  diameter 
of  the  dulness  measure  more  than  two  inches,  it  is  abnormally  enlarged. 
It  has  been  known  to  measure  seven  inches.  (Piorry.)  In  hydroperi- 
cardium,  the  dulness  has  been  remarked  to  exist  rather  at  the  superior 
part  of  the  sternum,  than  on  one  side  or  the  other.  (Piorry,  Reynaud.) 
In  pericarditis  it  bulges  out  interiorly  (Fig.  16,  1).  In  hypertrophy  and 
dilatation  of  the  right  auricle,  the  increased  extent  of  the  dulness 
stretches  towards  the  median  line,  and  sometimes  passes  over  it  (Fig.  17, 
3).  In  similar  hypertrophy  of  the  left  ventricle,  the  dulness  extends  on 
the  left  side  more  or  less,  according  to  the  increased  size  of  the  heart 
(Fig.  IT,  1,  and  Fig.  IS).  In  concentric  hypertrophy,  there  is  little  or 
no  enlargement,  but  the  density  is  greatly  increased. 

The  presence  of  tubercle  in  the 
lungs  surrounding  the  heart ;  aneu- 
risms or  other  tumoui-s  pressing 
upon,  or  in  the  neighbourhood  of, 
the  organ  ;  hypertrophied  liver,  ex- 
tensive empyema,  etc.  etc.,  may 
render  the  mensuration  of  the  ex- 
tent of  its  dulness  diificult  or  im- 
possible. The  changes  in  position 
of  the  heart  produced  by  a  pleurisy 
on  one  side  pushing  it  towards  the 
opposite  one,  or  by  the  pregnant 
uterus,  or  an  ovarian  tumour  or 
ascites  thrusting  it  upwards,  may 
also  be  determined  by  percussion, 
especially  if  the  impulse  can  be 
distinguished  by  palpation  or  auscul- 
tation. 

Liver. — Limitation  of  the  size  of 
the  liver  should  be  commenced  by 
Fig.  17.  placing  the  pleximeter  over  the  organ 

on  the  right  side,  where  the  dulness  and  resistance  are  greatest.      It 

Fie  n.  Hypertrophy  of  liver  and  heart.  1,  Hrpertropbied  liver,  which  may  be 
«tillftirther  enlareed  to  the  dotted  Unes  over  the  abdomen;  2,  Distended  gall-blad- 
der; 3,  Hypertrophied  right  auricle— 1,  Hypertrophied  ventricles;  4,  Loaded 
ceec'um';  5, 'Loaded  rectum  and  descending  colon. — {Fiorry.) 


BY   PERCUSSION. 


45 


should  tlien  be  carried  upwards,  until  tlie  clear  sound  of  tlie  lung  be 
distino-uished,  when  it  ought  again  to  be  brought  down,  and  the  limit 
marked.  This  huiit,  however,  may  indicate  either  the  inferior  margin 
of  the  lung,  or  superior  convex  surface  of  the  liver. 

Now,  as  a  thin  layer  of  lung  descends  in  front  of  the  liver,  it 
■will  be  necessary  to  determine  where  the  tympanitic  sound  ceases  infe- 
riorlv,  bv  striking  gently  with  the  hammer,  and  where  the  parenchy- 
matous sound  ceases  superiorly,  by  striking  forcibly,  so  that  vibrations 
may  be  communicated  to  the  organ  through  the  layer  of  lung.  The  space 
between  these  two  lines  thus  marked  on  the  surface  is  wider  in  some  in- 
dividuals than  in  others,  and  deeper  and  more  extensive  posteriorly  than 
anteriorly.  Bv  carrying  the  pleximeter  from  the  right  side  anteriorly,  and 
then  posteriorly  towards  the  left  of  the  patient,  the  whole  superior  margin 
may  be  thus  detected,  and  marked  with  ink  upon  the  surface,  except  where 
the"  liver  comes  in  contact,  through  the  medium  of  the  diaphragm,  with 
the  apex  of  the  heart.  The  inferior  margin  is  for  the  most  part  readily 
detected.  It  must  be  remembered,  however,  that  in  the  same  manner  as  a 
thin  layer  of  lung  covers  the  upper  margin,  so  a  thin  layer  of  liver  descends 
on  the'  rio-ht  side  over  the  intestine.     It  is,  therefore,  necessary  to  be 

cautious  in  determining  the  inferior  margins,  for  a  tolerably  strong  blow 

■with  the  hammer  may  give  rise  to  a  tympanitic  sound  from  the  intestine, 

heard  through  the  liver.     The  lower  margin  must  be  percussed  in  an 

invei-se  manner  to  the  superior,  and  as  we  proceed  downwards,  the  force 

of  the  blow  should  be  diminished. 

The  inferior  margin  of  the  liver  is 

in  general  readily  detected,  from  the 

contrast   which,   on    percussion,    its 

dulness   and   density    present,    con- 
trasted  with    the    tympanitic    and 

elastic    feel    of    the    intestines    and 

stomach. 

The  superior  limit  of  this  organ 

is  generally  found  about  two  inches 

below  the  right  nipple,  at  a  point 

corresponding  with  the  fifth  rib.    Its 

inferior  border  descends  to  the  lower 

margin  of  the  ribs.     The  extent  of 

the  jecoral  dulness  in  the   healthy 

state  is  in  general  two  inches  on  the 

left  side,  three  inches  in  the  hepatic 

region  anteriorly,  and  four  inches  in 

the  hepatic  region  laterally.  (Piorry.) 
Variations  in  the  size  of  the  liver, 

from   congestion,  inflammation,   ab- 
scesses, hydatids,  tumoui-s,  atrophy, 

etc.  etc.,  may  often  be  exactly  determinedby  means  of  percussion.    In  icterus, 

the  increase  and  diminution  of  this  organ,  as  evinced  by  lines  marked  on 


Fig.  18.  Hypertrophied  liver  and  spleen  in  leucocyihemia— Enlarged  heart.  1,  Hy- 
pertrophied  heart  with  dilatation  ;  2.  Great  dulness  over  the  larger  part  of  abdomen 
from  enlarged  liver  on  the  right  side ;  and  enlarged  spleen  on  the  Mt— {Partly  from 
Piorry.) 


46 


EXAMINATION   OF  THE   PATIENT 


the  skin,  will  o-enerally  be  found  to  bear  a  proportion  to  the  intensity  of 
oro-anic  disease.  "When  tumours  are  present,  the  inferior  border  often 
presents  an  irregular  form.  If  the  inferior  lobes  of  the  lung  be  indurated 
by  tubercles  or  hepatisation,  it  becomes  difficult  or  impossible  to  draw 
the  limit  between  them  and  the  liver.  "When  Huid  effusion  exists  in  the 
pleura,  the  increased  density  of  the  liver  may  still  serve  to  distinguish  it, 
and,  by  changing  the  position  of  the  patient,  its  upper  edge  in  the 
majority  of  cases  may  be  limited.  In  cases  of  ascites,  we  must  lay  the 
patient  on  the  left  side,  in  order  to  measure  the  right  lobe — on  the 
right  side  to  measure  the  left  lobe,  and  on  the  abdomen  to  percuss  it 
posteriorly.  Sometimes  the  right  lobe  of  the  liver  is  so  enormously 
hypertrophied,  that  its  inferior  margin  extends  to  the  right  iliac  fossa 
(Fig.  18). 

When  the  gall-bladder  is  much  distended  with  bile,  or  contains  gall- 
stones to  any  "amount,  it  may  readily  be  detected  by  percussion,  and  the 
dulness  it  occasions  immediately  under  the  inferior  margin  of  the  liver, 
anteriorly  and  somewhat  laterally,  may  be  marked  off  (Fig.  17,  2). 

Spleen. — In  percussing  the  spleen,  it  is  necessary  that  the  patient  lie 
on  the  right  side,  and  it  is  advantageous  that  the  examination  be  made 
before,  rather  than  after,  meals.  Anteriorly  the  sonoriety  of  the  sto- 
mach and  intestines  causes  the  margin  readily  to  be  distinguished.  Pos- 
teriorlv,  however,  where  the  organ  approaches  towards  the  kidneys,  this 
is  more  difficult.  Its  superior  and  inferior  margins  may  be  made  out 
bv  striking  the  instrument  with  some  force,  and 
following  the  rule  (Xo.  10)  previously  given,  p.  40. 
This  organ  offers  great  resistance  on  percussion. 

In  health  the  spleen  never  projects  below  the 
false  ribs,  even  during  a  deep  inspiration.  Its  gene- 
ral size  is  about  four  inches  long  and  three  inches 
wide.  (Piorry.)  In  diseased  states  it  may  be  atro- 
phied or  enlarged.  I  have  seen  it  measure  upwards 
of  twelve  inches  long  and  eight  wide,  and  it  then 
may  project  upwards  and  downwards,  as  indicated 
by  the  clotted  lines  in  Fig.  19.  A  pleuritic  effu- 
sion, ascites,  pneumonia,  or  tubercular  deposition 
in  the  inferior  lobe  of  the  left  lung,  may  render  a 
limitation  of  this  organ  difficult  or  impossible.  If 
the  dulness  cannot  be  detected,  we  may  infer  that 
its  dimensions  are  small.     (Mailliot.) 

Stomach  and  Intestines. — The  sounds  elicited  by 
percussion  of  the  stomach  and  intestines  are  of  the 
greatest  service  to  the  practitioner  : — 1st,  As  fur- 
nishing him  with  the  means  of  determining  the 
form  of  other  organs,  as  the  liver,  spleen,  or  blad- 
der ;  2dly,  As  enabling  him  to  distinguish  the  pre- 
^jg- 19-  sence  or  absence  of  foecal  or  alimentary  matter  ; 

and,  3dly,  As  the  means  of  diagnosing  abdominal  tumours.     Hence  it  is 

Fig.  19.  1,  Slightly  enlarged  spleen,  pushed  somewhat  upwards.  The  dotted  lines 
indicate  how  the  organ  may  be  enlarged  in  various  diseases.  1,  Elongation  down- 
wards in  leucocythemia. — {Slightly  modified  from  Piorry.) 


BY   PERCUSSION.  47 

incumbent  on  every  pln'sician  to  be  able  at  once  to  recognise  the  differ- 
ence between  the  tones  furnished  by  the  stomach,  small  and  large  intes- 
tines, under  various  circumstances.  To  arrive  at  this  knowledge,  it  is 
necessary  to  be  acquainted  with  the  relative  positions  of  the  different 
abdominal  viscera,  and  the  regions  of  the  abdomen  to  which  they  cor- 
respond. For  instance,  it  is  usually  the  liver  and  not  the  stomach  that 
occupies  the  so-called  epigastric  region  just  below  the  end  of  the  ster- 
num. The  last-named  organ  is  for  the  most  part  situated  within  the 
left  lower  costal  walls,  just  below  the  heart  and  the  base  of  the  left  lung 
(Figs.  1  and  2), 

In  exploring  the  abdomen  by  means  of  percussion,  the  pleximeter 
should  first  be  placed  immediately  below  the  xiphoid  cartilage,  pressed 
firmly  down,   and  carried  along  the  median   line  towards  the  pubes, 
striking  it  all  the  way,  now  hard,  now  gently,  with  the  hammer.     The 
different  tones  which  the  stomach,  colon,  and  small  intestines  furnish 
will  thus  be  distinctly  heard.     The  pleximeter  should  then  be  carried 
laterally,  alternately  to  the  one  side,  and  then  to  the  other,  till  the 
■whole  surface  be  percussed.     In  this  manner,  the  different  tones  pro- 
duced by  the  ccecum  and  ascending  colon  on  the  right  side,  as  well 
as  by  the  stomach  and  descending  colon  on  the  left,  will  be  respectively 
distinguished  from  that  furnished  by  the  small  intestines.     The  sounds 
and  sense  of  resistance  will  be  modified  according  as  the  different  viscera 
are  full  or  empt)',  as  any  one  can  determine  on  his  own  body  by  means 
of  the  pleximeter  and  hammer.     When  the  intestines  are  full  of  fluid 
or  solid  contents,  such  portions  may  be  circumscribed  and  marked  out 
on  the  surface  of  the  skin.     I  have  thus  often  succeeded  in  determining 
the    internal    margin   of  the    colon,    in    its   ascending,    transverse,    or 
descending  portions.     Sometimes  a  portion  of  intestine  is  found  lying 
between  the  abdominal  walls  and  the  stomach.     The  latter,  however, 
may  be  readily  limited,  by  pressing  down  the  pleximeter,  causing  the 
patient  to   eat  or  drink,   or   by  examining  after  dinner.      The  small 
intestines  rarely  ever  fail  to  yield  a  tympanitic  sound — a  circumstance 
bv  which  they  may  readily  be  distinguished  from  the  stomach  and  large 
intestines.     The  distance  of   any  particular  knuckle   of  intestine  from 
the  abdominal  walls   may  be  pretty  accurately  calculated  by  the  force 
necessary    to   be    employed   in    pressing    down    the    pleximeter,    and 
striking   with   the   hammer,   in  order   to   elicit   a  tympanitic  or   dull 
sound- 
It  is  unnecessary  to  point   out   the    numerous   circumstances,   and 
morbid  conditions,  in  which  percussion  of  the  abdomen  may  prove  useful 
in  practice.     Displacements  and  variations  in  size  of  the  stomach   or 
intestines,  femoral   and   scrotal   hernia,  mesenteric,  ovarian,  and  other 
tumoui"s,   peritoneal   adhesions    and    effusions,    may   all    frequently    be 
diagnosed,  and  their  limits  determined,  by  a  careful  examination  with 
the  pleximeter  and  hammer.     By  means  of  percussion,  even  the  nature 
of  the  tumour  may  often  be  arrived  at ;  as,  for  instance,  whether  it  be 
fungus  hematodes,  scirrhous,   encysted,   osseous,  etc.,   by  the  different 
degrees  of  resistance  thev  possess.     Care,  however,  must  be  taken  not 
to  confomid  with  tumours   an  enlarged   spleen   or   liver,   a  distended 
uterus  or  bladder,  stomach  full  of  alimentary  matter,  etc.      It  should 
also  be  remembered  that  when  the  patient  lies  on  his  back  the  percus- 


48 


EXAMESTATIOX   OF  THE   PATIEJfT 


si  on  sound   over  the  stomach   is   resonant,  but  when  he  stands  it  is 
generally  dull  from  the  gravitation  of  the  food. 

In  a  practical  point  of  view  it  is  often  useful  to  determine,  by 
means  of  percussion,  whether  an  enema  or  a  purgative  by  the  mouth 
is  likely  to  open  the  bowels  most  rapidly.  If,  for  instance,  there  be 
dulness  in  the  left  iliac  fossa,  in  the  track  of  the  descending  colon,  that 

part  of  the  intestine  must  be  full  of 
fceces,  and  an  enema  is  indicated. 
If,  on  the  other  hand,  the  left  iliac 
fossa  sound  tympanitic,  and  the 
j  right  sound  dull,  an  enema  is  of 
'little  service,  as  it  will  not  extend 
to  the  ccecum,  and  purgatives  by 
the  mouth  are  indicated  (Figs.  16 
and  IV). 

Etfusion  of  fluid  into  the  peri- 
toneum may  be  determined  with 
great  exactitude  by  means  of  per- 
cussion, and  the  height  of  the  fluid 
marked,  as  in  the  case  of  pleuritic 
eifusion.  In  the  same  manner,  a 
change  of  position  furnishes  similar 
results.  Abdominal  distension  from 
accumulation  of  air  may  also  be 
determined.  If  it  be  within  the  intes- 
tine, the  tympanitic  note  is  partial 
Fig.  20.  and  limited,  if  in  the  peritoneal  cavity 

more  equable  and  diffused  (Fig.  20). 

Kidneys. — To  percuss  the  kidneys,  the  patient  should  lie  on  the  abdo- 
men and  chest ;  a  position  which  allows  any  ascitic  fluid  that  may  be 
present  to  gravitate  downwards,  while  the  intestines  float  upwards.  The 
dulness  and  great  resistance  offered  by  the  renal  organs  are,  under  such 
circumstances,  at  once  determined  (Figs.  13  and  15).  Their  external 
marcjins  may  for  the  most  be  easily  limited,  in  consequence  of  the  loud 
tympanitic  note  of  the  intestines,  which  can  be  elicited  round  their 
external  circumference  in  the  two  flanks.  Internally  the  dulness  merges 
into  that  of  the  spinal  column.  Enlargement  of  one  or  both  of  these 
organs  from  calculus,  or  scrofulous  nephritis,  pyelitis,  or  other  diseases, 
may  in  this  manner  be  made  out  as  seen  (Fig.  15)  on  the  left  side. 
Atrophy  of  these  organs  is  more  difiicidt  to  determine  with  exactitude, 
but  may  be  demonstrated  by  careful  percussion. 

Bladder. — This  viscus  is  only  to  be  detected  by  percussion,  when  it 
is  more  or  less  distended,  and  rises  above  the  pubes.  It  may  then  be 
distinguished,  and  its  circular  margin  limited,  by  observing  the  tympanitic 


Fig.  20.  Dropsy  of  the  abdomen,  enlarged  heart,  and  aneurism.  1,  Aneurism  pro- 
jecting from  the  arch  of  the  aorta  on  the  right  side ;  2,  Hypertrophied  heart,  espe- 
cially of  the  right  auricle ;  3.  Liver,  pushed  upwards ;  4,  Ascitic  fluid,  gravitatmg 
inferioriy.  the  patient  being  on  the  back ;  5  and  6,  Stomach  and  intestines,  superiorly 
and  anteriorly. — {Piorry.) 


BY  AUSCULTATION.  49 

sound  of  the  intestines,  on  the  one  hand,  and  the  dull  sound  furnished 
by  the  bladder,  with  increased  resistance  on  the  other.  When  covered 
by  intestines,  it  Avill  be  necessary  to  press  down  the  pleximeter  with 
tolerable  firmness,  but  not  in  such  a  manner  as  to  give  the  patient  pain. 
In  the  infant,  the  situation  of  the  bladder  is  not  so  deep  in  the  pelvis, 
and  a  small  quantity  of  fluid  renders  it  cognizable  by  means  of  per- 
cussion. 

A  ready  approximation  of  the  state  of  the  bladder  will  be  found  of 
great  service  in  cases  of  fever,  apoplexy,  delirium,  imbecility,  paraplegia, 
etc.  etc.  In  several  cases  it  has  been  found  dangerously  distended,  on 
percussing  the  abdomen  to  determine  the  state  of  the  intestines. 

I  have  here  only  noticed  those  circumstances  in  the  art  of  percussion 
which  may  be  readily  accomplished,  and  which  every  one  may  master 
in  a  few  months  by  care  and  attention.  For  a  description  of  the  more 
delicate  points,  such  as  percussion  of  the  kidneys  and  foetus,  accurately 
limiting  the  auricles  and  ventricles,  determining  and  marking  out  the 
ascending  and  transverse  portions  of  the  arch  of  the  aorta,  etc.,  I  must 
refer  you  to  the  admirable  works  of  MM.  Piorry*  and  Mailliot.f 


AUSCULTATION. 

The  object  of  auscultation  is  to  ascertain  and  appreciate  the  nature 
of  the  various  sounds  which  occur  in  the  intei'ior  of  the  body.  It  has 
been  found  most  useful  when  applied  to  the  pulmonary  and  circulatory 
organs.  Auscultation  of  the  abdomen  is  occasionally  serviceable,  espe- 
cially in  certain  cases  of  pregnancy,  and  during  labour.  It  has  also 
been  applied  to  the  head,  although  I  have  never  been  able  to  make  out 
any  useful  results  from  the  practice. 


General  Eules  to  be  followed  in  the  Practice  of 
Auscultation. 

1.  Auscultation  may  be  practised  directly  by  applying  the  ear  to  the 
part,  or  indirectly  through  the  medium  of  a  stethoscope.  Generally 
speaking,  direct  auscultation  answers  every  necessary  purpose  except 
when  the  surface  is  unequal,  or  when  it  is  desirable  to  limit  the  sounds 
to  a  small  region,  as  during  auscultation  of  the  heart.  In  either  of 
these  cases  a  stethoscope  is  necessary.  The  instrument  is  also  useful  to 
confirm  or  nullify  the  existence  of  certain  fine  sounds  which  may  be 
detected  by  the  naked  ear ;  to  remove  the  head  of  the  practitioner  a 
respectable  distance  from  the  bodies  of  persons  not  distinguished  for 
cleanhness ;  and  lastly,  as  the  most  delicate  method  of  auscultating  the 

*  De  la  Percussion  Mediate,  etc.,  Paris,  1828.  Du  Procede  Operatoire,  Paris, 
1831.  De  rExaraen  Plessimetrique  de  I'Aorte  Ascendante,  et  de  la  Crosse  Aor- 
tique,  etc.  Archives  Gen.  de  Med.,  vol.  ix.,  1840,  p.  431.  On  Percussion  of  the 
Uterus,  and  its  Results  in  the  Diagnosis  of  Pregnancy:  Monthly  Journal,  1846-7, 
p.  857.     Atlas  de  Plessimetrisme,  Paris,  18.51. 

f  Mailliot  (L.)  Traite  de  la  Percussion  Mediate,  etc.,  Paris,  translated  into  English 
with  notes,  by  Dr.  George  Smith  of  Madras. 

4 


50  EXAMIXATIO^r  OF  THE   PATIEXT 

chest  anteriorly  in  women.  You  should  regard  the  stethoscope  merely 
as  a  means  to  an  end — that  end  being  the  right  appreciation  of  the 
pathological  changes  indicated  by  certain  sounds. 

2.  In  the  choice  of  a  stethoscope,  you  should  observe,  1st,  That  the 
ear-piece  fits  your  own  ear ;  2d,  That  the  trumpet-shaped  extremity  is 
not  above  an  inch  and  a  half  in  diameter,  and  is  rounded  so  as  not  to 
injure  the  patient's  skin  when  pressure  is  made  upon  it ;  3d,  That  it  is 
light  and  portable.  The  instruments  recently  made  of  gutta  percha 
fulfil  all  these  conditions. 

3.  In  applying  the  ear,  the  body  of  the  patient  should  be  covered  only 
with  a  smooth  piece  of  linen  or  a  towel.  But  the  stethoscope  should 
be  applied  to  the  naked  skin,  and  held  steady  immediately  above  the 
trumpet-shaped  extremity  by  the  thumb  and  index  finger  ;  it  should  be 
pi-essed  down  with  tolerable  firmness,  whilst  with  the  second,  third,  and 
fourth  fingers,  you  ascertain  whether  the  circular  edge  be  perfectly 
applied,  which  is  absolutely  essential. 

4.  The  position  of  the  patient  will  vary  according  to  the  part  ex- 
amined. In  auscultating  the  lungs  anteriorly,  the  erect  or  recumbent 
positions  may  be  chosen,  the  two  arms  being  placed  in  a  symmetrical 
position  by  the  side.  If  the  chest  be  examined  posteriorly,  the  indi- 
vidual should  lean  somewhat  forward  and  cross  the  arms  in  front.  In 
auscultation  of  the  abdomen,  various  positions  will  be  required,  according 
as  the  anterior,  lateral,  or  posterior  regions  demand  investigation.  The 
practitioner,  also,  should  choose  such  a  position  as  will  prevent  too  much 
stooping  or  straining.  Generally  speaking,  the  beds  in  the  Infirmary 
here  are  too  low,  and  render  auscultation  very  fatiguing  to  the  physician. 

5.  Whenever  individuals  are  thrown  into  such  a  state  of  agitation  as 
to  interfere  with  the  regular  action  of  the  heart  or  lungs,  the  examina- 
tion should  be  deferred  until  their  fear  diminishes,  or  the  greatest  cau- 
tion should  be  exercised  in  drawing  conclusions.  Non-attention  to  this 
rule  has  led  to  many  errors. 

6.  Before  examining  patients  in  a  hospital,  it  is  necessary  that  you 
should  have  made  yourselves  perfectly  acquainted  with  the  sounds  which 
are  continually  going  on  in  the  healthy  body.  Omission  of  this  rule 
not  only  renders  the  examination  of  patients  useless,  but  betrays  great 
want  of  consideration.  For,  as  it  is  only  from  the  alterations  the  healthy 
sounds  undergo,  or  from  their  being  replaced  by  others,  that  we  draw 
conclusions,  how  can  this  be  accomplished  if  we  are  ignorant  of  their 
character  in  the  first  instance  ?  It  is  expected,  therefore,  of  every  ex- 
amining pupil,  that  he  should  be  familiar  with  the  character  and  theory 
of  the  various  sounds  heard  in  the  healthy  body  before  coming  to  the 
bedside.  This  study  belongs  to  the  Institutes  of  Medicine,  rather  than 
to  that  of  Clinical  Instruction.* 

*  Before  commencing  the  actual  examination  of  patients,  you  should  make  one  or 
more  serious,  careful,  and  prolonged  examinations  of  the  chest  of  one  of  your  fellow- 
students  in  private,  so  as  to  familiarise  your  ear  with  the  liealthy  laryngeal,  tracheal, 
pulmonary,  and  cardiac  sounds,  and  with  tlie  character  of  tlie  vocal  resonance,  and 
of  tlie  cough,  as  heard  in  various  parts  of  the  chest.  You  should  then  listen  in  the 
same  manner  to  the  chest  of  a  young  boy  of  from  five  to  eight  years  of  age,  and 
observe  how  clear  and  exaggerated  the  pulmonary  sounds  are.  Then  read  the  sliort 
description  which  follows,  of  the  healthy  and  morbid  sounds,  and  subsequently  con- 
sult the  more  lengthened  systematic  treatises  on  this  subject. 


BY  AUSCULTATION.  51 


Special  Rules  to  be  followed  during  Auscultation  of 
THE  Pulmonary  Organs. 

1.  In  listening  to  the  sounds  produced  by  the  action  of  the  lungs,  we 
should  pay  attention  to  tliree  things :  1st,  The  natural  respiration ; 
2d,  The  forced  or  exaggerated  respiration ;  and  3d,  The  vocal  reso- 
nance. For  this  purpose,  having  listened  to  the  sounds  during  ordinary 
breathing,  we  direct  the  patient  to  take  a  deep  breath,  and  then,  still 
listening,  we  ask  him  a  question,  and  during  his  reply  judge  of  the  vocal 
resonance. 

2.  You  should  commence  the  examination  immediately  under  the 
centre  of  one  clavicle ;  and  having  ascertained  the  nature  of  the  sounds 
and  vocal  resonance  there,  you  should  immediately  listen  at  exactly  the 
corresponding  spot  on  the  opposite  side.  The  examination  should  be 
continued  alternately  from  one  side  to  the  other,  in  corresponding 
places,  until  tlie  whole  anterior  surface  of  the  chest  is  explored.  The 
posterior  surface  is  then  to  be  examined  in  like  manner. 

3.  When,  in  the  course  of  the  examination,  anything  different  from 
the  normal  condition  is  discovered  at  a  particular  place,  that  place  and 
the  parts  adjacent  should  be  made  the  subject  of  special  examination, 
until  all  the  facts  regarding  the  lesion  be  ascertained. 

4.  It  is  occasionally  useful  to  tell  the  patient  to  cough,  in  which  case 
we  are  enabled  to  judge, — 1st,  Of  forced  inspiration,  as  it  precedes  the 
cough  ;  and,  2d,  Of  the  resonance  which  the  cough  itself  occasions. 


Of  the  Sounds  produced  by  the  Pulmonary  Organs  in 
Health  and  in  Disease. 

I  am  anxious  to  impress  upon  you,  that  the  sounds  which  may  be 
heard  in  the  lungs  are  like  nothing  but  themselves.  Students  are  too 
apt  to  take  up  erroneous  notions  from  reading  on  this  subject,  and, 
instead  of  listening  to  the  sound  actually  produced,  fatigue  theiuselves 
in  a  vain  endeavour  to  hear  something  like  the  crackling  of  salt,  the 
rubbing  of  hair,  foaming  of  beer,  or  other  noises  to  which  these  sounds 
have  been  likened.  Preconceived  notions  frequently  oppose  themselves 
to  the  reception  of  the  truth,  and  have  to  be  got  rid  of  before  the  real 
state  of  matters  can  be  ascertained.  Hence  the  great  importance  of 
deriving  your  first  impressions  of  the  sounds  to  be  heard  by  auscul- 
tation, not  from  books  or  lectures,  but  from  the  living  body  itself. 

If  you  listen  through  your  stethoscope,  placed  over  the  larynx  and 
trachea  of  a  healthy  man,  you  will  hear  two  noises, — one  accompanying 
the  act  of  inspiration,  and  the  other  that  of  expiration.  These  are 
called  the  laryngeal  and  tracheal  sounds  or  murmurs.  If  you  next 
place  your  stethoscope  a  little  to  the  right  or  left  of  the  manubrium  of 
the  sternum,  you  will  hear  the  same  sounds  diminished  in  intensity. 
These  are  the  bronchial  sounds  or  murmurs.  If  now  you  listen  under 
and  outside  the  nipple  on  the  right  side,  or  posteriorly  over  the  inferior 
lobe  of  either  lung,  you  will  hear  two  very  fine  murmurs.  That  ac- 
companying the  inspiration  is  much  more  distinct  than   that  accom- 


52  EXAMINATION   OF  THE   PATIENT 

panying  the  expiration.  By  some,  on  account  of  its  excessive  fineness, 
it  is  stated  that  there  is  no  expiratory  murmur  in  heahh ;  but  this  is 
incorrect.  These  sounds,  then,  are  the  vesicular  resjnrotory  murmurs. 
All  these  sounds  become  exaggerated  during  forced  respiration,  but  in  a 
state  of  liealth  they  never  lose  their  soft  character.  Again,  if  you  listen 
in  the  same  places,  whilst  the  individual  speaks,  you  will  hear  a  peculiar 
resonance  of  the  voice,  which  has  been  called,  in  the  first  situation, 
pectoriloquy ;  in  the  second,  bronchojjhoni/  ;  Avhile  in  the  third  it  is 
scarcely  audible.  A  knowledge  of  these  circumstances,  and  a  capability 
of  appreciating  these  sounds,  are  necessary  preliminary  steps  to  the  right 
comprehension  and  detection  of  the  murmurs  which  may  be  heard 
during  disease. 

I  have  to  suppose,  then,  that  you  have  made  your  ears  familiar  with 
these  sounds,  and  that  you  are  acquainted  with  the  present  state  of 
theory  regarding  their  formation.  This  last  may  be  stated  in  very  few 
words  to  be,  that  the  respiratory  murmurs  are  occasioned  by  the  vibra- 
tion of  the  tubes  through  which  the  air  rushes,  according  to  well-known 
acoustic  principles.  Hence  they  are  loudest  in  the  trachea,  finer  in  the 
large  bronchi,  and  finest  in  their  ultimate  ramifications.  The  vocal 
resonance,  on  the  other  hand,  originates  in  the  larynx ;  and  diminishes 
or  increases — 1st,  According  to  the  distance  of  any  point  from  the 
source  of  the  sound  ;  and,  2d,  According  to  the  power  which  the  tex- 
tures have  in  propagating  it. 

If  now  you  examine,  in  succession,  any  six  of  the  cases  in  the  wards 
w^hich  are  labouring  under  well-marked  pulmonary  diseases,  you  will 
have  no  difficultv  in  recognising  that  all  the  sounds  you  hear  may  be 
classified  into  two  divisions  :  1st,  Alterations  of  the  natural  sounds  ;  2d, 
New,  or  abnormal  sounds,  never  heard  during  health. 

I.  Alterations  of  the  Natural  Sounds. — All  the  sounds  of  which 
we  have  spoken,  and  which  can  be  heard  in  the  lungs  during  health, 
may,  in  certain  diseased  conditions,  be  increased,  diminished,  or  absent ; 
their  character  or  condition  may  be  changed  ;  and  with  regard  to  the 
respiratory  murmurs,  they  may  present  alterations  in  rhythm  or  dura- 
tion with  respect  to  each  other. 

Alterations  in  Intensity. — Some  persons  have  naturally  louder  respi- 
ratory murmurs  than  others  ;  if  this  occur  uniformly  on  both  sides,  it  is 
a  healthy  condition.  Occasionally,  however,  the  sounds  are  evidently 
stronger  at  one  place,  or  on  one  side  [imerile  respiration),  and  then  they 
generally  indicate  increased  action  of  the  lung,  supplementary  to  dimi- 
nished action  in  some  other  part.  In  the  same  manner,  there  may  be 
feeble  respiration  simply  from  diminished  action,  as  in  feeble  or  old  per- 
sons ;  but  it  may  also  be  occasioned  by  pleurodynia,  obstructions  in  the 
larynx,  trachea,  or  bronchi — pleurisy,  or  pulmonary  emphysema,  or  exu- 
dations filling  up  a  greater  or  less  number  of  the  air-cells  and  smaller 
tubes,  as  in  pneumonia,  phthisis,  etc.  Complete  absence  of  respiration 
occurs  where  there  is  extensive  pleuritic  eft'usion  or  hydrothorax. 

Alterations  in  Character. — The  various  respiratory  murmurs  may,  in 
certain  conditions  of  the  lung,  assume  a  peculiar  harshness,  which,  to  the 
ear  of  the  practised  auscultator,  is  a  valuable  sign,  indicative  of  altered 
texture.     Thus,  in  incipient  phthisic,  the  vesicular  murmur  under  the 


BY   AUSCULTATION.  53 

clavicle  is  often  rude  or  harsh.  In  pneumonia  the  broncliial  respiratory 
murmur  presents  a  similar  character.  When  a  cavity  is  formed,  it  be- 
comes what  is  called  cavernous  (hoarse  or  blowing)  ;  and  in  certain  cases 
of  pneumothorax  with  pulmonary  fistula,  it  assumes  an  amphoric  cha- 
racter. 

Alterations  in  Position. — It  frequently  happens  that  the  sounds  which 
are  natural  to  certain  parts  of  the  chest,  are  heard  distinctly,  at  places, 
where  in  health  they  are  never  detected.  Thus,  in  pneumonia,  bronchial, 
or  tubular  breathing,  as  it  is  sometimes  called,  may  be  evident,  where 
only  a  vesicular  murmur  ought  to  exist.  This  is  often  well  marked  with 
regard  to  the  vocal  resonance,  as  certain  lesions,  which  occasion  conden- 
sation or  ulceration  of  the  lungs,  will  enable  us  to  hear  either  broncho- 
phony or  pectoriloquy,  Avhere,  under  ordinary  circumstances,  no  voice 
can  be  heard. 

Alterations  in  Rhythm. — In  health,  the  inspiration  is  usually  three  times 
as  long  as  the  expiration.  In  certain  diseased  conditions  this  relation  is 
altered,  or  even  inverted.  In  incipient  phthisis  we  often  find  the  expira- 
tion unnaturally  prolonged.  In  chronic  bronchitis  and  emphysema  it  is 
three  or  four  times  longer  than  the  inspiration. 

II.  New  or  Abnormal  Sounds. — These  are  of  three  kinds :  1st, 
Rubbing  or  friction  sounds;  2d,  Moist  rattles;   3d,  Vibrating  murmurs. 

1.  Rubbing  or  Friction  Sounds  are  caused  in  the  puhuonary  apparatus 
by  some  morbid  change  in  the  pleurae,  whereby,  instead  of  sliding  noise- 
lessly on  one  another,  they  emit  a  rubbing  sound.  This  may  be  so  fine 
as  to  resemble  the  rustling  of  the  softest  silk,  or  so  coarse  as  to  sound 
like  the  creaking  of  a  saddle,  grating,  rasping,  etc. ;  and  between  these 
two  extremes  you  may  have  every  intermediate  shade  of  friction  noise. 
This  variation  in  sound  is  dependent  on  the  nature  of  the  alteration 
which  the  pleurte  have  undergone.  If  covered  with  a  softened  thin  exu- 
dation, the  murmur  will  be  soft :  if  it  be  tougher  and  thicker,  the  sound 
will  be  louder;  if  hard,  dense,  and  rough,  it  will  assume  a  creaking,  harsh, 
or  grating  character.  These  noises  are  heard  in  the  various  forms  of 
pleurisy. 

2.  Moist  Rattles  are  produced  by  bubbles  of  air  traversing  or  breaking 
in  a  somewhat  viscous  fluid.  This  may  occur  in  the  bronchi  when  they 
contain  liquid  exudation,  mucus,  or  pus,  or  in  ulcers  of  various  sizes. 
They  may  be  so  fine  as  to  be  scarcely  audible  (when  they  have  been 
called  crepitating),  or  so  coarse  as  to  resemble  gurgling  or  splashing, 
when  they  have  received  the  name  of  cavernous.  Here,  again,  between 
these  two  extremes,  we  may  have  every  kind  of  gradation,  to  which 
auscultators  have  attached  names,  such  as  mucous,  submucous,  subcrepi- 
tating,  etc.  etc.  With  these  names  you  need  not  trouble  yourselves; 
all  that  it  is  important  for  you  to  determine  is,  whether  or  not  the 
sound  be  moist,  and  you  will  easily  recognise  that  the  rattles  are  coarse 
or  large,  in  proportion  to  the  size  of  the  tubes  or  ulcers  in  which  they 
are  produced,  and  the  amount  of  fluid  present.  These  rattles  may  be 
heard  in  pneumonia,  phthisis  pulmonalis,  bronchitis,  pulmonary  apoplexy, 
etc.  etc. 

3.  Dry  Vibrating  Murmurs  arise  when  the  air-tubes  are  obstructed, 
constricted,  or  lose  their  elasticity  and  become  enlarged,  whereby  the 


5-i  EXAMINATION"   OF  THE   PATIENT 

vibrations  into  whicli  they  are  thrown  by  the  column  of  air,  produce 
sounds  or  tones  of  an  abnormal  character.  Hence  murmurs  may  be 
occasioned  of  a  fine  squeaking  (^sibilous  murmur),  or  of  a  hoarse  snoring 
character  {sonorous  viurmu?'),  and  between  the  two  extremes  there  may 
be  all  kinds  of  variations,  to  which  ingenious  people  have  applied  names. 
These  only  cause  confusion  ;  all  that  is  necessary  is  to  ascertain  that  the 
murmur  is  dry,  and  you  will  readily  understand  that  the  fineness  or 
coarseness  of  the  sound  will  depend  on  the  calibre  of  the  tube  or  cavity 
thrown  into  vibrations.  They  are  usually  heard  in  cases  of  bronchitis 
and  emphysema.  Occasionally  they  present  a  blowing  character,  as 
when  ulcers  are  dry,  a  condition  which  often  occurs  in  phthisis. 

The  vocal  resonance,  besides  undergoing  the  changes  already  noticed 
in  intensity,  character,  and  i)osition,  may  give  rise  to  abnormal  sounds. 
Occasionally  it  presents  a  soft  reverberating  or  trembling  noise,  like  the 
bleating  of  a  goat  [cegojihomj).  The  value  of  this  sign,  as  indicative  of 
pleurisy,  was  much  overrated  by  Laennec.  At  present  it  is  little  esteemed. 
Sometimes  the  resonance  gives  rise  to  a  metallic  tinklivg,  a  noise  similar 
to  that  caused  by  dropping  a  shot  into  a  large  metallic  basin,  or  the  note 
produced  by  rubbing  a  wet  finger  round  the  edge  of  a  tumbler  or  glass 
vessel.  This  is  often  best  heard  immediately  after  a  cough  in  certain 
cases  of  chronic  phthisis,  ^gophony  is  supposed  to  be  produced  when 
a  thin  layer  of  serous  fluid  between  the  pleuroe  is  thrown  into  vibrations. 
The  cause  of  metallic  tinkling  has  created  great  discussion,  and  is  not 
yet  ascertained. 

Such,  then,  are  the  principal  sounds  Avhich  maybe  heard  on  ausculta- 
tion of  the  pulmonary  organs  in  health  and  during  disease.  Many  writers 
have  endeavoured  to  point  out  their  diagnostic  importance,  and  drawn 
up  rules  which  have  always  appeared  to  me  much  too  arbitrary.  Indeed, 
in  so  far  as  the  education  of  medical  students  is  concerned,  I  have  long 
been  persuaded  that  the  study  of  these  rules  has  retarded  their  powers 
of  diagnosis,  and  afterwards  led  to  dangerous  errors  in  practice.  I  know 
of  no  dogma,  for  instance,  more  mischievous  than  the  one  which  asserts 
a  crepitating  (that  is  a  fine  moist)  rattle  to  be  pathognomonic  of  pneu- 
monia, because  such  a  rattle  is  just  as  common  in  phthisis,  and  is  fre- 
quently heard  in  various  other  lesions  of  the  pulmonary  organs.  Hence 
we  should  regard  a  crepitating  rattle  not  as  distinctive  of  this  or  that 
so-called  disease,  but  simply  of  fluid  in  the  smaller  air-passages ;  so  also 
an  increased  resonance  of  the  voice,  as  indicating  hollow  spaces  with  vi- 
brating walls,  or  increased  induration  of  the  pulmonary  textures,  and  not 
as  diagnostic  of  phthisis,  pneumonia,  and  so  on.  I  wish,  then,  strongly 
to  impress  upon  you, — 

1st,  That\he  difterent  sounds  are  only  indicative  of  certain  physical 
conditions  of  the  lung,  and  in  themselves  bear  no  fixed  relation  to  the  so- 
called  diseases  of  systematic  writers. 

2d,  No  single  acoustic  sign,  or  combination  of  signs,  is  invariably 
pathognomonic  of  any  certain  pathological  state, — and  conversely,  there 
is  no  pathological  state  which  is  invariably  accompanied  by  any  series  of 
physical  signs. 

3d,  Auscultation  is  only  one  of  the  means  whereby  we  can  arrive  at  a 
just  diagnosis,  and  shouL;!  never  be  depended  on  alone. 


BY  auscultatio:n.  55 


Special  Rules  to  be  followed  cuRiNa  Auscultation  of  the 
Circulatory  Organs. 

1.  In  listening  to  the  sounds  produced  by  tlie  action  of  the  heart  and 
arteries,  we  should  pay  attention — 1st,  To  the  impulse ;  2d,  To  the  cha- 
racter and  rhythm  of  the  sounds ;  3d,  To  the  place  where  they  are 
heard  loudest,  and  the  direction  in  which  they  are  propagated, 

2.  You  should  commence  the  examination  by  feeling  for  the  spot 
where  the  apex  of  the  heart  beats  against  the  walls  of  the  chest,  wj|ich 
will  enable  you  to  judge  of  the  impulse.  This  ascertained,  place  your 
stethoscope  immediately  over  it,  and  listen  to  the  sounds.  Then  place 
the  instrument  above,  and  a  little  to  the  inside  of,  the  nipple,  near  the 
margin  of  the  sternum,  and  listen  to  the  sounds  there.  In  the  one 
situation  you  will  hear  the  first  or  systolic  sound,  in  the  other  the 
second  or  diastolic  sound  louder. 

3.  If  anything  different  from  the  normal  condition  be  discovered  in 
either  one  or  the  other  position,  or  in  both,  this  should  be  again  care- 
fully examined,  and  by  moving  the  stethoscope  below  and  round  the 
apex  of  the  heart,  or  above,  in  the  course  of  the  aortic  arch  or  carotids, 
on  the  right  and  left  side,  etc.,  etc.,  it  should  be  ascertained  at  what 
point,  or  over  what  space,  the  abnormal  sounds  are  heard  loudest,  and 
whether  they  be  or  be  not  propagated  in  the  course  of  the  large  vessels. 
Occasionally  listening  over  the  back  and  in  the  course  of  the  descending 
aorta  may  be  useful. 

4.  When,  during  the  above  examination,  we  discover  a  new^  source  of 
impulse  or  of  sound  in  one  of  the  large  vessels,  this  must  be  especially 
examined,  the  limits  of  such  impulse  and  sound  carefully  ascertained — 
whether  it  be  or  be  not  synchronous  with  those  originating  in  the 
heait — its  direction,  etc. 

5.  Under  ordinary  circumstances,  the  respiratory  do  not  interfere 
with  the  detection  of  the  cardiac  sounds ;  but  where  the  former  are 
very  loud  and  the  latter  indistinct,  it  is  useful  to  direct  the  individual  to 
hold  his  breath  for  a  few  moments.  Sometimes  the  impulse  and  sounds 
of  the  heart  are  heard  better  by  directing  the  patient  to  lean  forward ; 
they  may  also,  if  necessary,  be  exaggerated  and  rendered  more  distinct 
by  directing  him  to  walk  quickly,  or  to  make  some  exertion  for  a  short 
time. 


Of  the  Sounds  produced  by  the  Circulatory  Organs  in  Health 

AND  Disease. 

On  placing  your  ear  over  the  cardiac  region  in  a  healthy  person,  you 
will  feel  a  beating,  and  hear  two  sounds,  which  have  been  likened  to 
the  tic-tac  of  a  watch,  but  to  which  they  bear  no  resemblance.^  They 
may  be  imitated,  however,  very  nearly,  as  pointed  out  by  Dr.  Williams,^ 
by  pronouncing  in  succession  the  syllables  Itqyp,  diijq).  The  first  ot 
these  sounds,  which  is  dull,  deep,  and  more  prolonged  than  the  second, 
coincides  with  the  shock  of  the  apex  of  the  heart  against  the  thorax, 
and  immediately  precedes  the  radial  pulse  ;  it  has  its  maximum  intensity 


56  EXAMINATIOX   OF  THE   PATIEXT 

over  the  apex  of  the  heart — below  and  somewhat  to  the  inside  of  the 
nipple.  The  second  sound,  "nhich  is  sharper,  shorter,  and  more  superfi- 
cial, has  its  maximum  intensity  nearly  on  a  level  with  the  third  rib,  and 
a  little  above  and  to  the  right  of  the  nipple — near  the  left  edge  of  the 
sternum.  These  sounds,  therefore,  in  addition  to  the  terms  first  and 
second,  have  also  been  called  inferior  and  superior,  long  and  short,  dull 
and  sharp,  systolic  and  diastolic — which  expressions,  so  far  as  o-jving  a 
name  is  concerned,  are  synonymous. 

The  two  sounds  are  repeated  in  couples,  which,  if  we  commence  with 
the^rst  one,  follow  each  other  with  their  intervening  pauses,  thus — 1st, 
There  is  the  long  dull  sound  coinciding  with  the  shock  of  the  heart ; 
2d,  There  is  a  short  pause ;  3d,  The  short  sharp  sound,  and  4th,  A 
longer  pause, — all  which  correspond  with  one  pulsation.  In  figures,  the 
duration  of  these  sounds  and  pauses  by  some  has  been  represented 
thus, — the  first  sound  occupies  a  third,  the  short  pause  a  sixth,  the 
second  sound  a  sixth,  and  the  long  pause  a  third.  Others  have  divided 
the  whole  period  into  four  parts ;  of  which  the  two  first  are  occupied 
by  the  first  sound,  the  third  by  the  second  sound,  and  the  fourth  by  the 
pause.  The  duration,  as  well  as  the  loudness,  of  the  sounds,  however, 
are  very  variable,  even  in  health,  and  are  influenced  by  the  force  and 
rapidity  of  the  heart's  action,  individual  peculiarity,  and  form  of  the 
thorax.  Their  extent  also  difi"ers  greatly.  They  are  generally  distinctly 
heard  at  the  precordial  region,  and  diminish  in  proportion  as  we  with- 
draw the  ear  from  it.  They  are  less  audible  anteriorly  on  the  right 
side,  and  still  less  so  posteriorly  on  the  left  side.  On  the  right  side 
posteriorly  they  cannot  be  heard.  Their  tone  also  varies  in  diff'erent 
persons ;  but  in  health  they  are  free  from  a  hareh  or  blowing  character. 

Great  divei-sity  of  opinion  has  existed  regarding  the  causes  of  these 
sounds — which  you  will  have  heard  discussed  before  coming  here. 
You  must  never  forget,  however,  the  cardiac  actions  which  coincide 
with  them  ;  for  our  reasoning  from  any  changes  we  may  detect  in  the 
sounds  will  entirely  depend  upon  our  knowledge  of  these  coincidences. 
"VVe  mav  consider,  then,  that  there  occur  with  the  first  sound — 1st,  The 
impulse,  or  striking  of  the  apex  against  the  thoracic  walls  ;  2d,  Contrac- 
tion of  the  ventricles ;  3d,  Rushing  of  the  blood  through  the  aortic 
orifices :  and  4th,  Flapping  together  of  the  auriculo-ventricnlar  valves. 
There  coincide  with  the  second  sound — 1st,  Rushing  of  the  blood 
through  the  auriculo-ventricular  valves ;  and  2d,  Flapping  together  of 
the  aortic  valves.  Contraction  of  the  auricles  immediately  precedes 
that  of  the  ventricles.  The  result  of  numerous  pathological  observations, 
and  of  many  experiments,  is,  that  in  health  the  first  sound  is  produced 
by  the  combined  action  of  the  auriculo-ventricular  valves,  of  the  ven- 
tricles, and  of  the  rushing  of  the  blood,  which  sound  is  augmented  in  in- 
tensity by  the  impulsion  of  the  heart's  apex  against  the  thorax  ;  whereas 
the  second  sound  is  caused  only  by  the  flapping  together  of  the  sigmoid 
valves. 

T\'ith  the  cardiac  as  with  the  respiratory  sounds,  the  alterations 
which  take  place  during  disease  may  be  divided  into — 1st,  Modification 
of  the  sounds  heard  in  health;  2d,  Xew  or  abnormal  sounds. 

I.  MoDiFicATioxs  OF  THE  Healthy  Souxds. — These  refer  to  the 


BY  AUSCULTATION.  57 

variations  the  liealtliy  sounds  present  in  their  seat,   intensity,   extent, 
character,  and  rhythm. 

Seat. — The  somxls  may  be  lieard  at  their  maximum  intensity  lower 
than  at  the  points  previously  indicated,  as  in  cases  of  dilated  hyper- 
trophy of  the  left  ventricle,  enlargement  of  the  auricles,  or  of  tumours 
at  the  base,  depressino-  the  organ.  They  may  be  Imjher,  owing  to  any 
kind  of  abdominal  swelling  pushing  up  the  diaphragm.  They  may  be 
more  on  one  side  or  theother,  in  cases  where  the  heart  is  pushed 
laterally  by  effusions  of  air  or  fluid  in  a  pleural  cavity.  Various  other 
circumstances  may  also  modify  their  natural  position,  such  as  tumours 
in  the  anterior  or  posterior  mediastinum,  aneurisms  of  the  large  vessels, 
adhesions  of  the  pericardium,  deformity  in  the  bones  of  the  chest, 
etc.  etc. 

Intensity  and  Extent. — These  are  diminished  in  cases  where  the  heart 
. is  atrophied  or  softened  ;  when  there  is  pericardial  cflfusion,  concentric 
hypertrophy  of  the  left  ventricle,  or  emphysema  at  the  anterior  border 
of  the  left  fung.  They  are  increased  in  cases  of  dilated  hypertrophy,  of 
nervous  palpitations,  and  when  neighbouring  portions  of  the  lung  are 
indurated,  especially  in  certain  cases  of  pneumonia  and  phthisis  pul- 
monalis. 

Character. — The  sounds  become  clearer  or  duller  than  usual,  accord- 
ing as  the  walls  of  the  heart  are  thinner  or  thicker.  Occasionally  they 
sound  muffled  in  cases  of  hypertrophy  or  softening  of  the  muscular  walls. 
Not  unfre'quently  there  is  a  certain  degree  of  roughness,  which  is  difficult 
to  determine  as  being  healthy  or  morbid.  Occasionally  it  ushers  in 
more  decided  changes ;  at  other  times  it  continues  for  years  without 
alteration.  These  alterations  in  character  are  distinguished  by  some 
auscultators  as  variations  in  the  tone  of  the  sounds. 

Rhythm  or  Time. — I  need  not  say  that  the  frequency  of  the  pulsations 
differs  greatly  in  numerous  affections  altogether  independent  of  any 
special  disease  in  the  heart.  In  certain  cardiac  affections,  however,  the 
beats  are  intermittent,  in  others  irregular — that  is,  they  succeed  each 
other  at  unexpected  intervals.  The  number  of  the  sounds  also  varies. 
Sometimes  only  one  can  be  distinguished,  it  being  so  prolonged  as  to 
mask  the  other.  Occasionally  three  or  even  four  sounds  may  be  heard, 
depending  either  on  reduplication  in  the  action  of  ■the  valves  when 
diseased,  "or  on  want  of  synch ronisin  between  the  two  sides  of  the  heart. 
Not  unfrequently  the  increased  and  irregular  movements  of  the  organ, 
combined  with  the  sounds,  are  of  such  a  character  as  to  receive  the  name 
of  tumultuous. 

IT.  New  or  Abnormal  Sounds. — These  are  of  two  kinds :  1st, 
Friction  murmurs ;  2d,  Blowing  or  vibrating  murmurs.  Dr.  Latham 
has  called  them  exocardial  and  endocardial.  I  am  in  the  habit  of  deno- 
minating i\\eiQ  jyericardial  and  valvular. 

Pericardial  or  Friction  Murmurs. — These  murmurs  are  the  same  in 
character,  and  originate  from  the  same  causes,  as  the  friction  noises  con- 
nected with  the  pulmonary  organs.  It  is  only  necessary  to  observe,  that 
occasionally  they  are  so  soft  as  closely  to  resemble  blowing  murmurs, 
from  which  they  are  only  to  be  distinguished  by  their  superficial  character 
and  limited  extent. 


58  EXAMINATION   OF  THE   PATIENT. 

Valvular  or  Vibrating  Murmurs. — These  murraurs  vary  greatl}'  in 
character ;  some  being  so  soft  as  to  resemble  the  passage  of  the  gentlest 
wind  ;  others  are  like  the  blowing  or  puff  from  the  nozzle  of  a  bellows 
(bellows  murmurs) ;  whilst  others  are  harsher,  resembling  the  noise 
produced  by  grating,  filing,  sawing,  etc.  They  are  all  occasioned, 
however,  by  diseases  interfering  with  the  functions  of  the  valves.  Some- 
times these  do  not  close,  and  the  blood  consequently  regurgitates  through 
them ;  at  others,  whilst  this  is  the  case,  they  are  constricted,  indurated, 
roughened,  and  even  calcareous — whence  the  harsher  sounds.  They 
mB.y  be  single  or  double,  and  have  their  origin  either  in  the  auriculo- 
ventricular  or  arterial  valves,  or  in  both  at  once,  the  detection  of  which 
constitutes  the  diagnosis  of  the  special  diseases  of  the  organ.  Occa- 
sionally these  sounds  resemble  musical  notes,  more  or  less  resembling 
the  cooing  of  a  dove,  singing  or  twittering  of  certain  small  birds,  whis- 
tling, tinkling,  etc.  etc.  These  depend  either  upon  excessive  narrowing 
of  the  orifices,  or  upon  any  causes  which  induce  vibrations  of  solids  in 
the  current  of  blood — as,  when  there  are  perforations  in  the  valves, 
irregularities  of  their  margins,  string-like  or  other  shaped  exudations  on 
their  surface,  etc.  etc. 


Auscultation  of  the  Abdomen. 

On  applying  the  stethoscope  over  the  stomach  and  intestines  in  a 
healthy  state,  various  gurgling  and  churning  noises  may  be  heard.  In 
the  former  they  may  assume  an  amphoric  or  metallic  character,  in  the 
latter  they  are  called  borhorygmi.  They  are  caused  by  the  displacements 
of  gas  and  water,  and  are  most  audible  during  the  period  of  digestion, 
and  the  action  of  a  purgative  or  enema.  The  impulse  of  the  aorta  can 
be  detected  especially  in  thin  subjects,  when  the  pressure  of  the  stetho- 
scope may  often  be  made  to  elicit  a  blowing  sound. 

In  disease  these  sounds  may  be  increased  or  diminished,  and  in  addi- 
tion, there  may  be  present  various  kinds  of  friction  or  grating  sounds 
when  the  surface  of  the  peritoneum  is  roughened,  owing  to  exuda- 
tion or  the  unequal  pressure  of  tumours.  These  last  may  also  give  rise 
to  blowing  murmurs,  when  it  often  becomes  difficult  to  determine 
whether  the  morbid  sound  originates  in  the  tumour  itself,  or  is  the 
result  of  the  pressure  it  exercises  on  the  aorta.  In  cases  of  doubtful 
pregnancy,  the  marked  rapidity  of  the  foetal  pulse  contrasted  with  that 
of  the  individual  examined,  constitutes  a  positive  sign. 


Auscultation  of  the  Large  Vessels. 

On  listening  through  the  stethoscope  placed  over  the  arteries  in  the 
neighbourhood  of  the  heart,  w^e  hear  the  same  sounds  as  are  produced 
at  the  sigmoid  valves,  propagated  along  its  course,  but  more  indistinctly 
as  we  remove  the  instrument  away  from  the  base  of  the  heart.  In  those 
which  are  more  distant  only  one  sound,  which  is  synchronous  with  their 
impulse  and  their  dilatation,  is  heard.  This  sound  is  of  a  dull  character, 
but  in  health  always  soft. 


USE   OF  THE   MICROSCOPE.  59 

In  tlie  various  conditions  of  disease  we  have  a  single  or  double  bellows 
sound,  or  it  may  be  harsh,  grating-,  rasping,  etc.  In  the  first  place,  you 
must  ascertain  whether  any  of  th'ese  sounds  are  propagated  along  the 
artery  from  the  heart,  and  this  you  will  learn  by  listening  over  its  course 
from'that  organ,  and  by  observing  whether  they  increase  as  you  proceed 
towards  it.  If  the  sound  have  an  independent  origin,  it  may  originate 
fi-om  disease  of  the  internal  surface  of  the  artery,  when  it  will  be  harsh 
in  proportion  to  the  roughness ;  from  stricture  of,  or  pressure  on  the 
vessel,  or  from  its  dilatation.  Generally  speaking,  the  more  dilated  and 
superficially  seated  the  vessel  is,  the  sharper  is  the  sound.  Sometimes 
there  is  a  double  murmur  in  the  course  of  a  vessel,  having  an  undoubt- 
edly independent  origin.  This  is  most  common  in  cases  Avhere  there  is 
an  aneurismal  pouch!^  into  which  the  blood  passes  in  and  out  through  an 
opening  narrower  than  the  swelling  itself.  Occasionally  one  or  both 
such  murmurs  may  possess  somewhat  of  a  metallic  ringing,  or  even 
musical  character, 'and  in  such  case  the  margins  of  the  opening  are 
probablv  tense,  and  thrown  into  peculiar  vibrations. 

Not  {infrequently  a  soft  systolic  blowing  is  audible  at  the  base  of  the 
heart,  or  over  the  carotid  and  deep  jugular  vein.  At  other  times  it  is 
continuous,  resembling  humming,  or  the  noise  of  a  Parisian  toy  called 
le  diahle.  These  mm-murs  are'distinguished  from  valvular  ones — 1st, 
By  being  systolic  at  the  base  of  the  heart;  2d,  By  their  softness;  3d, 
By  not  being  permanent ;  and  4th,  By  occurring  in  ana'mic  or  debilitated 
persons,  and  especially  in  young  girls. 

I  have  already  told  you  never  to  form  a  conclusion  as  to  the  natiire 
of  the  disease  fi-om  auscultation  alone.  Even  when  combined  with 
percussion,  it  is  not  safe  to  form  a  diagnosis  without  a  knowledge  of 
all  the  circumstances  of  the  case.  Hence  why  I  repudiate  those  rules 
which  have  been  published  in  books,  that  have  for  their  object  the 
establishment  of  opinions  from  physical  signs  alone.  At  the  same 
time,  there  can  be  no  doubt  that  percussion  and  auscultation  are  abso- 
lutely essential  to  the  proper  investigation  of  maladies,  although  not 
more  so  than  other  modes  of  inquiry.  I  have,  therefore,  thought  it 
best  to  give  you  a  condensed  resume  of  the  sounds  which  may  be 
heard  by  auscultation  of  the  lungs,  heart,  abdomen,  and  large  vessels; 
pointing^  out  a  few  of  the  diseased  states  in  which  they  may  be  some- 
times (not  always)  heard,  and  especially  indicating  the  physical  con- 
ditions on  which  they  are  supposed  to  depend.  Their  true  diagnostic 
value  can   only  be  learned   by  the   careful   examination  of  individual 


cases. 


rSE  OF  THE  MICROSCOPE. 

A  knowledge  of  the  ultimate  structure  of  the  human  body,  in  its 
healthy  and  diseased  conditions,  is  now  so  advanced  as  to  necessitate 
the  introduction  of  the  microscope  among  the  ordinary  instruments  of 
the  medical  practitioner.  But  you  must  not  suppose  that  an  additional 
method  of  gaining  information  implies  abandonment  of  those,  the  utility 
of  Avhich  has  stood  the  test  of  experience.     Men  must  learn  the  every- 


60  EXAMINATION  OF  THE  PATIENT. 

day  nse  of  theii"  senses ;  must  know  liow  to  feel,  hear,  and  see,  in  the 
same  manner  as  they  did  before  instruments  were  invented.  We  don't 
see  the  stars  less  clearly  with  our  naked  sight,  because  the  telescope  is 
necessary  for  an  astronomer.  Neither  should  a  physician  observe  the 
sjTnptoms  of  a  disease  less  accurately  because  he  examines  the  chest 
with  a  stethoscope,  or  a  surgeon  be  less  dexterous  with  the  knife,  because 
it  is  only  by  means  of  the  microscope  he  can  determine  with  exactitude 
the  nature  of  a  tumour.  But  it  is  unnecessary  to  enter  into  a  lengthened 
argument  to  prove  that  the  science  and  art  of  medicine  are  greatly 
indebted,  in  modern  times,  to  the  invention  and  proper  application  of 
ingenious  instruments.  The  following  examples  will  serve  to  convince 
you  that  the  microscope  is  one  of  these : — 

Example  1. — Some  years  ago  I  was  summoned  to  see  a  Dispensary 
patient  labouring  under  bronchitis,  who  was  spitting  tlorid  blood.  On 
examining  the  sputum  with  a  microscope,  I  found  that  the  coloured  blood 
corpuscles  were  those  of  a  bird.  On  my  telling  her  she  had  mixed  a 
bird's  blood  with  the  expectoration,  her  astonishment  was  unbounded, 
and  she  confessed  that  she  had  done  so  for  the  purpose  of  imposition. 

Example  2. — A  gentleman,  for  some  years,  had  laboured  under  a 
variety  of  anomalous  symptoms,  referable  to  the  head  and  digestive 
systems,  under  which  he  had  become  greatly  reduced.  He  had  con- 
sulted many  practitioners,  and  visited  innumerable  watering  places,  in  a 
vain  search  after  health.  On  examining  the  urine  with  a  microscope,  I 
found  it  crowded  with  spermatozoa.  He  evidently  laboured  under  sper- 
matorrhoea, a  disease  which  had  never  been  suspected,  but  which  was 
readily  cured  on  the  employment  of  an  appropriate  treatment. 

Examjjle  3. — A  boy  was  brought  to  me  with  an  eruption  on  the 
scalp,  which  was  of  so  indefinite  a  character  that  its  nature  could  not 
be  determined.  He  had  lately  been  elected  to  occupy  a  vacancy  in  one 
of  our  charitable  educational  establishments,  and  the  question  to  decide 
was,  whether  the  disease  was  or  was  not  contagious.  On  examining 
the  scab  with  a  microscope,  I  readily  discovered  the  Achorion  Schoen- 
leini,  or  fungus  constituting  true  favus  ;  and  as  this  has  been  experimen- 
tally proved  to  be  inoculable,  I  had  no  hesitation  in  preventing  his 
admission  to  the  school. 

Example  4. — A  child  was  supposed  to  be  affected  with  worms,  be- 
cause it  passed  in  abundance  yellowish  shreds,  which,  to  the  naked  eve, 
closely  resembled  ascarides.  All  kinds  of  vermifuge  remedies  had  been 
tried  in  vain.  On  examining  the  shreds  with  a  microscope,  I  found 
them  to  consist  of  the  undigested  spiral  vessels  of  plants ;  and  they 
ceased  to  appear  when  the  vegetable  broth  used  as  food  was  abandoned. 

Example  5. — I  was  called  to  see  an  infant  a  month  old,  which  was  in 
a  state  of  considerable  emaciation,  with  constant  diarrhoea. — The  mother, 
however,  maintained  that  her  milk  was  abundant,  and  that  it  was  taken 
in  sufficient  quantity.  On  being  examined  with  a  microscope,  it  was 
found  to  contain  numerous  compound  granular  bodies,  and  compara- 
tively few  milk  globules.  In  short,  it  presented,  in  an  exaggerated 
degree,  all  the  characters  of  colostrum,  and  this  thirty  days  after  deliv- 
ery. It  was  evident,  then,  that  the  qualiti/  of  the  milk  was  iu  fault,  an 
opinion  which  was  confirmed  by  the  recovery  of  the  infant,  when  a 
healthy  nurse  was  procured. 


USE   OF  THE   MICROSCOPE,  61 

Example  6. — An  individual  was  supposed  to  be  labouring  under 
dysentery,  from  the  frequent  passage  of  yellowish  pulpy  masses  in  the 
stools,  accompanied  witli  tormina  and  other  symptoms.  On  examining 
these  masses  with  the  microscope,  I  found  them  to  consist  of  undigested 
potato  skins.  On  inquiry,  it  was  ascertained  that  this  person  had  eaten 
the  skins  with  the  potatoes.  On  causing  these  to  be  removed  before 
dinner,  the  alarming  appearance  ceased,  and  the  other  symptoms  also 
disappeared. 

Example  7. — An  elderly  lady  conceived  herself  to  be  affected  with 
insects  continually  fonuing  in  the  skin,  which  produced  incessant  itch- 
ing and  tingling.  All  the  hair  was  removed,  and  every  kind  of  applica- 
tion, including  mercurial  preparations,  was  tried  without  eft'ect.  On 
rubbing  the  surface,  she  always  saw  minute  white  rolls  and  black  specks, 
which  she  regarded  as  insects  in  different  stages  of  development.  The 
toiTuent  and  anxiety  this  caused  her  for  many  months  it  is  scarcely  pos- 
sible to  conceive.  At  length  she  laboured  under  the  idea  that  she  was 
communicating  the  disease  to  her  husband  and  daughter,  when,  at  the 
request  of  her  medical  attendant  in  the  west  of  Scotland,  she  came  to 
Edinburgh,  in  order  that  I  might  investigate  and  treat  it.  I  had  the 
pleasure  of  shewing  this  lady,  under  the  microscope,  that  the  white 
bodies  were  minute  rolls  of  epidermis  or  of  the  cotton  cloth  with  which 
she  rubbed  the  skin,  and  that  the  black  specks  were  portions  of  dust  or 
soot.  Her  hallucination  being  in  this  way  dissipated,  she  returned  home 
perfectly  well. 

Example  8. — A  child  had  been  suffering  for  four  years  from  copious 
and  foetid  discharge  fi'om  the  nostrils,  accompanied  with  great  pain.  At 
the  end  of  that  time,  a  dark  brown  and  indurated  mass  was  discharged, 
about  an  inch  long,  and  a  quarter  of  an  inch  broad,  closely  resembling  a 
sequestrum  of  bone.  This  mass  I  was  requested  to  examine  microscopi- 
cally by  Dr.  Littlejohn,  under  whose  care  the  patient  was,  and  from  its 
structure  I  readily  determined  that  it  consisted  of  some  fir  wood.  When 
this  was  known,  the  parents  remembered  that,  about  the  time  the  dis- 
ease commenced,  alterations  were  made  in  the  house,  and  that  the  chil- 
dren used  to  play  with  the  wood  shavings.  There  could  be  little  doubt 
that  a  piece  of  shaving  had  been  thrust  up  the  nose,  and  been  the  cause 
of  all  the  svmptoms. 

Examples  of  this  kind  could  be  readily  multiplied.  Xo  doubt  mis- 
takes will  be  made  with  this  instrument  in  the  hands  of  inexperienced 
persons,  in  the  same  manner  as  the  use  of  the  stethoscope,  or  of  a  scalpel, 
may  lead  to  a  false  conclusion,  or  to  an  accident.  But  this,  so  far  from 
being  an  argument  opposed  to  their  employment,  only  proves  the  neces- 
sity of  becoming  more  skilful  in  their  use.  Certainly  there  is  no  instru- 
ment which  requires  more  expert  management  in  itself,  or  more  caution 
in  drawing  conclusions  from  its  employment,  than  the  microscope. 


Description  of  the  Microscope. 

It  is  not  my  intention  to  enter  upon  a  description  of  the  optical  prin- 
ciples on  which  microscopes  are  constructed,  although  you  will  find  a 
knowledge  of  these  very  useful.     I  shall  suppose  that  you  are  desirous 


62 


EXAMIlSrATIOJ^  OF  THE   PATIENT. 


of  obtaining  an  instrument  that  will  answer  all  the  purposes  of  the  ana- 
tomist and  physiologist,  as  well  as  afford  you  every  possible  assistance  in 
the  way  of  diagnosis  as  medical  men.  For  this  purpose,  you  should 
learn  to  distinguish  what  is  necessary  from  what  is  unnecessary,  in  order 
that  you  may  procure  the  former  in  as  convenient  a  form,  and  at  as 
moderate  a  cost  as  possible. 

A  microscope  may  be  divided  into  mechanical  and  optical  parts. 
The  former  determine  its  general  form  and  appearance.  Of  the 
numerous  models   which  have  been   invented,   the    one  here  figured, 

exactly  one-fourth  its  real  size,  ap- 
pears to  me  the  most  useful  for  all 
the  purposes  of  the  physiologist  and 
medical  practitioner.  The  body 
consists  of  a  telescope  tube,  eight 
inches  in  length,  held  by  a  split 
tube,  three  inches  long.  It  may 
be  elevated  and  depressed  with 
great  readiness  by  a  cork-screw 
movement,  communicated  to  it  by 
the  hand,  and  this  constitutes  the 
coarse  adjustment.  It  is  attached 
to  a  cross-bar  and  pillar,  at  the 
lower  portion  of  which  last,  veiy 
conveniently  placed  for  the  hand  of 
the  observer,  is  the  fine  adjust- 
ment. The  stage  is  three  inches 
broad,  and  two  and  a  half  inches 
deep,  strong  and  solid,  with  a  cir- 
cular diaphragm  below  it.  The 
base  of  the  instrument  is  heavily 
loaded  with  lead  to  give  it  the 
necessary  steadiness. 

This  form  of  microscope  possesses 
all  the  mechanical  qualities  required 
in  such  an  instrument.  These  are — 
1st,  Steadiness;  2d,  Power  of  easy  adjustment ;  3d,  Facility  for  obser- 
vation and  demonstration  ;  and,  4th,  Portability. 

1.  Steadiness. — It  must  be  evident  that  if  the  stage  of  the  microscope 
is  subject  to  any  sensible  -vnbration,  minute  objects,  Avhen  magnified 
highly,  so  far  from  being  stationary,  may  be  thrown  altogether  out  of  the 
field  of  view.  Nothing  contributes  more  to  the  comfort  of  an  observer 
than  this  quality  of  a  microscope,  and  great  pains  have  been  taken  to 
produce  it.  In  the  large  London  instruments  this  end  has  been  admira- 
bly attained,  but  at  so  much  cost  and  increase  of  bulk  as  to  render  it 
almost  useless.  In  the  small  model  I  have  recommended,  all  the  steadi- 
ness required  is  present  in  the  most  convenient  form. 


Fi?.  21. 


Fig.  21.  Oberhaeuser's  model,  made  at  my  suggestion  for  medical  men,  ^i\\  real 
size.  Tliis  instrument  may  be  procured  at  M.  O.'s  manufactory,  Place  Dauphine, 
Paris,  or  at  Mr.  Youngs,  cutler,  Princes  Street,  and  Mr.  Kemp's,  Infirmary  Street, 
Edinburs-h. 


USE   OF  THE   MICROSCOPE.  63 

2.  Poioer  of  Uasy  Adjustment. — It  is  a  matter  of  great  importance 
to  tliose  who  use  the  instrument  much,  and  work  with  it  for  hours 
together,  that  the  adjustment  should  work  easily  and  rapidly,  and  be 
placed  in  convenient  situations.  Nothing  can  be  more  commodious  than 
the  manner  in  which  these  ends  are  arrived  at  in  the  model  figured.  By 
insertion  of  the  body  of  the  instrument  within  a  split  tube,  you  may,  by 
a  spiral  movement,  elevate  and  depress  it  with  the  greatest  rapidity,  and 
even  remove  it  altogether  if  necessary.  The  necessity  of  continually 
turning  the  large  screws  affixed  to  most  microscopes  becomes  fatiguing 
in  the  extreme.  Then  the  fine  adjustment,  placed  conveniently  behind 
the  microscope,  near  the  hand  which  rests  on  the  table,  is  in  the  very 
best  position ;  whereas,  in  some  London  instruments,  it  is  placed  on  the 
top  of  the  pillar,  so  that  you  must  raise  your  hand  and  arm  every  time 
it  is  touched.  In  other  London  instruments,  it  is  placed  in  front  of  the 
body,  so  that  you  must  stretch  out  the  arm  and  twist  the  wrist  to  get  at 
it.     No  one  could  woi-k  long  with  so  inconvenient  a  contrivance. 

3.  Facility  for  Observation  and  Demonstration. — For  facility  of  ob- 
servation and  demonstration,  it  is  necessary  that  the  instrument  should 
be  of  a  convenient  height,  and  that  the  stage  on  which  the  objects  are 
placed  should  be  easily  accessible.  Here,  again,  nothing  can  be  more 
commodious  than  the  microscope  I  have  recommended,  for,  when  it  is 
placed  on  a  table,  its  height  is  almost  on  a  level  with  the  eye,  and  we 
can  look  through  it  for  hours  without  the  slightest  fatigue.  On  the 
other  hand,  the  stage  is  elevated,  just  so  much  as  enables  the  two 
hands,  resting  on  their  external  edges,  to  manipulate  with  facility  all 
kinds  of  objects  placed  upon  it.  The  large  London  instruments  are  so 
high  as  to  render  it  necessary  to  stand  up  to  see  through  them.  To 
obviate  this  disadvantage,  a  movement  is  given  to  the  body,  by  which 
it  can  be  depressed  to  any  angle.  But  this  movement  renders  the  stage 
oblique,  and  removes  it  to  a  distance,  where  it  becomes  very  inconvenient 
to  manipulate  on  its  surface.  To  obviate  this  difficulty,  the  stage  itself 
has  been  rendered  moveable  in  various  ways  by  diff"erent  screws,  so  that 
in  this  way  complexity  has  been  added  to  complexity,  until  a  mass  of 
brass  work  and  screws  is  accumulated,  to  the  advantage  of  the  optician, 
but  to  the  perplexity  and  fatigue  of  the  observer.  But  by  no  contrivance 
is  it  possible  to  avoid  the  aching  arms  which  such  a  position  of  the  stage 
invariably  produces  in  those  who  work  with  such  a  cumbrous  machine 
for  any  length  of  time. 

4.  Portabilitij. — This  is  a  property  which  should  by  no  means  be 
overlooked  in  instruments  that  are  intended  more  for  utility  than  orna- 
ment. A  medical  man  is  often  called  upon  to  verify  facts  in  various 
places ;  at  his  own  house,  at  a  hospital,  at  the  bed-side  of  his  patient, 
or  at  a  private  post-mortem  examination.  It  is  under  such  circum- 
stances that  the  value  of  portability  is  recognised.  The  large  London 
instruments  require  an  equipage  or  a  porter  to  transport  them  from 
place  to  place  ;  even  the  putting  them  in  and  out  of  the  large  boxes  or 
cabinets  that  are  built  around  them,  is  a  matter  of  labour.  In  short, 
notwithstanding  the  splendour  of  the  screws,  the  glittering  of  the  brass, 
and  the  fine  workmanship,  there  can  be  little  doubt  that,  on  the  whole, 
they  are  very  clumsy  afi'airs. 

There  are  many  occasions  on  which  a  medical  man  may  find  it  useful 


•64 


EXAMINATION   OF  THE   PATIENT. 


to  carry  a  microscope  with  hiin,  especially  in  the  case  of  post-mortem 
examinations.     Many  attempts  have  been  made  to  construct  a  pocket 

microscope  ;  and  for  the  pur- 
poses above  alluded  to,  I 
myself  caused  one  to  be  con- 
structed some  years  ago, 
Avhich,  with  its  case,  resem- 
bled a  small  pocket  tele- 
scope. Dr.  Gruby  of  Paris, 
however,  has  planned  the 
most  ingenious  instrument 
of  this  kind,  which  possesses 
most  of  the  properties  we 
have  enumerated,  and  will 
be  found  very  useful  for 
those  accustomed  to  micro- 
scopic manipulation.  It  is 
contained  in  a  case,  the  size 
Fig.  22.  of  an    ordinary    snutF-box, 

and  possesses  all  the  conveniences  of  the  larger  instruments,  with 
various  lenses,  a  micrometer,  slips  of  glass,  needle,  knife,  and  forceps,  in 
that  small  compass.  The  annexed  woodcuts,  exactly  one-half  the  real 
size,  will  give  an  idea  of  this  ingenious  microscope,  manufactured  by 
Brunner  of  Paris.  For  a  more  minute  description,  I  must  refer  you  to 
the  "  Monthly  Journal  of  Medical  Science"  for  December  1846. 

There  is  a  general  feeling  among  the  public  that  the  larger  a  micro- 
scope is,  the  more  it  must 
magnify ;  but  I  need  not 
tell  you  this  is  error.  A 
very  imposing  mass  of  brass 
work  and  mechanical  com- 
plexity is  no  guarantee  that 
you  will  see  objects  better, 
or,  what  is  of  more  conse- 
,  quence,  become  good  ob- 
servers. On  the  contrary, 
the  more  unwieldy  the  in- 
strument, the  less  disposed 
will  you  be  to  use  it. 
Besides,  the  habitual  em- 
ployment of  artificial  me- 
thods of  moving  about  the 
object,  as  by  the  screws  of 
a  moveable  stage,  will  pre- 
\ent  your  acquiring  that 
dexterous  use  of  your  fin- 
gers and  accuracy  of  mani- 
pulation which  are  at  all 
times  so    useful.      Nothing,  indeed,  can  be  more  amusing  than  to  see 

Fig.  22.  Gruby's  compound  pocket  microscope,  exactly  one  half  the  real  size. 
Fig.  23.  The  same  microscope  mounted,  ready  for  use. 


Fig.  23. 


USE   OF  THE   MICROSCOPE.  65 

a  man  twisting  his  screws,  pushing  his  heavy  awkward  stage  about,  and 
laboriously  wasting  time  to  find  a  minute  object  which  another  can 
do  in  a  moment,  and  without  fatigue,  by  the  simple  use  of  his  fingers. 
But  perhaps  you  will  consider  the  weightiest  objection  to  the  large 
instruments  is  the  expense  they  necessitate, — the  cost  being  necessarily 
in  proportion  to  the  amount  of  brass  and  mechanical  labour  employed 
upon  them.  If,  then,  you  have  to  choose  between  a  complex  model  and 
a  simple  one,  I  strongly  advise  you,  as  a  matter  of  real  economy,  to  choose 
the  latter.     Indeed  the  former,  to  a  practical  histologist,  is  worthless. 

We  have  next  to  speak  of  the  optical  parts  of  microscopes,  which  are 
certainly  much  more  important  than  the  mechanical  ones — for  every- 
thing depends  upon  obtaining  a  clear  and  distinct  image  of  the  object 
examined.  Under  this  head  we  may  describe  the  objective,  the  eye- 
piece, and  methods  of  illumination. 

1.  The  Objective^  or  series  of  Achromatic  Lenses,  is  that  part  of  the 
optical  portion  of  a  microscope  which  is  placed  at  the  bottom  of  the 
tube  or  bod}',  and  is  near  the  object  to  be  examined.  This  may  be 
considered  the  most  important  part  of  the  instrument,  and  the  greatest 
pains  have  been  taken  by  all  opticians  in  the  manufacture  of  good 
lenses.  It  is  here  I  consider  that  the  London  opticians  are  pre-emi- 
nent, for  I  am  not  aware  that  in  any  part  of  the  world  such  perfect 
objectives  have  been  manufactured  as  the  eighth  of  an  inch  by  Smith, 
the  twelfth  of  an  inch  by  Eoss,  and  the  sixteenth  of  an  inch  by  Powell. 
But  when  we  come  down  to  the  one-fourth  of  an  inch,  which  is  bv  far 
the  most  useful  objective  for  anatomical  and  medical  purposes,  the 
superiority  of  the  London  opticians  is  very  slight,  if  any.  At  this  mag- 
nifying power  the  compound  lenses  of  C.  Chevalier,  Oberhaeuser,  Brun- 
ner,  and  Xachet  of  Paris  ;  Schick  and  Pistor  of  Berlin  ;  Frauenhofer  of 
Munich,  and  Ploesl  of  Vienna,  may  be  employed  with  the  greatest  con- 
fidence, and  it  may  be  said  that  by  far  the  largest  number  of  important 
discoveries  in  science  have  been  made  through  their  employment.  The 
Parisian  lenses,  in  addition,  have  one  great  advantage,  namely,  their 
cheapness. 

The  London  opticians  have  succeeded  in  combining  the  lenses  of  their 
objectives,  so  as  to  obtain  a  large  field  of  vision,  with  as  little  loss  of 
light  as  possible.  These  qualities  are  valuable  in  the  lower  magnifying 
lenses  during  the  examination  of  opaque  objects,  and  in  the  higher  ones 
■when  observing  transparent  objects  by  transmitted  light.  But  in  the 
lenses  of  medium  power,  such  as  the  one-fourth  of  an  inch,  the  amount 
of  light  is  so  great  as  to  be  almost  a  defect.  Notwithstanding  careful 
management  of  the  mirror  and  diaphragm,  the  field  of  vision  is  often 
dazzling,  and  always  presents  a  glare  most  detrimental  to  the  eyes  of 
the  observer.  I  cannot  employ  Ross's  fourth  of  an  inch  for  fifteen 
minutes  without  feeling  intense  headache,  and  I  know  of  more  than  one 
excellent  observer  in  whom  the  sight  has  so  much  suff'ered  from  this 
cause  as  to  incapacitate  them  from  continuing  their  researches.  In  the 
same  manner,  the  lenses  of  Brunner  and  Xachet  give  rise  to  a  yellow 
light  highly  disagreeable  ;  while  those  of  Oberhaeuser,  Schick  and  Pis- 
tor,  and  Frauenhofer  (with  Amici's  and  Ploesl's  I  am  not  familiar),  pre- 
sent a  pale  blue  light,  most  pleasant  to  work  with,  and  which  may  be 
gazed  at  for  hours  without  fatiguing  the  eye. 

5 


66  EXAMINATION  OF  THE   PATIENT. 

For  the  above  reasons,  as  well  as  from  considerable  experience  in  the 
use  of  many  kinds  of  microscopes  by  different  manufacturers,  I  am  satis- 
fied that  tiie  best  lens  you  can  employ  for  ordinary  purposes  is  Ober- 
haeuser's  No.  1,  which  corresponds  to  vfhat  is  called  in  England  the 
quarter  of  an  inch.  For  low  powers  yon  may  have  Oberhaeuser's  No. 
3,  or  the  one-inch  lens  of  the  London  opticians.  For  all  the  wants  of 
the  medical  man  these  will  be  suificient.  The  anatomist  may  occasion- 
ally require  a  higher  lens,  as  during  the  examination  of  the  ultimate 
fibrillaj  of  muscle,  when  the  eightb,"twelfth,  or  sixteenth  of  an  inch  of 
the  London  opticians  may  be  procured.  All  these  lenses  may  be  at- 
tached to  the  model  we  have  recommended  by  means  of  a  brass  screw 
made  on  purpose. 

2.  The  Eye-piece. — This  is  that  portion  of  the  optical  apparatus  which 
is  placed  at  the  upper  end  of  the  tube  or  body,  and  is  near  the  eye  of 
the  observer.  While  the  objective  magnifies  the  object  itselt;  the  eye- 
piece only  magnifies  the  image  transmitted  from  below.  Hence,  as  a 
source  of  magnifying  power,  it  is  inferior  to  the  lens ;  and  when  this 
possesses  any  defects,  these  are  enlarged  by  the  eye-piece.  Two  eye- 
pieces are  all  that  is  necessary  with  tlie  model  I  have  recommended, 
and  those  of  Oberhaeuser,  called  Nos.  3  and  4,  are  the  most  useful  for 
the  medical  man. 

3.  Methods  of  niumination. — There  are  few  things  of  more  impor- 
tance to  the  practical  histologist  than  the  mode  of  illumination.  This 
is  accomplished — 1st,  By  transmitted  light ;  2d,  By  reflected  light;  and 
3d,  By  achromatic  light. 

Transmitted  light  is  obtained  by  means  of  a  mirror  placed  below  the 
object  which,  to  be  seen,  must  therefore  be  transparent.  In  large  micro- 
scopes the  mirrors  are  provided  with  universal  joints,  so  that  they  may 
easily  be  turned  in  any  direction.  Below  the  stage  every  microscope 
should  possess  a  diaphragm  pierced  with  variously  sized  holes,  whereby 
the  amount  of  light  furnished  by  the  mirror  may  be  moderated.  lu 
Oberhaeuser's  and  Nachet's  instruments  the  smallest  aperture  should  be 
employed  for  the  higher  objective.  It  is  also  useful  in  the  examination 
of  many  objects  that  the  light  should  be  directed  upon  them  sideways  ; 
this  may  be  done  by  the  diaphragm,  or  by  the  mirror,  and  in  the  small 
model  formerly  figured,  is  admirably  attained  by  simply  turning  the 
whole  microscope.  The  best  light  for  microscopic  purposes  is  that 
obtained  by  catching  the  rays  which  are  reflected  from  a  white  cloud. 
The  conjoined  use  of  the  mirror  and  diaphragm  can  only  be  learned 
from  actual  experience. 

Reflected  light  is  employed  in  the  examination  of  opaque  objects,  and 
the  lenses  of  "low  power, 'manufactured  by  the  principal  London  opti- 
cians, enable  us  to  do  so  without  assistance.  Occasionally,  however,  the 
light  of  the  sun  is  useful ;  and  when  this  cannot  be  obtained,  the  rays  of 
a  lamp  or  gas  light,  concentrated  by  a  bull's-eye  lens,  may  be  emploved. 
Hence  every  microscope  should  be  possessed  of  such  a  lens,  and  it  is 
most  convenient  to  have  it  attached  to  the  body  of  the  instrument  by  a 
moveable  ring,  and  stem  with  two  joints,  as  in  the  model  figured. 

Achromatic  light  is  only  serviceable  in  the  examination  of  very  deli- 
cate objects,  witii  high  powers.  The  apparatus  necessary  for  obtaining 
it  is  occasionally  useful  in  ascertaining  the  ultimate  structure  of  muscle, 


USE   OF   THE   MICROSCOPE.  67 

or  the  nature  of  tbe  marking-s  on  minute  scales  or  fossils,  but  is  useless 
for  the  purposes  of  the  medical  man.  In  the  same  way  I  know  of  no 
benefit  to  be  obtained  by  a  polarising  apparatus. 

In  addition  to  the  mechanical  and  optical  parts  constituting  the 
microscope  itself,  the  box  which  contains  it  should  possess  a  convenient 
place  for  holding  a  few  slips  of  glass,  a  pair  of  small  forceps,  a  knife,  and 
two  needles  firmly  set  in  handles.  A  micrometer  to  measure  objects 
with  is  also  essential  to  those  who  are  making  observations  with  a  view 
to  their  exact  description.     No  other  accessories  are  necessary. 

An  excellent  microscope  of  the  model  previously  figured,  by  Ober- 
haeuser,  with  two  objectives  (Nos.  3  and  7),  two  eye-pieces  (Nos.  3  and 
4),  a  neat  box  with  all  the  accessories  necessary  (with  the  exception  of 
a  micrometer,  which  had  better  he  English),  may  be  obtained  in  Paris 
for  the  sum  of  about  150  francs  (£0),  and  will  cost  in  Edinburgh,  after 
payment  of  carriage  and  duty,  about  seven  guineas.  Nachet's  and 
Brunner's  instruments  are  much  cheaper,  as  are  the  smaller  models  of 
Oberhaeuser.  Either  of  them,  for  all  the  purposes  of  the  medical  man, 
is  amply  sufficient. 

Test-Objects. — The  defining  power  of  a  microscope  is  generally 
tested  by  examining  with  it  a  transparent  object,  having  certain  fine 
markings,  which  can  only  be  rendered  clearly  visible  when  the  glasses 
are  good.  In  all  such  cases,  it  is  of  course  necessary  to  be  familiar  with 
the  structure  of  the  test-object  in  the  first  instance.  If  you  are  not 
confident  on  this  point,  it  is  better  to  trust  to  the  judgment  of  a 
friend,  whose  knowledge  of  histology  is  ascertained,  or  place  your 
dependence  entirely  on  a  respectable  optician.  One  of  the  best  test- 
objects  for  a  quarter  of  an  inch  lens  is  a  drop  of  saliva  from  the  mouth. 
For,  if  the  microscope  shows  with  clearness  the  epithelial  scales,  the 
structure  of  the  salivary  globules,  their  nuclei,  and  contained  molecules, 
you  may  be  satisfied  that  the  instrument  will  exhibit  all  the  facts  Avith 
which,  as  medical  men,  you  have  to  do — (See  Fig.  25.) 


Mensuration  and  Demonstkation. 

Having,  then,  obtained  a  good  instrument,  and  tested  its  qualities  in 
the  manner  described,  you  should  next  determine  the  number  of  diame- 
ters linear  the  various  combinations  of  glasses  magnify.  This  you  may 
do  for  yourself  with  the  aid  of  a  micrometer,  a  pair  of  compasses,  and  a 
measure. 

A  micrometer  is  a  piece  of  glass  on  which  lines  are  ruled  at  the 
distance  of  y^g  or  yoVo  *^^"  ^^^  inch.  This  must  be  placed  under  the 
instrument,  when  the  lines  and  the  distances  between  them  will  of 
course  be  magnified  by  the  combination  of  glasses  employed,  like  any 
other  object.  Taking  a  pair  of  compasses  in  one  hand,  we  separate 
the  points,  and  place  them  on  the  stage  (always  on  a  level  with  the 
micrometer  magnified).  Now,  looking  through  the  instrument  with  one 
eye,  we  regard  the  points  of  the  compasses  with  the  other,  and  mark 
off  by  the  naked  sight,  say  the  y^oth  of  an  inch,  as  magnified  by  the 
instrument.  Though  difficult  at  first,  a  little  practice  enables  us  to  do 
this  with  the  greatest  accuracy.     The   result  is,  that  if  the  distance 


68 


EXAMINATION   OF   THE   PATIENT. 


uiao-nified  and  so  raarted  off  (y^oth  of  an  inch)  is  equal  to  three  inches, 
the  instrument  magnifies  SOU  times  linear;  if  two  inches,  200  times; 
and  so  on. 

To  measure  the  size  of  objects,  they  may  be  placed  directly  on  the 
micrometer ;  but  as  this  is  at  all  times  inconvenient,  whilst  the  object 
and  micrometer,  from  their  not  being  in  the  same  plane,  cannot,  under 
high  powers,  both  be  brought  into  focus  at  once,  it  is  better  to  use  an 
eve-micrometer.  Many  ingenious  inventions  of  this  kind  are  to  be 
procured.  The  most  simple  is  a  ruled  micrometer  placed  in  the  focus 
of  the  upper  glass  of  the  eye-piece.  With  this  we  observe  how  many 
divisions  of  the  eye-micrometer  correspond  with  one  of  those  magnified 
bv  the  microscope,  always  making  our  observation  in  the  centre  of  the 
field,  where  the  aberration  of  sphericity  is  least.  On  the  latter  being- 
removed  and  replaced  by  an  object,  it  becomes  a  matter  of  mere  calcu- 
lation to  determine  its  size.  Thus,  supposing  each  of  the  upper  spaces 
in  Fig.  24  to  represent  the  VoVo^^^  of  an  inch  magnified  250  diameters 
Imear,  and  five  of  the  lower  spaces,  as  seen  in  an  eye-micrometer,  to 
^'g-  24-  correspond  with  one  of  these — it  follows  that  each 

of  these  latter  must  measure  j oVo^^^  ^^  ^^  inch. 
Oberhaeuser  has  made  beautifully  ruled  eye-micro- 
meters, for  the  model  recommended,  which  those 
who  wnsh  to  make  measurements  would  do  well  to 
procure. 

If  it  be  not  in  your  power  to  estimate  the 
Spaces  equal  to  l-ioooth  of  magnifying  power  for  yourself,  the  optician  will 
an  inch  magnified  250  dia-  give  vou  a  table.  Setting  foitli  the  various  degrees 
meters  Imear.  ^^  enlargement  possessed  by  the  lenses,  and  different 

eye-pieces,  with  the  tube  up  or  down.  This  table 
should  always  be  referred  to  during  the  description 
of  objects,  and  the  amount  of  magnifying  power 
invariably  stated. 

The  art  of  demonstrating  under  the  microscope 
is  only  to  be    acquired  by  long  practice,  and,  like 
Five  ruled  spaces  in  an  everything  requiring  practical  skill,  cannot  be  learnt 

eve-micrometer,     corres-  ,.  it  x  i.-     i      x  t  i      ii 

ponding  to  one  of  those  troui  books  or  systematic  lectures,  i  can  only,  there- 
above,  and  consequently  f    g   „j^-g  „q^  ^^^.y  nreueral  directions  on  tliis  head. 

equal  tothel-5000thofan  '&         .'.  •'    o         .  ..         j.,        ,, 

inch.  All  that  is  necessary  m  examining  fluid  substan- 

ces, is  to  place  a  drop  in  the  centre  of  a  slip  of  glass,  and  letting  a 
smaller  and  thinner  piece  of  glass  fall  gently  upon  it,  so  as  to  exclude 
air  bubbles,  place  it  upon  the  stage  under  the  objective.  In  this  way 
the  fluid  substance  will  be  diffused  equally  over  a  flat  surface,  and 
evaporation  prevented  which  would  dim  the  objective.  The  illumina- 
tion must  now  be  carefully  arranged,  and  the  focus  obtained,  first  by 
means  of  the  coarse,  and  then  by  means  of  the  fine,  adjustment.  It  will 
save  much  time,  in  examining  structures,  to  employ  always,  at  one 
sittiiif,  the  same  slips  of  glass,  as  it  is  easier  to  clean  these  with  a  towel, 
after  dipping  them  in  water,  than  to  be  perpetually  shifting  the  coarse 
adjustment. 

The  action  of  water,  acetic  acid,  and  of  other  re-agents,  on  the 
particles  contained  in  a  fluid,  may  be  observed  by  mixing  with  it  a 
drop  of  the  re-agent  before  covering  with  the  upper  glass ;  or  if  this 


USE   OF  THE   MICROSCOPE.  69 

be  already  done,  the  drop  of  re-agent  may  be  placed  at  the  edge  of  the 
upper  glass,  when  it  will  be  difiused  through  the  fluid  under  ex'araina- 
tion  by  imbibition. 

The^  mode  of  demonstrating  solid  substances  will  vary  according  as 
they  are  soft  or  hard,  cellular  or  fibrous.  The  structure  of  a  soft  tissue, 
such  as  the  kidney,  skin,  cartilage,  etc.,  is  determined  by  making  very 
minute,  thin,  and  "transparent  slices  of  it  in  various  directions,  by  means 
of  a  sharp  knife  or  razor.  These  sections  should  be  laid  upon  a  slip  of 
glass,  then  covered  over,  and  slightly  pressed  fiat,  by  means  of  an  upper 
one.  The  addition  of  a  drop  ot^  water  renders  the  parts  more  clear,  and 
facilitates  the  examination,  although  it  should  never  be  forgotten  that 
most  cell-structures  are  thereby  enlarged  or  altered  in  shape  fi-om  endos- 
mosis.  Acid  and  other  re-agents  may  be  applied  in  like  manner.  The 
double-bladed  knife  of  Valentin  will*  enable  you  to  obtain  large,  thin, 
and  equable  sections  of  such  tissues,  and  permit  you  to  see  the  manner 
in  which  the  various  elements  they  contain  are  arranged  with  regard  to 
each  other.  Harder  tissues,  such  as  wood,  horn,  indurated  cuticle,  etc., 
may  also  be  examined  after  making  thin  sections  of  them.  Very  dense 
tissues,  such  as  bone,  teeth,  shell,  etc.,  require  to  be  cut  into  thin  sec- 
tions, and  afterwards  ground  down  to  the  necessary  thinness.  Prepara- 
tions of  this  kind  arenow  manufactured  on  a  large  scale,  and  may  be 
obtained  at  a  trifiing  cost.  A  cellular  parenchymatous  structure,  such 
as  the  liver,  may  be  examined  by  crushing  a  minute  portion  between 
two  glasses.  If  it  be  membranous,  as  the  cuticle  of  plants,  epithelial 
layers,  etc.,  the  membrane  should  be  carefully  laid  fiat  upon  the  lower 
glass,  and  covered  with  an  upper  one.  A  fibrous  structure,  such  as  the 
areolar,  elastic,  muscular,  and  nervous  tissues,  must  be  separated  by 
means  of  needles,  and  then  spread  out  into  a  thin  layer  before  examina- 
tion, with  or  without  water,  etc. 

The  commencing  observer  should  not  be  discouraged  by  the  difil- 
culties  he  will  have  to  encounter  in  dissecting  and  displaying  many 
tissues.  He  must  remember  that  the  figures  he  sees  published  in  books 
are  generally  either  fortunate  or  very  carefully  prepared  specimens. 
Practice  will'  soon  enable  him  to  obtain  the  necessary  dexterity,  and  to 
convince  himself  of  the  importance  of  this  mode  of  inquiry.  He  should 
early  learn  to  draw  the  various  objects  he  sees,  before  and  after  the 
action  of  re-agents,  not  only  because  such  copies  constitute  the  best 
notes  he  can  keep,  but  because  drawing  necessitates  a  more  careful  and 
accurate  examination  of  the  objects  themselves.  A  note-book  and  pen- 
cil for  the  purpose  should  be  the  invariable  accompaniments  of  every 
microscope. 

How  TO  Observe  with  a  Microscope. 

The  art  of  observation  is  at  all  times  difficult,  but  is  especially  so  with 
a  microscope,  which  presents  us  with  forms  and  structures  concerning 
which  we  had  no  previous  idea.  Rigid  and  exact  investigation,  there- 
fore, should  be  methodically  cultivated  from  the  first,  in  order  to  avoid 
those  errors  into  which  the"  tyro,  when  using  a  microscope,  is  particu- 
larly liable  to  fall.  Thus,  you  should  carefully  examine  the  physical 
properties  of  the  particles  and  ultimate  structures  you  may  see,  and  not 


70  EXAMINATION   OF  THE   PATIENT. 

hastily  conclude  tliat  you  have  under  observation  so-called  pus,  tubercle, 
or  cancer-corpuscles,  because  they  were  obtained  from  what  was,  a  j^fiori, 
believed  to  be  pus,  tubercle,  or  cancer.  Nothing  has  been  more  clearly 
demonstrated  by  the  progress  of  histology,  than  the  fact,  that  the  naked 
sight  has  confounded  different  structures  together,  from  a  similarity  of 
external  appearance,  and  that  the  gi-eatest  caution  is  required  at  all 
times,  but  especially  by  learners,  in  forming  opinions  as  to  the  nature  of 
different  tissues. 

The  physical  characters  which  distinguish  microscopic  objects  consist 
of — 1st,  Shape;  2d,  Colour;  3d,  Edge  or  border;  4th,  Size;  5th, 
Transparency ;  6th,  Surface ;  7th,  Contents ;  and  8th,  Effects  of  re- 
agents.    These  we  may  notice  in  succession. 

1.  Shajje. — Accurate  observation  of  the  shape  of  bodies  is  very  neces- 
sary, as  many  of  these  are  distinguished  bv  this  physical  property.  Thusthe 
human  blood  globules,  presenting  a  bi-concave  round  disk,  are  in  this 
respect  diff'ereiit  from  the  oval  corpuscles  of  the  camelida?,  of  birds,  rep- 
tiles, and  fishes.  The  distinction  between  circular  and  globular  is  very 
necessary  to  be  attended  to.  Human  blood  corpuscles  are  circular  and 
flat,  but  they  become  globular  on  the  addition  of  water.  Minute  struc- 
tures seen  under  the  microscope  may  also  be  likened  to  the  shape  of  well- 
known  objects,  such  as  that  of  a  pear,  balloon,  kidney,  heart,  etc.  etc. 

2.  Colour. — The  colour  of  structures  varies  greatly,  and  often  differs, 
under  the  microscope,  from  w^hat  Avas  previously  conceived  regarding 
them.  Thus  the  coloured  corpuscles  of  the  blood,  though  commonly 
called  red,  are  in  point  of  fact  yellow.  Many  objects  present  different 
colours,  according  to  the  mode  of  illumination — that  is,  as  the  light  is 
reflected  from,  or  transmitted  through  their  substance,  as  in  the  case  of 
certain  scales  of  insects,  feathers  of  birds,  etc.  Colour  is  often  produced, 
modified,  or  lost,  by  re-agents,  as  when  iodine  comes  in  contact  with 
starch  corpuscles,  when  nitric  acid  is  added  to  the  granules  of  chlorophyle, 
or  chlorine  water  affects  the  pigment  cells  of  the  choroid,  and  so  on. 

3.  Edge  or  Border. — The  edge  or  border  may  present  peculiarities 
Avhich  are  worthy  of  notice.  Thus,  it  may  be  dark  and  abrupt  on  the 
field  of  the  microscope,  or  so  fine  as  to  be  scarcely  visible.  It  may  be 
smooth,  irregular,  serrated,  beaded,  etc.  etc. 

4.  Size. — The  size  of  the  minute  bodies,  fibres,  or  tubes,  which  are 
found  in  the  various  textures  of  animals,  can  only  be  determined  with 
exactitude  by  actual  measurement,  in  the  manner  formerly  described.  It 
will  be  observed,  for  the  most  part,  that  these  minute  structures  vary 
in  diameter,  so  that  when  their  medium  size  cannot  be  determined,  the 
variations  in  size  from  the  smaller  to  the  larger  should  be  stated.  Human 
blood  globules  in  a  state  of  health  have  a  pretty  general  medium  size, 
and  these  may  consequently  be  taken  as  a  standard  with  advantage,  and 
bodies  may  be  described  as  being  two,  three,  or  more  times  larger  than 
this  structure. 

5.  Transparency . — This  visible  property  varies  greatly  in  the  ultimate 
elements  of  numerous  textures.  Some  corpuscles  are  quite  diaphanous, 
others  are  more  or  less  opaque.  The  opacity  may  depend  upon  corru- 
gation or  irregularities  on  the  external  surface,  or  upon  contents  of  dif- 
ferent kinds.  Some  bodies  are  so  opaque  as  to  prevent  the  transmission 
of  the  rays  of  light,  whgn  they  look  black  by  transmitted  light,  although 


USE   OF  THE  MICROSCOPE.  71 

they  be  white,  seen  by  reflected  light.  Others,  such  as  fatty  particles  and 
oil  "globules,  refract  the  rays  of  light  strongly,  and  present  a  peculiar 
luminous  appearance. 

6.  Surface. — Many  textures,  especially  laminated  ones,  present  a  dif- 
ferent structure  on  the  surface  from  that  which  exists  below.  If,  then, 
in  the  demonstration,  these  have  not  been  separated,  the  focal  point 
must  be  changed  by  means  of  the  fine  adjustment.  In  this  way  the 
capillaries  in  the  web  of  the  frog's  foot  may  be  seen  to  be  covered  with 
an  epidermic  layer,  and  the  cuticle  of  certain  minute  fungi  or  infusoria 
to  possess  peculiar  markings.  Not  unfrequently  the  fracture  of  such 
structures  enables  us,  on  examining  the  broken  edge,  to  distinguish  the 
difference  in  structure  between  the  sui-face  and  the  deeper  layers  of  the 
tissue  under  examination. 

7.  Contents.— The  contents  of  those  structures,  which  consist  of  enve- 
lopes, as  cells,  or  of  various  kinds  of  tubes,  are  very  important.  These 
may  consist  of  included  cells  or  nuclei,  granules  of  ditferent  kinds,  pig- 
ment matter,  or  crystals.  Occasionally  their  contents  present  definite 
moving  currents,  as  in  the  cells  of  some  vegetables  or  trembling  rotatory 
molecular  movements,  as  in  the  ordinary  globules  of  saliva  in  the  mouth. 

8.  Ufects  of  Re-(ujeuts. — These  are' most  important  in  determining 
the  structure  and  chemical  composition  of  numerous  tissues.  Indeed,  in 
the  same  manner  that  the  anatomist  with  his  knife  separates  the  various 
layers  of  a  texture  he  is  examining,  so  the  histologist,  by  the  use  of  re- 
agents, determines  the  exact  nature  and  composition  of  the  minute 
bodies  that  fall  under  his  inspection.  Thus,  rvater  generally  causes  cell 
formations  to  swell  out  from  endosmosis  ;  whilst  syrup,  gum  water,  and 
concentrated  saline  solutions,  cause  them  to  collapse  from  exosmosis. 
Acetic  acid  possesses  the  valuable  property  of  dissolving  coagulated  albu- 
men, and,  in  consequence,  renders  the  whole  class  of  albuminous  tissues 
more  transparent.  Thus,  it  operates  on  cell  walls,  causing  them  either 
to  dissolve  or  become  so  thin  as  to  display  their  contents  more  clearly. 
JEther,  on  the  other  hand,  and  the  alkalies,  operate  on  the  fatty  com- 
pounds, causing  their  solution  and  disappearance.  The  mineral  acids 
dissolve  most  of  the  mineral  constituents  that  are  met  with,  so  that  in 
this  way  we  are  enabled  to  tell,  with  tolerable  certainty,  at  all  events  the 
group  of  chemical  compounds  to  which  any  particular  structure  may  be 
referred. 


PRINCIPAL  APPLICATIONS  OF  THE  MICROSCOPE  TO 
DIAGNOSIS. 

A  perfect  application  of  the  microscope,  for  the  purpose  of  diagnosis, 
can  only  be  arrived  at  by  obtaining,  in  the  first  instance,  a  complete 
knowledge  of  the  tissues  of  plants  and  animals,  both  in  their  healthy 
and  diseased  conditions.  The  medical  practitioner  may  be  called  upon 
to  distinguish,  not  only  the  various  structures  which  enter  into  every 
species  of  food,  every  kind  of  animal  texture  and  fluid,  and  every  form 
of  morbid  product,  but  he  will  frequently  have  to  judge  of  these  when 
more  or  less  disintegrated,  changed,  or  otherwise  aff'ected  by  the  pro- 


72  EXAMINATION  OF  THE   PATIENT. 

cesses  of  mastication,  digestion,  expectoration,  ulceration,  putrefaction, 
maceration,  etc.,  etc.  In  this  place,  however,  I  propose  merely  calling 
your  attention  to  those  points  -which  are  more  likely  to  fall  under  your 
notice  at  the  bed-side.  No  doubt,  the  practical  applications  of  the 
microscope  are  daily  extending,  and  whilst  there  are  many  points  which 
may  be  said  to  be  scarcely  investigated,  those  Avhich  have  been  most  so 
require  to  be  further  studied.  At  the  same  time,  a  careful  and  perse- 
vering examination  of  the  morphological  elements  found  in  the  various 
excreta  of  the  body,  as  modified  by  different  diseases,  or  by  constitution 
and  diet,  cannot  but  prove  of  great  importance  in  the  present  state  of 
practical  medicine.  Hence,  besides  shortly  discussing  what  is  known, 
I  shall  especially  indicate  Avhat  are  those  subjects  which  may  be  elu- 
cidated by  such  of  you  as,  by  previous  histological  observations,  are  qua- 
lified for  the  task. 

Saliva. 

The  readiest  way  of  examining  the  saliva  is  to  collect  a  drop  of  that 
fluid  at  the  extremity  of  the  tongue,  and  let  it  fall  on  the  centre  of 
a  slip  of  glass.  It  should  be  allowed  to  remain  quiescent  for  a  minute 
or  so,  until  most  of  the  bubbles  of  air  have  collected  in  a  mass  on  the 
surface.  This  should  then  be  gently  scraped  off  or  placed  aside  with  a 
needle,  and  the  subjacent  fluid  covered  with  a  thin  glass.  There  will 
now  be  observed,  with  a  magnifying  power  of  250  diameters  linear, — 
1st,  The  salivary  corpuscles ;  2d,  Epithelial  scales  of  the  mouth  ;  3d, 
Molecules  and  granules. 

1.  The  salivary  corpuscles  are  colourless  spherical  bodies,  with  smooth 
margins,  varying  in  size  from  the  3-0V0  to  the  y-gV^  of  an  inch  in  dia- 
meter. They  contain  a  round  nucleus,  varying  in  size,  but  generally 
occupying  a  third  of  the  cell;  and  between  this  nucleus  and  the  cell 
wall  are  numerous  molecules  and  granules,  which  communicate  to  the 
entire  corpuscle  a  finely  molecular  aspect.  The  addition  of  water 
causes  these  bodies  to  swell  out  and  enlarge  from  endosmosis.     Acetic 

acid  somewhat  dissolves  the  cell  wall,  and  it 
becomes  more  transparent ;  Avhile  the  nucleus 
appears  more  distinct  as  a  single,  double,  or  tri- 
partite   body.     Both  water  and   acetic  acid 
,--'     produce  also  coagulation  of  the  albuminous 
•  Y".    matter  contained  in  the  fluid  of  the  saliva, 
^'0.;.     which  assumes  the  form  of  molecular  fibres, 
.-^.-»-. '      in  which  the  corpuscles  and  epithelial  scales 
become  entangled,  and  25resent  to  the  naked 
^'^-  ^^-  eye  a  white  film. 

2.  The  Epithelial  scales  found  in  the  saliva  are  derived  from  the 
mouth,  and  consist  of  flat  plates,  variously  shaped,  but  generally  pre- 
senting an  oblong  or  squarish  form,  more  or  less  curled  up  at  the  sides. 
Not  unfrequently  these  have  five  or  six  sides,  and  are  assembled  together 
in  groups,  with  their  edges  adherent.     In  size  they  vary  from  the  g-^oth 

Fig.  25.  Salivary  corpuscles,  epithelial  scales,  with  molecules  and  granules,  as 
seen  in  a  drop  of  saliva. 


USE   OF  THE   MICROSCOPE. 


73 


to  the  -J^otli  of  an  inch  in  length.  Embedded  in  their  substance  is  a 
round  or  oval  nucleus,  together  with  numerous  molecules  and  granules. 
Water  produces  no  change  in  these  bodies ;  but  acetic  acid  renders^  the 
scale  more  transparent,  and  causes  the  nucleus  to  appear  more  distinct, 
with  a  darker  edge. 

3.  Associated  with  the  salivary  corpuscles  and  epithelial  scales  are 
several  molecules  and  granules,  which  vary  in  number  in  different  people, 
and  at  various  times  of  the  day. 

There  may  also  be  occasionally  found  in  the  saliva  various  foreign 
substances  derived  from  the  food — such  as  granular  debris  of  different 
kinds,  starch  globules  or  vegetable  cells,  muscular  fasciculi,  portions  of 
areolar  tissue,  tendon,  or  spiral  filaments,  etc. — derived  from  pieces  of 
texture  which  have  adhered  to  the  teeth  during  mastication. 

The  saliva  may  present  various  alterations,  dependent  on  disease  of 
the  mucous  membranes  of  the  mouth  and  tongue.  This,  when  ulcerated, 
causes  an  increase  in  the  molecular  and  granular  matter.  Many  of  the 
epithelial  scales  also  lose  their      . 

\mmm 


:SjS\C);^:. 


transparent    character   and    be 
come  opaque,  from  an  augmen- 
tation of  granular  matter  in  their 
substance.       Not    unfrequently, 
under  such  circumstances,  they 
give  rise  to  confervoid  growths, 
which  mainly  spring  up  in  the 
debris  collected  in   the  mouth, 
either  on  the  surface  of  ulcers, 
in  the  sordes  which  collect  on  the  teeth,  gums,  and  tongue  of  individuals 
labouring  under  fever,  or  even  in  the  inspis- 
sated mucus  of  persons  who  sleep  for  a  con- 
siderable time  with  the   mouth   open   (Fig. 
26).      In  infants  the  tongue  and  cavity  of 
the  mouth  are  not  unfrequently  covered  with 
a  yellowish  flocculent  matter,  constituting  the  \ 
disease  named  muguet  by  the  French,  in  which    \^' 
sporules  and  confervoid  filaments,  in  a  high 
state   of  development,  may  be   detected    in 
considerable  numbers  (Fig.  2*7). 

In  epithelial  cancroid  of  the  tongue,  the 
epithelial  scales  exhibit  a  great  tendency  to 
split  up  and  form  fibres,  and  may  frequently 
be  found  on  the  surface  of  the  ulcer,  present- 
ing the  form  here  figured  (Fig.  28). 

An  histological  examination  of  the  saliva,  of  the  fur  and  load  of  the 
tongue,  in  the  great  majority  of  diseases,  is  still  a  desideratum. 


Fig.  26.  Minute  confervoid  filaments  springing  from  an  altered  epithelial  scale, 
scraped  from  the  surface  of  a  cancroid  ulcer  of  the  tongue  {Leptothrix  huccalis). 

Fig.  27.  Confervoid  filaments  and  sporules,  in  the  exudation  on  the  mouth  and 
gums,  constituting  Muguet  in  infants. 

Fig.  28.  Fringe-like  epithelium,  from  the  surface  of  an  ulcer  on  the  tongue. 

Magnified  250  diameters  linear. 


74  EXAMINATION   OF  THE   PATIENT. 


Milk. 

On  examining  a  drop  of  milk*  we  observe  a  number  of  bodies  rolling 
in  a  clear  fluid."  These  bodies,  in  healthy  milk,  are  perfectly  spherical, 
-with  dark  margins,  smooth  and  abrupt  on  the  field  of  the  microscope, 
with  a  clear  transparent  centre,  which  strongly  refracts  light.  In  size 
they  vary  in  different  specimens  from  a  point  scarcely  measurable,  up  to 
the  joV^th  or  3 oVoth  of  an  inch  in  diameter.  In  excess  of  ether  they 
are  dissolved  or  disappear ;  but  if  this  re-agent  be  in  small  quantity, 
exosmosis  takes  place,  and  the  field  of  the  microscope  is  covered  with 
loose  globules  of  oil,  of  various  forms.  Water  causes  tlie  milk  globules 
to  swell  out,  but  very  slightly.  Acetic  acid  coagulates  the  caseous  fluid 
in  which  they  swim,  and  causes  the  globnles  to  be  aggregated  together 
in  masses.  'Several  of  the  globules  also  exhibit,  under  the  action  of 
this  re-agent,  a  certain  flaccidity,  and  readily  run  into  one  another  under 
pressure. 

These  globules  consist  of  a  delicate  envelope  of  casein,  enclosing  a 
drop  of  oil  or  butter.  The  membrane  keeps  them  separate,  so  long  as 
it  is  intact ;  but,  dissolved  by  means  of  acetic  acid,  or  ruptured  by  heat 
or  mechanical  violence  (as  in  the  churn),  the  butter  is  readily  separated 
and  collected.  Cream  is  composed  of  the  larger  of  these  globnles,  which, 
owing  to  their  low  specific  gravity,  float  on  the  surface  of  milk  when 
allowed  to  repose. 

The  richness  of  milk  is  determined  by  the  quantity  of  these  globules. 
An  examination  of  cow's  and  human  milk  will  at  once  show  that  the 
former  contains  a  larger  number  than  the  latter.  In  all  efforts,  however, 
to  determine  the  relative  value  of  milk  by  microscopic  examination, 
great  care  must  be  taken  that  the  drop  of  fluid  examined  should  be  of 
the  same  bulk,  that  the  same  upper  glass  should  be  used  in  every  case, 
and  that  it  should  be  applied  and  pressed  down  with  the  same  force.  It 
it  very  diflBcult  at  all  times  strictly  to  fulfil  these  conditions,  for  not  only 
is  great  skill  in  manipulation  required,  but  an  intimate  acquaintance 
with  the  appearance  of  milk  as  seen  under  the  microscope,  is  necessary, 
before  any  confidence  can  be  placed  in  this  mode  of  testing  the  quality 

g  ,  ^  ^  of   different   specimens    of    the 

fluid.     At  the   same   time,   the 
difference  in  the  amount  of  oily 


M^9p^§^^        ^^^■■'^e-°-''^^    constituents   between   the  milk 
■■M:^^'^^^        ^^i:'mS^'^mo''o    of   the    cow,    ass,    and    human 


'mSm^^  ^-l^iM'      determined. 


In  the  same  manner  the  va- 

Fig-  29.  Fig-  30.  rious  adulterations  of  milk  are 

at  once  determined.     Water,  of  course,  separates  the  globules  more  and 

more  from  each  other  according  to  its  amount.     Flour  will  exhibit  the 

*  The  mode  of  examining  all  fluids  is  the  same,  and  is  described  p.  67. 


Fig.  29.  Globules  of  cow's  milk. 

Fig.  30.  Colostrum  of  the  human  female,  containing  milk  globules  greatly  varying 
in;size,  with  compound  granular  corpuscles.  250  dtam. 


USE   OF  THE   MICROSCOPE.  75 

large  starch  corpuscles,  which  are  changed  blue  by  the  action  of  iodine. 
Chalk  shews  numerous  irregular  mineral  particles,  -which  are  soluble  in 
the  mineral  acids;  and  broken-down  brain  will  be  distinguished  by  large 
oil  globules,  mingled  with  fragments  of  fine  nerve-tubes.  Milk,  when 
acid,  exhibits  the  same  character  that  it  does  under  the  action  of  acetic 
acid. 

Healthy  and  fresh  milk  is  indicated  by  a  certain  uniformity  in  the  size 
of  the  globules;  by  their  perfectly  globular  form  ;  by  their  rolling  freely 
over  each  other,  and  not  collecting  together  in  masses  (Fig.  29).  When 
the  latter  circuinstance  occurs,  it  is  a  sign  of  acidity. 

The  milk  first  secreted  after  parturition  is  called  the  colostrum.  It  is 
yellow  in  colour,  and  may  be  seen  under  the  microscope  to  contain  glo- 
bules more  variable  in  size,  mingled  with  a  greater  or  less  number  of 
granule  cells  (Fig.  30).  These  latter  ought  to  disappear  in  the  human 
female  on  the  fifth  or  sixth  day  after  parturition,  but  occasionally  they 
remain,  when  the  milk  must  be  considered  as  unhealthy.  In  some  cases 
I  have  seen  them  abundant  so  late  as  six  weeks  after  the  birth  of  the 
infant. 

On  some  occasions,  milk  may  be  mixed  with  pus  and  blood,  which  are 
readily  detected  by  the  characters  distinctive  of  each.  Dr.  Peddie  has 
pointed  out  that  milk  can  be  squeezed  from  the  mamma  during  the  early 
months  of  pregnancy.  Under  such  circumstances,  it  constitutes  a  most 
important  sign  of  the  pi'egnant  state,  especially  of  a  first  pregnancy ; 
for  although  the  secretion  at  this  time  has  seldom  the  external  appear- 
ance of  milk,  but  is  serous-looking,  and  often  very  viscid  and  syrupy, 
still,  if  examined  with  the  microscope,  the  characteristic  milk  globules 
will  at  once  appear.  See  his  valuable  paper,  "  Monthly  Journal  of 
Medical  Science,"  August  1848. 


The  Blood. 

On  examining  a  drop  of  blood  drawn  from  the  extremity  of  the  finger 
by  pricking  it,  there  will  be  seen  a  multitude  of  yellow  round  bi-concave 
discs,  rolling  in  the  field  of  the 
microscope,  which  soon  exhibit  a 
tendency  to  turn  upon  their  edge, 
and  arrange  themselves  in  rolls,  like 
rouleaux  of  coins.  These  rouleaux, 
by  crossing  one  another,  dispose 
themselves  in  a  kind  of  net-work, 
between  which  may  be  seen  a  few 
colourless  spherical  corpuscles,  hav- 
ing a  molecular  surface,  and  a  few 
granules.     The  coloured-blood  corpuscles  vary  in  size  from  the  joVo"^^ 

Fig.  31.  Blood-corpuscles,  drawn  from  the  extremity  of  the  finger.  On  the  left  of 
the  figure  thej'-  are  isolated,  some  flat  and  on  edge,  some  having  a  dark  and  others  a 
light  centre,  according  to  the  focal  point  in  which  they  are  viewed.  On  the  right  of 
the  figure  several  rolls  have  formed.  Two  colourless  corpuscles  and  a  few  granules 
are  also  visible. 

Fig.  32.  Blood-corpuscles  altered  in  shape  from  exosmosis.  250  diam. 


76 


EXAMINATION   OF  THE   PATIENT. 


to  the  aoVotli  of  an  inch  in  diameter,  their  average  size  being  about  the 
~Vott  of  an  inch — according  to  Gulliver,  3  aVo^li  of  an  inch.  Owing  to 
their  bi-concave  form,  they  present  a  bright  external  rim  with  a  central 
shadowed  spot,  or  a  bright  centre  and  a  dark  edge,  according  to  the 
focal  point  in  which  they  are  viewed  (Fig.  31).  If  the  blood  be  exposed 
to  the  air  a  little  time  before  examination,  or  if  it  be  obtained  by 
venesection,  the  edges  of  the  corpuscles  may  often  be  observed  to 
have  lost  their  smooth  outline,  and  to  have  become  irregular,  notched, 
serrated,  beaded,  etc.  (Fig.  32).  Long  maceration  in  serum,  or  other 
circumstances,  frequently  cause  them  to  diminish  in  bulk  half  their 
natural  size,  and  to  present  a  perfectly  spherical  coloured  body.  On  the 
addition  of  water,  the  blood  discs  become  spherical,  and  lose  their  colour. 
On  adding  syrup,  they  become  flaccid  and  irregular.  Strong  acetic  acid 
dissolves  them  rapidly,  and  very  weak  acetic  acid  does  so  slowly,  or 
diminishes  their  bulk  by  one-half. 

The  colourless  corpuscles  of  the  blood  are  spherical  in  form,  and  vary 
in  size  from  the  2 sVoth  to  the  ^ oV ott  of  an  inch  in  diameter.  Their 
surface  presents  a  molecular  or  dotted  appearance,  almost  disappearing 
on  the  addition  of  water,  when  they  swell  out  by  endosraosis.  Acetic 
acid  renders  the  external  cell-wall  very  transparent,  and  brings  the 
nucleus  into  view,  consisting  of  one,  two,  or  three  round  granules. 

The  examination  of  the  blood  by  the  microscope  enables  us  to  deter- 
mine certain  pathological  conditions  of  that  fluid,  which,  though  few  in 
number,  are  by  no  means  unimportant. 

In  several  diseases,  the  blood  presents  unusual  spissitude,  depending 
on  excess  of  fibrine.  In  this  condition  the  coloured  blood-corpuscles 
easily  lose  under  pressure  their  rounded  margin,  and  assume  a  caudate 

or   ilask-like  shape.     They  do 

f^\Q;-}Q.,::         not  present  their  usual  tendency 

-M'fi>;°;'f^-.'¥®     to  accumulate  in  rolls,  but  ag- 

trrefate  themselves  tocjether  in 


■^     jy°^:^^ 


•   ^; 


Fip.  34. 


irregular  masses,  as  represented 
Fig."  33. 

In    certain    internal    hemor- 
rhages   the     blood  -  corpuscles 
Fig.  .33.  Fip.  34.  break   down,    or    become  par- 

tially dissolved,  when  the  external  envelope  is  seen  very  transparent,  the 
shadowed  spot  disappears,  and  there  is  found  in  their  interior  one  or 
more  granules.  The  liquor  sanguinis  also  contains  an  unusual  number 
of  granules  (Fig.  34).  The  same  change  is  occasionally  observable  in 
the  blood  extraTvasated  below  the  skin  in  scurvy  or  purpura  hemor- 
rhagica. 

In  a  woman  who  died  of  cholera,  Dr.  James  M.  Cowan  observed  a 
remarkable  alteration  in  the  blood,  which  he  was  so  good  as  to  shew 
me.  It  consisted  in  the  coloured  corpuscles  being  paler  than  usual,  and 
the  colourless  ones  normal,  but  mingled  with  these  were  others  varying 


Fig.  33.  Blood-corpuscles  altered  in  form,  and  aggregated  together,  in  thickened 
blood. 

Fig.  34.  Altered  blood-corpuscles  in  the  fluid  of  an  hsematocele.  250  cUam. 


USE   OF  THE   MICROSCOPE.  77 

in  shape    and   size.      They   were    generally    circular,  bnt    some   were 

oval,  and  a  few  caudate.      Tliey  had  a  well-defined 

external  smooth  border,  having  one  or  two  bright        0°  ^  °       °  ^ 

refracting  granules,  generally  situated  in  the  external       o /p*  o  o    J^  •»  r\ 

membrane,    and    occasionally    projecting   from    it.     O^^^   c?^^o 

Wlien    seen    edgeways,   they  were   flattened,  and     g\  ^^     f\'-^''  O 

existed   in   the  proportion  of  one  to  seven  of  the        v    \  (T^^  O"  " 

coloured  corpuscles.     Their  long  diameter  varied     "Zr-^K^'   v^crS"^ 

from  the^2Vo th  to  the  20^*00^^^  ^^  ^'^  inch,  and  their      ^q  ^S  q-^  q 

transverse  diameter  from  the  2 oVo^^^  ^^  the  joVo^^^  Fie  35 

of  an  inch.      The  addition  of  acetic  acid   caused 

them    to    swell    out,  dissolved  their  external   wall,   and    liberated   the 

granules.       Aqua  potassae   rendered  the  whole   structure  paler,  and  a 

solution  of  muriate  of  soda  rendered  them  more  distinct,  and  of  smaller 

size.* 

We  have  seen  that,  in  a  healthy  condition,  the  blood  possesses  very 
few  colourless  corpuscles ;  but  there  is  a  certain  state  of  that  fluid  I  was 
the  first  to  describe  in  1845,  and  have  since  called  "  Leucocythemia," 
or  white-cell  blood,  in  which  they  are  very  numerous,  generally  associ- 
ated with  enlargement  of  the   spleen  or  other  lymphatic  glands.     The 


-       0  1^ 


"ff )  )^^  m 


foV^>  f^ 


Fig.  37.  Fig   3S. 

blood  then  presents  the  characters  represented  in  the  accompanying 
figures.     (See  also  the  section  on  diseases  of  the  blood.) 

It  has  been  affirmed  that  the  colour  and  number  of  the  corpuscles 
of  the  blood  undergo  a  change  in  plethora,  fever,  jaundice,  dropsies, 
cholera,  etc.,  but  exact  observations  are  wanted  to  confirm  the  statement. 
I  have  never  been  able  to  satisfy  myself  that  any  such  changes  were 
observable  in  these  diseases  by  means  of  the  miCToscope.  In  chlorosis 
the  number  of  the  blood-globules  is  undoubtedly  diminished ;  but 
this  is  determined  by  the  size  of  the  clot,  rather  than  by  microscopic 
demonstration. 

Occasionally  the  serum  of  the  blood  presents  a  lactescent  appear- 
ance ;  and,  on  being  allowed  to  remain  at  rest  some  hours,  a  white 
creamy  pellicle  forms  on  the  surface.      This  consists   of  very  minute 

*  See  Dr.  Cowan's  case — Monthly  Journal  of  Medical  Science.    March,  1854. 


Fig.  35.  Appearance  of  blood  once  observed  in  a  case  of  cholera. 

Fig.  36.  Appearance  of  a  drop  of  blood,  in  Leucocytlaemia. 

Fig.  37.  Tlie  same,  after  the  addition  of  acetic  acid. 

Fig.  38.  The  same  after  the  blood  has  stood  24  hours.  250  dia7n. 


78  EXAMINATION  OF  THE   PATIENT. 

particles  of  oil,  which  resemble  the  smaller  molecules  found  in  milk, 
and  in  the  chyle. 

Pus. 

Normal  or  good  pus,  when  examined  under  a  microscope,  is  found 
to  consist  of  numerous  corpuscles,  floating  in  a  clear  fluid,  the  liquor 

^^         puris.     The  corpuscles  are  glo- 

(  %)    (qS>)        bular  in  form,  having  a  smooth 

(mS (^'^■''''/^\    "margin,  and  finely  granular  sur- 

^•-'^.^•;_--'  \0 ;    face.     They   vary    in    size   from 

iCP  i©(  §  j  ^ /~--:    the  ifoVot^  t^  t^^^  TzVotb   of  an 


^  ^    ,     ,_ ,.     inch  in  diameter.     In    some  of 

leCr  :  (.<J^;./^-,      them    there    may   be   generally 

observed  a  i-ound  or  oval  nucleus. 


'©»" — 

Tig.  39.  Fig.  40.  which    is    very   distinct   on   the 

addition  of  water,  when  also  the  entire  corpuscle  becomes  distended 
from  endosmosis,  and  its  granular  surface  is  more  or  less  diminished. 
On  the  addition  of  strong  acetic  acid  the  cell-wall  is  dissolved,  and  the 
nuclei  liberated  in  the  form  of  two,  three,  four,  or  rarely  five  granules, 
each  of  which  has  a  central  shadowed  spot.  If,  however,  the  re-agent 
be  w-eak,  the  cell-wall  is  merely  rendered  transparent  and  diaphanous, 
through  which  the  divided  nucleus  is  very  visible. 

Occasionally  these  bodies  are  seen  surrounded  by  another  fine  mem- 
brane, as  in  Fig,  41.     At  other  times  they  are  not  perfectly  globular, 
^^  but  present  a  more  or  less  ir- 

.^■"Sj^'-^/'i^""':  .  <;^V.cf5.     regular  margin,  and  are  associ- 

i^^^S^^      'it^Sfifi    »t^''^  ^'^^'^  numerous  molecules 
•'^/^f"""'' '~"l      •V^A  r7^-'^S'i>>rv    and  granules.     This  occurs  in 

■vi^i.'/-'^.      _.  \^^//    ^       ^-vo'i-Vt^i:;^^      what  IS  called  scrofulous   pus, 
^  ^Qi^^  60^     ^"'1  ^'ai-ious  kinds  of  unhealthy 


discharges    from    wounds    and 
^'?-  ^^-  ■^'^'  ^^-  granulating  surfaces.    (Fig.  42.) 

In  gangrenous  and  ichorous  sores,  we  find  a  few  of  these  irregular  pus 
corpuscles  associated  with  a  multitude  of  molecules  and  granules,  and 
with  transformed  and  broken-down  blood  globules,  the  debris  of  the 
involved  tissues,  etc.,  etc. 

Sputum. 

A  microscopic  examination  of  the  sputum  demands  a  most  extensive 
knowledge  of  both  animal  and  vegetable  structures.  I  have  found  in 
it, — 1st,  All  the  tissues  which  enter  into  the  composition  of  the  lung, 
such  as  filamentous  tissue,  young  and  old  epithelial  cells,  blood-cor- 
puscles, etc.  2d,  Mucus  from  the  oesophagus,  fauces,  or  mouth.  3d, 
Morbid  growths,  such  as  pus,  pyoid,  and  granular  cells ;  tubercle  cor- 
puscles, granules,  and  amorphous  molecular  matter ;  pigmentary  deposits 
of  various  forms,  and  parasitic  vegetations,  which  are  occasionally  found 

Fig.  39.  Pus  corpuscles,  as  seen  in  healthy  pus. 

Fig.  40.  The  same,  after  the  addition  of  acetic  acid. 

Fig  41.  Pus  corpuscles,  surrounded  by  a  delicate  cell-wall. 

Fig.  42.  IiTegular-shaped  pus  corpuscles,  in  scrofulous  pus.  250  diam. 


USE   OF   THE   MICROSCOPE.  79 

on  the  lining  membrane  of  tubercular  cavities.  4tb,  All  tbe  elements 
tbat  enter  into  the  composition  of  tbe  food,  whetber  animal  or  vegeta- 
ble, wbicb  become  attached  to  tbe  moutb  or  teeth,  and  which  are  often 
mingled  with  the  sputum,  such  as  pieces  of  bone  or  cartilage,  muscular 
fasciculi,  portions  of  esculent  vegetables,  as  turnips,  carrots,  cabbages, 
etc. ;  or  of  grain,  as  barley,  tapioca,  sago,  etc. ;  or  of  bread  and  cakes  ; 
or  of  fruit,  as  grapes,  apples,  oranges,  etc.  All  these  substances  render 
a  microscopic  examination  of  expectorated  matters  anything  but  easy  to 
the  student. 

To  examine  sputum,  it  should  be  thrown  into  water,  when,  on  account 
of  the  air  it  contains,  it  will  generally  tloat  on  the  surface;  while  the 
more  dense  portions,  such  as  masses  of  crude  tubercle  or  cretaceous 
concretions,  occasionally  mingled  with  it,  will  fall  to  the  bottom.  It 
should  be  then  teased,  or  broken  up  with  a  rod,  when  the  various  ele- 
ments and  particles  it  contains  will  gradually  disengage  themselves,  and 
may  be  separated  from  the  mass  without  difficulty.  Xothing  is  more 
common,  on  examining  portions  of  sputum  with  a  microscope,  than  to 
observe  the  various  a(ro:reofations  of  molecular  and  g-ranular  matter  here 
fiofured — 


t^      1^     ^4m     #^ 

.^..  fe^..^  ^^  ^^^ 


^H^. 


Fig.  43.  Fig.  44.  Fig.  45.  Fig.  46.  Fig.  47. 

Occasionally  little  masses  of  a  cheesy  substance,  and  yellowish  colour, 
may  be  found  entangled  in  the  purulent  mucus,  or  collected  at  the  bot- 
tom of  the  vessel.  These,  when  examined,  present  a  number  of  irregular 
shaped  bodies  approaching  a  round,  oval,  or  triangular  form,  varying  in 
their  longest  diameter  from  the  ^ oVo^^  to  ^oVoth  of  an  inch.  These 
bodies  contain  from  one  to  seven  granules,  are  unatfected  by  water,  but 
are  rendered  very  transparent  by  acetic  acid.  They  are  what  have 
been  called  tubercle  coqjusdes.  They  are  frequently  mingled  with  a 
multitude  of  molecules  and  granules,  which  are  more 
A  ^^^^  numerous  in  proportion  to  the  softness  of  the  tubercle 

C^^^^^^S   (Fig.  47).     (See  also  description  of  the  tubercular  exu- 
"^    "~  dation.) 

Sometimes  indurated  or  gritty  little  masses  are 
brought  up  with  the  sputum,  which  are  derived  from 
the  cretaceous  or  calcareous  transformation  of  chronic 
tubercle  in  the  lungs.  They  consist  of  irregular  masses 
of  phosphate  of  lime,  combined  with  more  or  less  ani- 
mal matter.  On  scjueezing  such  as  are  friable  between 
Fig.  4S.  glasses,  and  examining  their  structure,  they  frequently 

may  be  seen  to  contain  the  elements  represented  in  Fig.  48. 

Fig.  43.  ilass,  consisting  of  minute  molecules,  frequently  seen  in  disintegrated 
tubercle. 

Figs.  44  and  45.  Masses  composed  of  molecules  and  oily  granules  varying  in  size 
and  mode  of  aggregation. 

Fig.  46.  Mass  partly  composed  of  the  debris  of  a  fibrous  structure. 

Fig.  47.  Mass  composed  of  tubercle  corpuscles. 

Fig.  48.  Fragments  of  phosphate  of  lime  occasionally  found  in  the  sputum.  250  c?j. 


80 


EXAMINATION   OF  THE   PATIENT. 


Sputum  frequently  presents  the  fibrillated  appearance  which  is  com- 
mon to  all  mucous  discharges.  It  is  caused  by  the  deposition  in  viscid 
mucus  of  molecules,  which  assume  a  linear  arrangement.  This  deposi- 
tion is  increased  by  the  addition  of  water  and  acetic  acid,  so  that  they 
consist  of  albumen.  These  fine  molecular  fibres  (see  Figs.  55,  69,  72), 
must  be  distinguished  from  the  ai'eolar  and  elastic  tissue  of  the  lung, 
which  is  not  uufrequently  found  in  sputum,  and  which  indicates  ulcera- 
tion or  sloughing  of  the  pulmonary  texture  (Figs.  49,  50,  51).  Sehroeder 
van  der  Kolk  has  lately  stated  that  these  fragments  may  be  found  in  the 
sputum  before  the  physical  signs  of  ulceration  of  the  lung,  as  determined 
by  auscultation,  are  well  characterised.  This  fact  I  have  confirmed,  and 
believe  it  to  be  one  of  great  diagnostic  importance. 


Fig  49.  Fig.   50.  Fig.  51. 

In  acute  pneumonia,  the  sputum  fi-equently  contains  fibrinous  casts  of 


Fig.  52.  Fi^.  53. 

the  minute  bronchi,  which  present  a  branched  mould   of  the  tubes. 

Fig.  49.  Fragment  of  elastic  tissue  of  the  lung,  in  phthisical  sputum. 

Fig.  50.    Fragment  of  areolar  and  elastic  tissue,  still  exhibiting  the  form  of  air 
cells,  from  phthisical  sputum. 

Fig.  51.  Another  fragment. — (  Van  der  Kolk.y 

Fig.  52.  Fibrinous  coagula  in  sputum,  exliibiting  moulds  of  the  bronchi.     Natural 
size. — ( After  Peacock.) 

Fig.  53.  Fibres,  with  corpuscles,  in  a  fibrinous  coagulum  from  a  bronchus. 

250  diam. 


USE   OF   THE    MICROSCOPE. 


81 


Tliese  casts  (Fig.  52)  may  be  readily  separated  in  water,  as  previously 
described  ;  and  when  examined  with  the  microscope,  are  found  to  consist 
of  molecular  fibres,  in  which  pyoid  and  pus  corpuscles  are  infiltrated. 
(Fig.  53.) 

The  inspissated  sputum,  so  commonly  expectorated  in  the  morning, 
is  derived  from  the  fauces.  It  often  presents  a  dirty  green  or  brownish 
colour,  passing  into  black.  When  examined  with  a  microscope,  it  may 
be  seen  to  consist  of  epithelial  cells,  more  or  less  compressed  together, 
and  varying  in  size  from  the  2  oVo^^i  ^o  the  ^\o^^  of  an  inch  in  diameter. 
The  smaller  ones  are  round,  and  closely  resemble  pus  corpuscles ;  the 
larger  ones  are  round  or  oval,  with  a  distinct  nucleus.  In  the  dark- 
coloured  portions  of  this  sputum,  the  cells  contain  numerous  granules 
and  molecules,  several  of  which  are  black  and  quite  opaque.  This  black 
matter  consists  of  carbon,  and  .,.;  .^.■^,.    ,fl■^5^, 

is  unaffected  by  re-agents.   The        ;i;';,  = ;  ;      ■ 

addition  of  acetic  acid  causes       '-t'-'  V 
coagulation  of  the    mucus   in         ; 
which  the  cells  are  embedded ; 
and   whilst   it   produces   little 
chanjre   in  the  older   cells,   it    ; 
dissolves,   or   renders   transpa- 
rent, the  walls  of  such  as  are  Fig.  54. 
young,  displaying  a  round,  oval,  or  divided  nucleus,  as  seen  in  the  figure 
(Fig.  55). 

In  the  "  black  phthisis  "  of  colliers  the  sputum  is  ink-black,  and  more 
or  less  tenacious.  On  examination  with  a  microscope,  the  cells  iu  it  are 
seen  to  be  loaded  with  carbonaceous  pigment.  Sevei'al  of  these  cells 
are  perfectly  opaque,  whilst  others  are  almost 
colourless ;  and  between  the  two  extremes 
there  is  every  gradation  as  to  intensity  of 
blackness.  This  black  pigment  is  unaffected 
by  the  strongest  re-agents,  nitro-muriatic  acid, 
chlorine,  and  even  the  blow-pipe,  failing  to 
decompose  it.  It  is,  therefore,  pure  carbon, 
and  differs  from  the  pigment  contained  in  cells  of  similar  appearance  in 
melanotic  tumours,  as  in  these  latter  the  re-agents  just  mentioned  at  once 
destroy  the  colour.     (  See  Carbonaceous  Lungs.) 


Fig.  56. 


Vomited  Matters. 

The  matters  rendered  by  vomiting  have  not  been  made  so  frequent  an 
obiect  of  microscopical  observation  as  is  necessary  for  the  purposes  ol 
diagnosis.  In  organic  diseases  of  the  organ,  nothing  has  been  ascer- 
tained on  this  head.  In  other  cases,  it  almost  always  happens,  that  the 
matters  returned  consist — 1st,  Of  food  and  drink,  in  various  stages  of 

Fig.  54.  Epithelial  cells,  embedded  in  mucus,  expeclorated  from  the  fauces.  Some 
are  seen  to  contain  black  pigment ;  others  resemble  pus  corpuscles. 

Fig.  55.  Another  portion  of  expectorated  mucus  from  the  feuces,  acted  on  by 
acetic  acid,  showing  fibrillation  and  the  ciianges  in  the  young  cells. 

Fig.  56  and  57.  Cells  loaded  with  pigment  in  the  sputum  of  the  collier.    250  diam. 

6 


82 


EXAMINATION  OF  THE   PATIENT. 


decomposition  and  disintegration  ;  2d,  Of  portions  of  the  epithelial 
lining  membrane  of  the  stomach,  oesophagus,  or  pharynx,  altered  in  its 
characters,  and  mingled  with  more  or  less  mucus ;  3d,  Of  certain  new 
formations,  which  are  produced  in  the  fluids  of  the  stomach. 

1.  It  would  constitute  a  very  interesting  series  of  obseiTations,  to 
determine,  with  the  aid  of  the  microscope,  the  structural  changes  which 
various  articles  of  food  undergo  during  the  process  of  digestion  in  the 
stomach.  This  has  not  yet  been  done  with  accuracy,  although  there 
can  be  little  doubt  that  compound  tissues  become  disintegrated  in  the 
inverse  order  to  that  in  which  they  are  produced — that  is  to  say,  fibres 
become  separated,  embedded  cells  become  loose,  and,  when  aggregated 
together,  their  cohesion  is  destroyed.  The  cell-walls  then  dissolve,  the 
nucleus  still  resisting  the  solvent  process  for  some  time  ;  but  at  length 
the  whole  is  resolved  into  a  molecular  and  granular  mass,  which  in  its 

turn  becomes  fluid.  Such,  however,  are  the  differ- 
ent soluble  properties  of  various  edible  substances, 
that,  in  a  time  sufficient  for  the  perfect  solution  of 
some,  others  are  scarcely  affected.  It  may  readily 
be  conceived,  that  the  transitions  which  these  sub- 
stances undergo,  may  occasionally  render  their 
detection  difficult ;  and  such  is  really  the  case. 
Starch  corpuscles,  for  instance,  break  down  into 
rounded  granules  or  molecules,  and  are  very  liable 
to  puzzle  an  inexperienced  observer.     Tincture  of 

iodine,  from  its  peculiar  reaction  on  these  bodies,  will  always  enable  us 

to  recognise  them. 

2.  The  various  epithelial  cells  which  line  the  passages  leading  to  the 
stomach,  as  well  as  the  structures  peculiar  to  that  organ  itself,  may 
be  found  in  the  vomited  matters — of  course  mingled  with  the  debris  of 

Fig.  59. 

edible  substances.  They  also  may  have  undergone  various  chancres  in 
appearance,  from  endosmosis,  or  even  partiardigestion.  In  clfolera, 
the  vomited  matter  consists  principally  of  such  altered  epithelial  cells  or 
scales,  many  of  which  are  derived  from  the  fauces  or  oesophagus. 

8.  The  new  formations  which  may  be  produced  in  the  stomach  are 
prmcipally  vegetable  fungi— such  as  various  kinds  of  torula?  (see  Fig. 

^•^'  ro    :^PP^^''^"ce  of  starch  corpuscles  after  partial  digestion  in  the  stomach 
tl^\-^     W^^^J^  tl^e  nce-water  vomiting  of  a  cholera  patient,  shewing,  a,  large 
epithelial  cells;  b,  milk  globules,  and  coagulated  caseine ;    c,  toruke-  and  d  ha&- 
digested  epithelial  scales,  with  liberated  nuclei,  more  or  less  broken  down. 

Fig.  60.  Structures  observed  in  certain  rice-water  vomitings  from  a  cholera  patient 
filiewing  bodies  which  consist  of  the  half-digested  uredo  in  bread.  250  diam.    ' 


•v;^ 


USE  OF   THE   MICROSCOPE. 


83 


59,  c),  and  especially  one  first  discovered  in  vomited  matters  by  Mr. 
Goodsir,  and  which  he  has  called  Sarcina  VentricuU.  It  consists  of 
square  particles,  which  apparently  increase  by  fissiparous  division  in 
reu-ular  order,  so  that  they  present  square  bundles  of  four,  sixteen,  or 
some  other  multiple  of  four.  Although  at  first  supposed  to  be  peculiar 
to  the  stomach,  I  have  frequently  found  them  in 
the  foeces;  and  in  one  case,  in  the  urine.  They 
have  also  been  found  by  Virchow  and  by  myself, 
in  the  lung,  and  by  Robin,  inside  the  capsule  of  the 
crystalline  letis. 

In  addition  to  the  bodies  now  alluded  to,  vomited 
matters  may  contain  various  morbid  products,  such 
as  blood,  pus,  and  cancer  cells,  colouring  matter  of  the  bile,  etc. 


FCECES. 

The  same  difiiculty  attends  the  examination  of  the  foeces  as  of  the 
sputum;  for  there  may  be  found  in  it, — 1st,  All  the  parts  which  com- 
pose the  structure  of  the  w^alls  of  the  alimentary  canal :  2d,  All  kinds  of 
morbid  products ;  and  3d,  All  the  elements  which  enter  into  the  com- 
position of  food.  The  only  difference  is,  that  these  last  are  generally 
more  broken  down  or  disintegrated. 

Under  certain  circumstances,  the  diagnostic  value  attached  to  the 
examination  of  the  foeces  is  greater  than  that  of  the  sputum,  or  of 
vomited  matters.  For  instance,  when  pus  or  blood  globules  are  detected, 
we  may  infer  that  the  more  perfect  these  are,  the  nearer  to  the  anus  is 
their  origin.  In  examples  4  and  6  (pp.  60,  61)  I  have  shewn  how  the 
detection  of  certain  vegetable  structures,  used  as  food,  was  serviceable 
in  diagnosis ;  but  this  subject  merits  more  extensive  attention  than  has 
hitherto  been  paid  to  it. 

Among  the  indigestible  articles  connected  with  the  food,  it  was 
observed  in  the  autumn  of  1849,  that  curious-shaped  bodies  were  detect- 
able, both  in  the  vomited  matters  and  stools  of  cholera  patients.  These 
were  supposed  to   be  parasitic  formations  connected  with  the  cause  of 


Fig.  63. 


Fis.  64. 


cholera,  but  were   pointed   out  by  Mr.  Busk  to  be  the  uredo-segitum, 
occasionally  found  in  bread.     (Figs.  60  and  62.) 


Fig.  61.  Sarciua  Ventriculi. 

Fig.  62.  Portions  of  the  uredo  in  bread,  still  further  digested  and  disintegrated  than 
is  observable  in  the  vomited  matters.     (Fig.  60.)     Some  toruhe  are  also  present. 
Fig.  63.  Structure  of  confervoid  mass  passed  from  the  bowels.  250  diain. 

Fig.  64.  The  same,  magnified  500  diameters  linear,  shewing  their  vegetable  nature. 


84 


EXAMINATION  OF  THE   PATIENT, 


On  one  occasion,  a  dispensary  patient  brought  to  me  a  membranons 
mass,  which  had  been  evacuated  by  the  bowels.  It  resembled  a  piece 
of  boiled  fine  leather,  of  a  greenish-yellow  colour,  and  fibrous  structure. 
On  microscopic  examination,  it  was  found  to  be  made  up  of  an  inex- 
tricable mesh  work  of  confervoid,  gi'owths,  consisting  of  long  tubes,  with 
joints,  and  a  few  oval  sporules,  the  former  having  a  great  tendency  to 
break  across,     (Figs.  63  and  64.) 

In  typhus,  and  other  putrid  fevers,  the  stools  contain  masses  of 
large  crystals  of  phosphates  or  carbonates,  as  in  the  case  of  a  girl  of  18 
admitted  into  Addinbroke's  Hospital,  Cambridge.  The  material  passed 
from  the  bowel  was  of  a  very  dark  colour,  perfectly  fluid,  and  yielded  a 


Fig.  65. 

precipitate  on  the  application  of  heat,  and  the  addition  of  nitric  acid. 
(See  Fig.  IV,  BeaWs  Archives,  vol.  i.  p,  141,)     In  dysentery  they  are 

X;---  ^  loaded  with  pus  and  blood ;   and  the  former  may 

;:::::?  o  ^^vi^^jPs:!  also  be  detected  on  the  surface  of  foecal  masses  when 
the  intestine  is  ulcerated.  There  may  also  be  ob- 
served numerous  torula3,  and  occasionally  sarcinae. 
In  cholera  the  white  stools  consist  of  mucus,  in 
which  the  debris  of  epithelial  cells  is  entangled ;  and 
as  the  nuclei  of  these  cells  resist  disintegration  for  a  long  time,  these 
round  or  oval  bodies  generally  exist  in  considerable  number  (Fig.  60), 

In  a  disease  very  common  in  Edinburgh,  especially  in  women,  flakes 
of  membranous  matter  are  thrown  off  from  the  bowels  in  large  quan- 
tities; these  present  a  very  similar  appearance  to  the  cholera  flakes  ja.st 
noticed. 


Fist. 


Fig.  65.  a.  Rounded  masses  of  earthy  matter,  probably  carbonate  and  phosphate  of 
lime.  b.  Crystals  of  triple  or  ammoniaco-magnesian  phosphate,  c.  Oval  masses, 
probably  fragments  of  a  clot.  In  one  to  the  left  of  the  figure  the  outline  of  the 
blood  corpuscles  is  more  distinct  than  in  most,  and  in  a  the  individual  corpuscles 
can  be  seen.  e.  Dark  amorplious  masses,  probably  derived  from  the  food.  /.  Ovum 
of  an  entozoon,  probably  an  ascaris.     g.  Small  coUec'ion  of  blood  globules.— {5ea?€.) 

Fig.  66.  Structure  of  flakes  in  a  rice-water  stool,  from  a  cholera  patient.    250  diam. 


USE   OF  THE   MICROSCOPE.  85 


Uterine  and  Vaginal  Discharges. 

The  diagnostic  indications  to  be  derived  from  the  microscopic  examina- 
tion of  these  discharges,  have  not  been  much  investigated  ;  but  there 
are  few  subjects  which  hold  out  the  promise  of  more  useful  results  to  the 
medical  practitioner.  It  can  only  be  prosecuted  by  the  obstetric  histolo- 
gist,  who,  on  collecting  the  secretions  poured  out  from  the  os  uteri,  or 
on  the  vaginal  walls,  by  means  of  the  speculum,  should  observe  their 
structural  peculiarities  when  quite  fresh.* 

The  menstrual  discharge  will  be  found  to  consist  of  young  epithelial 
cells,  old  e2:»ithelial  scales,  and    blood  globules,  the  number  of  which 


~X-'e-o  ">'    ^—    -—    —  -^ 

Fig  G7 

last  will  be  greater  or  less  according  to  the  intensity  of  the  colour.  A 
leucorrhoeal  discharge  always  consists  of  old  epithelial  scales,  which  may 
be  more  or  less  loaded  with  fat,  combined  with  numerous  young  epithe- 
lial cells  (round  or  oval),  and  pus  corpuscles.     (Fig.  67.) 

The  white  gelatinous  discharge,  so  frequently  seen  with  the  speculum 
to  be  derived  from  the  os  uteri,  consists  of  gelatinous  mucus,  in  which 
round  or  oval  young  epithelial  cells  are  mingled.  The  mucus  is  copiously 
deposited  in  a  molecular  form,  on  the  addition  of  acetic  acid  or  water, 
M'hilst  the  walls  of  the  cells  are  rendered  transparent,  and  an  oval  granular 
nucleus  made  visible.     (Figs.  68  and  69.) 

Not  unfrequently  leucorrhoeal  and  other  discharges  contain  groups  of 
blood  globules,  the  shapes  of  which  are  almost  always  more  or  less  altered 
by  exosmosis,  on  account  of  the  viscid  fluid  mingling  with  them  (see  Fig. 
67).  Indeed,  the  variations  observable  in  these  discharges  are  dependent 
for  the  most  part  on  the  excess'of  one  or  other  of  the  elements  just  men- 
tioned— namely,  epithelial  cells  or  scales,  pus  or  blood  corpuscles,  and 
gelatinous  mucus.     In  dysmenorrhoea  considerable  patches  of  the  epi- 

*  On  this  poiut  Dr.  Tyler  Smith's  work  ou  Leucorrhoea  may  be  consulted  with 
advantage. 

Fig  67.  Corpuscles  seen  in  a  chronic  leucorrhoeal  discharge,  consisting  of, — 1st, 
Large  epithelial  scales,  from  the  vagina  and  cervix  uteri  On  the  left  of  the  figure 
some  of  these  may  be  observed  to  have  undergone  the  fatty  degeneration.  2d, 
Numerous  pus  corpuscles;  and  3d,  Blood  globules,  the  external  edges  of  which  are 
more  or  less  dentated  from  exosmosis. 

Fig.  68.  Structure  of  gelatinous  mucus  from  the  os  uteri. 

Fig.  69.  The  same,  after  the  addition  of  acetic  acid.  250  diam. 


86  EXAMINATION   OF  THE   PATIENT. 

thfclial  membrane  desquamate,  and  even  entire  casts  of  the  uterus  or 
vagina  have  been  separated. 

In  addition  to  the  fluid  discharges  poured  out  from  the  uterus  and 
vagina,  tliere  are  a  variety  of  morbid  growths  connected  with  these 
oi-gans,  tlie  diagnosis  of  which  may  be  materially  facilitated  by  micro- 
scopic examination.     The  separation  of  fibrous,  epithelial,  and  cancerous 


Fig.  TO. 


tumours  and  ulcers  belongs  to  this  category,  and  must  be  conducted  on 
the  principles  referable  to  the  diagnosis  of  morbid  growths  in  general.  I 
have  had  abundant  opportunities  of  satisfying  myself  of  the  importance 
of  this  mode  of  proceeding,  in  cases  where  the  substance,  mucous  sur- 
face, or  cervix  of  the  uterus  has  been  more  or  less  involved. 


Mrcus. 

In  all  fluids  secreted  from  a  mucous  membrane,  many  of  which  have 
been  noticed,  there  may  be  found  a  gelatinous  material,  which  has  long 
been  called  mucus.  It  may  vary  in  colour  from  a  milk-white  to  a  yel- 
lowish brown  or  even  black  tint,  these  variations  being  dependent  on  the 
cell  structures  or  pigment  it  contains.  By  some  it  has  been  supposed 
that  there  are  certain  cell  formations  peculiar  to  mucus,  which  have 
been  called  "  mucus  corpuscles  ;"  but  it  has  alwaj's  appeared  to  me  that 
the  various  bodies  found  in  this  secretion  are  either  dift'erent  forms  of 
epithelium,  on  the  one  hand,  or  pus  cells  on  the  other.  Thus  the  round 
epithelial  cells  found  in  mucous  crypts,  or  the  bodies  constituting  per- 
manent epithelium,  when  newly  formed,  before  they  have  had  time  to 
flatten  out,  and  become  perhaps  more  or  less  aflfected  by  endosraosis,  are 
represented.  Figs.  54  and  68.  These  are  the  mucous  corpuscles  of  some 
writers.  Again,  when  exudation  is  poured  out  on  a  mucous  surface,  and 
is  mino-led  in  greater  or  less  quantity  w  ith  the  gelatinous  secretion,  it 
presents  a  marked  tendency  to  be  transfoimed  into  pus  corpuscles,  and 
hence  whv  all  irritations  of  mucous  surfaces  are  usually  accompanied  by 
purulent  discharges.  The  pus  corpuscles,  under  such  circumstances, 
present  all  the  characters  formerly  noticed  as  peculiar  to  these  bodies 
(see  Figs.  39  and  6*7). 

Hence,  properly  speaking,  there  is  no  such  body  as  a  mucus  corpuscle, 

Figs.  70  and  71.     Two  specimens  of  cancerous  juice  squeezed  from  the  uterus. 

250  diam. 


USE   OF  THE   MICROSCOPE. 


87 


the  cells  found  in  mucus  being  either  epithelial  or  pus  cells,  the  number 
of  which  present  communicates  certain  peculiarities  to  the  discharge. 
Thus,  as  we  have  seen,  the  white  gelatinous  mucus  discharged  from  the  os 
uteri  contains  the  former,  whilst  the  pe- 
culiar  fluid  characteristic  of  a  gonorrhoea  '<£) .  ^-^J^J^ 
or  catarrh,  in  either  sex,  abounds  in  the  ,,-=«-'^"''/^"  @) 
latter.  The  gelatinous  substance,  how-  ■•:::::::^3~i^i^^'^ 
ever,  in  which  these  bodies  are  found 
[Mucin),  is  what  is  peculiar  to  the  fluid 
secreted  from  mucous  surfaces,  containing, 
as  it  does,  a  large  amount  of  albumen 
possessing  a  remarkable  tendency  to  co- 
agulate in  the  form  of  molecular  fibres. 
(Fig.  72.)  When  recent,  these  are  few  in 
number,  but  on  the  addition  of  water  or 
acetic  acid  they  are  precipitated  in  such  numbers  as  to  entangle  the  cell 
formations,  and  present  a  semi-opaque  membranous  structure  (Fio-s  55 
and  69).  *  ' 

The  more  healthy  a  mucous  secretion,  the  more  it  abounds  in  this 
viscous  albuminous  matter,  and  the  fewer  are  its  cell  elements.  On  the 
other  hand,  when  altered  by  disease,  the  cell  elements  increase,  and  the 
viscosity  diminishes. 


Dropsical  Fluids. 


Fig.  T3. 


The  fluids  obtained  by  puncture  of  dropsical  swellings,  may  in  some 
cases,  when  examined  microscopically,  present  peculiarities  worthy  of 
notice.  Thus,  in  the  serum  collected  within  the  tunica 
vaginalis  testis,  numerous  spermatozoa  may  be  found, 
constituting  what  has  been  called  spermatocele.  How 
these  bodies  find  their  way  into  this  fluid  is  unknown, 
as  no  direct  communication  with  the  substance  of  the 
testicle  has  ever  been  seen ;  neither  does  their  occur- 
rence seem  to  interfere  in  any  way  with  the  successful 
treatment  of  this  kind  of  dropsy,  by  injections,  as  prac- 
tised in  hydrocele. 

In  the  fluid  of  ascites,  when  removed  from  the  body,  there  may  usually 
be  observed  a  few  epithelial  scales  from  the  serous  layer  of  the  abdomen, 
which  are  more  abundant  in  some  cases  than  in  others.  Occasionally 
blood  and  pus  corpuscles  may  be  detected  in  greater  or  less  quantity. 

In  ovarian  dropsy,  various  products  may  be  found  in  the  evacuated 
fluid,  according  to  the  nature  of  the  contents  of  the  cyst.  Pus  and  blood 
corpuscles  are  common  elements,  but  more  commonly  epithelial  cells 
and  scales,  which  occasionally  accumulate  in  the  cysts  of  ovarian  tumours. 
(Fig.  74.)     At  other  times,  masses  of  gelatinous   or  colloid  matter  are 


Fig.  72.  Viscid  greyish  yellow  S2mta  of  pneumonia,  treated  with  dilute  acetic 
acid,  containing  fibrinous  mucin,  pus  corpuscles,  and  epithelial  cells  containing  fatty 
and  pigment  granules. — {Afie?-  Wedl.)  300  diam. 

Fig.  73.  Spermatozoa  as  observed  in  the  fluid  of  Spermatocele.  250  diam. 


EXAMINATION   OF  THE   PATIENT. 


evacuated,  whicli  present  various  appearances,  according  to  the  time 
that  has  elapsed  since  its  formation  (see 
Colloid  Cancer  and  Ovarian  Dropsy). 

In  the  examination  of  dropsical  fluids  also, 
there  can  be  little  doubt  that  further  research 
will  lead  to  very  important  results  in  diagnosis. 


Urine. 


FifT.  74. 


Healthy  human  urine  examined  -with  the 
microscope,  when  recently  passed,  is  abso- 
lutely structureless.  Allowed  to  repose  for  twelve  hours,  there  is  no 
precipitate;  occasionally  a  slight  cloudy  deposition  may  be  observed, 
in  Avhich  may  be  discovered  a  few  epithelial  scales  from  the  bladder, 
a  slight  sediinent  of  granular  urate  of  ammonia,  or  a  few  crystals  of 
triple  phosphate.  In  certain  derangements  of  the  constitution,  however, 
various  substances  are  found  in  the  urine,  which,  in  a  diagnostic  point  of 
view,  are  highly  important,  and  which  we  shall  shortly  notice  in  succession. 
To  examine  the  deposits  found  in  urine,  this  fluid  should  be  poured,  in 
the  first  instance,  and  left  to  stand  for  a  time,  in  a  tall  glass  jar ;  the 
clear  liquid  should  then  be  decanted,  and  the  lower  turbid  portion  put 
into  a  tall  test  tube,  and  the  deposit  again  allowed  to  form.  In  this 
manner  the  structural  elements  are  accumulated  in  the  smallest  possible 
compass,  so  that  a  large  number  of  them  are  brought  into  the  field  of 
the  microscope  at  once.  The  quantity  of  any  salt  or  deposit  in  the  urine 
can  never  be  ascertained  by  the  microscope.     But  in  the  great  majority 


Fig.  75. 


of  cases,  the  appearances  observed  with  that  instrument,  are  sufficient  in 
themselves  to  distinguish  the  nature  of  the  various  kinds  of  sediment  met 
with,  and  these  consequently  are  all  that  need  be  described  in  this  place. 
Uric  Acid. — Uric  acid  crystals  are  almost  always  coloured,  the  tint 
varying  from  a  light  fawn  to  a  deep  orange  red.  The  general  colour  is 
yellow;  They  present  a  great  variety  of  forms,  the  most  common  being 
rhomboidal.  "The  lozenge-shaped  and  square  crystals,  which  are  more 
rarely  met  with,  isolated  and  in  groups,  are  represented.  Fig.  75.  Not 
unfrequently  they  present  adhering  masses  or  flat  scales  Avith  transverse 
or  longitudinal  markings,  as  seen".  Fig.  76.     Occasionally  they  assume 


Fio-.  74.  Cells  in  fluid,  removed  from  an  ovarian  dropsy. 

Fit;;.  75.  Lozenfj^e-sliaped  and  rhomboidal  crystals  of  uric  acid. 

Fig.  76.  Aggregated  and  flat  striated  crystals  of  uric  acid. 


250  diam. 


USE   OF   THE   MICROSCOPE. 


89 


the  form  of  truncated  rounded  columns,  as  represented,  ■with  other  struc- 
tures, Fig.  81. 

Urate  of  Ammonia  most  commonly  assumes  a  molecular  and  granular 
form,  occurring  in  irregularly  aggregated  amorphous  masses.  (Fig.  78.) 
This  may  be  separated  from  a  similardooking  deposit  of  phosphate  of 
lime  by  the  action  of  dilute  muriatic  acid,  which  immediately  dissolves 
the  last-named  salt,  but  acts  slowly  on  urate  of 
ammonia,  setting  free  the  uric  acid.  Some- 
times, however,  it  occurs  in  spherical  bodies 
of  a  bistre  brown  colour,  varying  in  size  from 


the  5  0-Vot^  ^^  t^6  ¥  0^*0  o'th  of  an  inch  in  diame- 


'c 


*:^/>^- 
'[/'- 


"    O    OOCO 


Fif. 


ter.  The  latter  size  rarely  occurs.  Occasion- 
ally they  assume  a  stellate  form,  needle-like  or 
spicular  prolongations  coming  off  from  the 
spherical  body.  I  have  seen  both  these  forms 
associated,  and  the  former  so  curiously  aggregated  together  as  to  assume 
the  appearance  of  an  organic  membrane,  for  which  by  some  observers  it 
was  mistaken,  until  it  was  found  to  dissolve  under  the  action  of  dilute 
nitric  acid.     (Fig.  77.) 

Triple  Phosphate  or  xhnmonio-Phosjihate  of  Magnesia. — These  crys- 
tals are  very  commonly  met  with  in  urine, 
and  are  generally  well  defined,  presenting  the 
form  of  triangular  prisms,  sometimes  trun- 
cated, at  others  having  terminal  facets.  (Fig. 
78.)  If  an  excess  of  ammonia  exist,  or  be 
added  artificially,  they  present  a  star-like  or 
foliaceous  appearance,  which,  however,  is  sel- 
dom seen  at  the  bed-side. 

Most  of  the  forms  of  urate  of  ammonia 
are  represented.  Figs.  77  and  78,  in  the  latter 
they  are  associated  with  the  triple  phosphate. 

Oxalate  of  Lime  most  commonly  appears  in  the  form  of  octahedra, 
varying  in  size,  the  smaller  aggregated  together  in  masses.  Once  seen, 
these  bodies  are  readily  recognised  (Fig.  79).  Very  rarely  thev  present 
the  form  of  dumb-bells,  or  of  an  oval  body,  the  central  transparent  portion 
of  which  presents  a  dumb- 


Fig.  78. 


cr3 


<&P 


\zz 


bell  shape,  while  the  sha- 
dowed dark  portion  fills 
up  the  concavities. 

Cystine  takes  the  form 
of  flat  hexagonal  plates, 
presenting  on  their  surface 
marks  of  similar  irregular 
crystals  (Fig.  80).  Occa- 
sionally their  centre  is  opaque,  having  radiations  more  or  less  numerous, 
passing  towards  the  circumference. 

Fig.  77.  Urate  of  ammonia,  in  a   granular  membranous  form,  and  in  rounded 
masses,  with  spicula. 

Fig.  78.  Triple  phosphate,  with  various  forms  of  urate  of  ammonia. 

Fig.  79.  Octahedral  and  dumb-bell  shaped  crystals  of  oxalate  of  lime. 

Fig.  80.  Flat  and  rosette-hke  crystals  of  cystine.  250  dlam. 


Fig.  79. 


Fig. 


90 


EXAMINATION  OF  THE   PATIENT. 


In  addition  to  the  various  salts  found  in  the  urine,  there  may  occasionally 

be  found  different  organic 


yH 


P  )'^     ^    fi^ 


Fig.  81. 


products,    such    as    blood 
and    pus  corpuscles,    sper- 
matozoa,   vegetable    fungi, 
exudation  casts  of  the  tubes, 
or  epithelial  scales  from  the 
bladder  or  mucous  passages. 
Frequently    one  or  more  of 
these    are  found   together, 
as   in  the   annexed  figure. 
Very    rarely    casts    of  the 
tubes,  principally  composed 
of  oily  granules,  may  be  seen, 
or  epithelial  cells,  more  or 
less  loaded  with  similar  granules,  several  of  which  also  float  loose  in 
the  urine,  as  in  the  accompanying  figure : — 
Although  these  casts  of  the  tubes  were  at 
one  time  confounded  together,  they  may  now 
be  separated  into  at  least  four  distinct  kinds, 
namely, — 1st,    Fibrinous    or    exudative  ;    2d, 
Desquamative ;    3d,   Fatty ;    and   4th,   AVaxy 
casts.     The  inferences  to  be  derived  from  the 
presence  of  one  or  more  of  these  will  be  es- 
pecially dwelt  on  in  the  section  which  treats 
of  urinary  diseases. 


■^> 


Fie.  62. 


Sy 


Fig.  83. 


Fig.  84 


Fig.  81.  Bodies  observed  in  the  urine  of  a  scarlatina  patient,  24  liours  after  being 
passed,  a.  Desquamated  fragment  of  uriniferous  tube,  b,  Exudation  casts  of  uri- 
niferous  tubes,  c,  Amorplious  urate  of  ammonia,  d,  Columnar  crystals  of  uric  acid. 
e,  Blood  corpuscles.  /,  Pus  corpuscles,  g,  Torulae  and  vegetable  fungi,  which  had 
been  formed  since  the  urine  was  excreted. 

Fig.  82.  Cast  of  a  uriniferous  tube,  principally  composed  of  oil  granules,  with  fatty 
epithelial  cell,  and  free  oil  granules,  in  urine  of  Bright's  disease.  250  diam. 

Fig.  83.  Fatty  casts,  at  an  early  period  of  formation  (/),  with  granule  cells  (e),  and 
crystals  of  triple-phosphate. 

Fig.  84.  Fragments  of  fatty  and  waxy  casts.  One  of  the  latter  is  represented  at 
the  lower  part  of  the  figure.     {Chrisiison.)  200  diam. 


USE   OF  THE  MICE05C0PE. 


91 


Spermatozoa  are  occasionally  fovind  in  the  urine,  but  must  not  be  con- 
sidered as  of  any  importance,  unless  accompanied  by  the  peculiar  symp- 
toms of  spermatorrhoea  (see  Fig.  73).  The  presence  of  torulje  in  con- 
siderable quantity  (Fis:.  81,  f/)  is  indicative  of  the  existence  of  sugar, 
which  requires,  however,  for  its  confirmation,  the  application  of  chemical 
tests. 

All  the  various  appearances  here  noticed  are  only  diagnostic  when 
accompanied  by  concomitant  symptoms.  Alone,  they  are  not  to  be 
depended  on ;  but,  in  combination  with  the  history  and  accompanying 
phenomena,  they  are  capable  of  aftording  the  greatest  assistance  in  the 
detection  of  disease. 


CcTAXEOus  Eruptions  axd  ITlcers. 


An  examination  of  the  various  products  thrown  out  upon  the  skin  in 
the  different  forms  of  eruption,  ulcer,  and  morbid  growth,  may  in  many 
cases  be  of  high  diagnostic  value.     Of  these  we  shall  speak  separately. 

1.  Cutaneous  Eruptions. — Tn  the  vesicular  and  pustular  diseases, 
there  may  be  observed  below  the  epidermis  all  the  stages  of  pus  forma- 
tion, commencing  in  exudation  of  the  liquor  sanguinis,  gradual  deposi- 
tion of  molecular  and  granular  matter,  and  formation  around  them  of 
cell-walls.  The  eruption  produced  artificially  by  tartar  emetic  ointment 
offers  the  best  opportunity  of  examining  the  gradual  formation  of  these 
bodies  under  the  microscope.  Pus  taken  from  all  kinds  of  eruptions 
and  sores  presents  the  same  characters,  there  being  no  difference  between 
the  pus  in  impetigo  and  that  in  variola.  "When  a  scab  is  formed,  as  in 
eczema  or  impetie;o,  a  small  portion  of  it  broken  down,  mixed  with 
water  and  examined  under  the  microscope,  presents  an  amorphous 
collection  of  granules,  oil  globules,  and  epithelial  scales. 

The  squamous  eruptions  of  the  skin  are  three  in  number — namely, 
psoriasis,  pityriasis,  and  ichthyosis. 


The  dry  incrustations  which  form 

on  the  surface  in  these  diseases, 

essentially    consist    of   epidermic 

scales    more    or   less  aggregated 

together.     They  are  verv  loose  in 

pityriasis,and  occasionally  mingled 

with  debris  of  vegetable  confervse, 

similar   to   what    grows    on    the 

mucous  membrane  of  the  mouth 

(Figs.  26  and  27).     The  scales  are  more  aggregated  together  in  psoriasis, 

and  greatly  condensed  in  ichthyosis — occasionally  in  the  latter  disease 

presenting  the  hardness  and  structure  of  horn. 

The  epidermic  tumours  of  the  skin  assume  the  form  of  corns,  callosities, 
condylomatous  warts,  and  what  has  been  called  Verruca  achrocordon. 
They  all  consist,  in  like  manner,  of  epidermic  scales  more  or  less  con- 
densed together ;  in  the  latter  growth  they  surround  a  canal  furnished 
with  blood-vessels.     Sometimes  thev  assume  a  regular  form,  their  interior 


Fig.  35.  Epidermic  cells  from  crust  of  Psoriasis. 


92 


EXAMINATION   OF  THE   PATIENT. 


being  more  or  less  hard,  fibrous,  and  vascular — in  short,  a  prolongation 
of  the  epidermis  (Fig.  85).  At  other  times  they  soften  on  their  summits, 
and  assume  the  structural  peculiarities  of  the  epithelial  ulcer  afterwards 
to  be  described. 


Tis.  sr. 


Fig.  89. 


Fig.  86. 


The  favus  crust  is  composed  of  a  capsule  of  epidermis  scales,  lined 
by  a  finely  granular  mass,  from  which  millions  of  cryptogramic  plants 
spring  up  and  fructify.  Tlie  presence  of  these  paVasittc  vegetations 
constitutes  the  pathognomonic  character  of  the  disease  (See  Favus). 
Other  forms  of  vegetable  parasite  are  occasionally  found  in  connexion 
with  the  skin,  of  which  that  described  by  Mayer  and  Grove,  in  the 
nieatus  of  the  ear,  is  a  good  example.  The  latte"r,  as  figured  by  Beale, 
is  given  Fig.  86. 

The  skin  is  also  attacked  by  certain  animal  parasites.     Of  these  the 

pediculi,  or  lice,  are  too  well  known 
to  need  description.  The  Acarus 
scabiei  and  the  Entozoon  follicu- 
lorum  are  described  and  figured  in 
the  section  on  skin  diseases. 

2.  Cutaneous  Ulcers. — In  healthy 
granulating   sores,  whilst   the    sur- 


'dV.-^ 


0 


Q 


0 


■  0^ 


^i\0( 


^(J)  face 


oo 


is   covered   with    normal   pus 

\  n  -^  b    corpuscles  (Fig.  39),  thegranulations 

J  ^\^J     themselves  present  fibre  cells  in  all 

V^J  stages  of  development  passing  into 

'■^'"-.A  ''.'^■''^■ifliW  fibres.     In  scrofulous  and  unhealthy 

^'^-  -^-  ^'S-  90-  sores,  the  pus  is  more  or  less  broken 

down,  or  resembles  tubercle  corpuscles  (Fig.  42). 

The  epithelial  ulcer  is  very  common  on  the  under  lip,  commencing  in 


Pig.  86.  Tlialli  of  the  fungus  found  in  the  ear  by  Mr.  Grove  {Beak).     See  also 
Trans,  of  the  Microscopical  Society,  vol.  v.  p.  16],  and  plate  vii. 
Fig.  87.  The  fungus  {Achorion  SchonMni)  from  a  favus  crust. 
Fig.  88.  The  same,  magnified  500  diameters  linear. 
Fig.  89.  Epithelial  cells,  from  the  surface  of  an  ulcer  of  the  lip. 
Fig.  90.  The  same,  after  the  addition  of  acetic  acid.  250  diam. 


USE   OF   THE   MICROSCOPE. 


93 


the  form  of  a  small  induration  or  wart,  but  rapidly  softening  in  the  centre, 
it  assumes  a  cup-shaped  depression,  with  indurated  margins,  which  extend 
in  a  circular  form  more  or  less  over  the  cheek  and  chin.  An  examination 
of  the  softened  matter  sometimes  exhibits  epithelial  cells,  in  various 
stages  of  development,  as  in  Fig.  89.    At  other  times  the  cells  are  enlarged, 


flattened  out,  and  more  or  less  loaded  with  fat  molecules  and  granules,  or 
compressed  concentrically  round  a  centre,  forming  what  have  been  called 
nest-cells.  These  growths,  though  generally  denominated  cancer,  are 
at  once  distinguished  by  a  microscopic  examination.  The  so-called 
chimney-sweep's  cancer  of  the  scrotum  is  essentially  a  similar  formation 
(See  Epithelioma). 

The  cancerous  ulcer  of  the  skin  is  often  difiicult  to  distinguish  micro- 
scopically from  the  epithelial  ulcer,  because  the  external  layer,  like  it,  is 
often  composed  of  softened  epidermis.  "When,  however,  a  drop  of  can- 
cerous juice  can  be  squeezed  from  the  surtace,  it  is  found  to  contain 


■4  R\\>i-i  \ 


^1^/ 


groups  of  cancer  cells,  which,  from  their  general  appearance,  mav  for  the 
most  part  be  easily  distinguished.     Considerable  experience,  however. 


Fig.  91.  Epidermic  cells  from  the  edge  of  a  softened  epithelioma. 

Fig.  92.  Other  ceUs  from  the  centre  of  the  softened  portion. 

Fig.  93.  Appearance  of  section  of  cancerous  ulcer  of  the  skin, — a,  Epidermic  scales 
and  fusiform  corpuscles  on  the  external  surface,  b,  Group  of  epidermic  scales. 
c,  Fibrous  tissue  of  the  dermis,  d.  Cancer-cells  infiltrated  into  the  fibrous  tissue,  and 
filling  up  the  locuU  of  the  dermis.  250  diam. 


94  EXAMINATION   OF  THE   PATIENT. 

in  the  knowledge,  and  skill  in  the  demonstration,  of  cancerons  and  can- 
croid growths,  are  necessary  in  order  to  pronounce  confidently  on  this 
point,  and  to  this  end  an  acquaintance  with  the  whole  subject  of  the 
histolog)'  of  morbid  growths  is  essential.* 


USE  OF  CHEMICAL  TESTS. 

The  chemical  examination  of  urine,  blood,  milk,  and  other  animal 
fluids,  as  well  as  the  detection  of  poisons  in  vomited  matters,  or  other 
organic  mixtures  and  tissues,  constitutes  an  extensive  field  of  inquiry, — 
for  a  description  of  which,  I  must  refer  to  works  on  chemistry  and  medi- 
cal jurisprudence.  At  the  bed-side  much  of  this  kind  of  investigation 
is  now  superseded  by  the  use  of  the  microscope,  which  at  a  glance 
enables  us  to  detect  the  poverty  and  adulterations  of  milk,  the  spissitude 
and  altered  condition  of  blood,  the  natures  of  various  salts  and  precipi- 
tates in  urine,  etc.  The  action  of  chemical  re-agents  on  the  corpuscles, 
made  visible  by  this  instrument,  has  already  been  alluded  to.  Chemical 
tests  are  most  valuable  at  the  bed-side  to  determine  the  presence  of 
albumen,  bile,  sugar,  or  chlorides  in  the  urine,  to  which  points  alone  I 
shall  in  this  place  direct  your  attention. 

Before  proceeding  to  test  the  urine  for  particular  substances,  notice 
should  be  taken  of  its  general  properties  ;  such  as  its  colour,  odour, 
density,  and  re-action.  The  naked-eye  characters  of  the  cloud  or  pre- 
cipitate which  appears  in  almost  every  kind  of  urine,  when  allowed  to 
remain  at  rest  for  some  time  after  emission,  should  also  be  observed, 
and  its  morphological  constituents  determined  by  means  of  the  micro- 
scope. The  observation  of  one  or  more  such  properties  may  lead  at  once 
to  the  establishment  of  a  correct  diagnosis,  and  will  certainly  direct  the 
path  we  should  take  in  the  subsequent  chemical  investigation  of  the  fluid. 

The  Specific  Gravitij  of  the  Urine  is  at  once  obtained  by  means  of 
a  urinometer,  and  should  always  be  noted  at  the  commencement  of 
the  examination  of  this  fluid,  as  it  furnishes  important  indications  for 
further  proceedings.  Thus  the  specific  gravity  is  generally  diminished 
in  chronic  cases  of  Bright's  disease,  and  increased  in  cases  of  Diabetes. 

To  detect  Albumen  in  the  Urine. — Boil  a  portion  of  urine  in  a  test 
tube  over  the  flame  of  a  spirit  lamp,  and  observe  the  result.  If  the 
urine,  which  has  in  the  preliminary  examination  proved  to  be  acid, 
become  hazy  or  coagulate,  the  presence  of  albumen  is  certain ;  but  if  it 
be  neutral  or  alkaline  in  its  reaction,  the  cloudiness  may  be  occasioned 
by  the  deposition  of  eai-thy  phosphates.  One  drop  of  nitric  acid  should 
therefore,  in  the  latter  instance,  be  added,  which  will  immediately  clear 
up  the  opacity  of  the  fluid  if  due  to  phosphates,  but  serve  to  increase  its 
turbidity  if  depending  solely  on  coagulated  albumen. 

To  detect  Bile  in  the  Urine. — The  test  for  bile-pigment  is  nitric  acid, 
which  changes  the  fluid  containing  it  in  any  quantity,  first  into  a  grass 
green,  and  then,  if  the  test  be  added  in  excess,  into  a  ruby-red  or  reddish 
brown  tint.     If  the  urine  be  very  much  loaded  with  bile,  as  sometimes 

*  See  the  author's  Treatise  ou  Cancerous  and  Cancroid  Growths.     Edin.  1849. 


USE   OF   CHEMICAL  TESTS.  95 

happens  in  cases  of  jaundice,  so  that  it  resembles  porter  in  appearance, 
it  is  better  to  dikite  it  with  water  before  adding  the  acid.  If  the  test  be 
applied  to  the  urine,  placed  in  a  clean  white  plate,  so  as  to  form  a  thin 
laver  over  the  surface,  the  plav  of  colours  may  often  be  distinctly  seen 
a^uming  green,  violet,  pink,  and  yellow  hues.  The  same  succession  of 
tints  may  "be  induce(i  by  nitric  acid  acting  upon  urine  containing  an 
excess  of  indican  (Schunck),  in  consequence  of  this  substance  being 
resolved  into  blue  and  red  indigo,  which  are  subsequently  destroyed  by 
the  continued  action  of  the  acid.  There  is,  however,  little  chance  of 
fallacy  arisinar  from  this  source,  as  a  marked  excess  of  indican  has  hitherto 
only  been  observed  in  two  cases  (Carter),  and  never  in  connexion  with 
urine  presenting  a  bilious  appearance.  Pettenkofers  test. — Pettenkofer's 
test  for  bilin,  or,  rather,  for  the  choleic  acid  of  the  bUe,  is  applied  in  the 
following  manner.  A  few  drops  of  simple  syrup  are  mixed  with  a  small 
quantitv  of  urine  contained  in  a  test-tube,  or  still  better,  in  a  porcelain 
capsule';  concentrated  sulphuric  acid  is  then  graduaUy  added  in  con- 
siderable quantity.  If  choleic  acid  be  present,  the  mixture  will  exhibit  a 
most  intense  and  beautiful  purple  colour.  The  vessel  employed  should 
be  placed  in  cold  water  before  the  acid  is  added,  in  order  to  prevent  the 
suo-ar  beino-  decomposed  into  certain  brown  compounds,  which  would 
tend  to  obscure  the  development  of  the  reaction  which  has  been 
described.  True  bile  is  seldom  found  in  urine,  even  when  large  quanti- 
ties of  the  colouring  matters  exist. 

To  detect  Sugar  in  the  Urine. — The  three  best  tests  for  sugar  in 
urine  are  those  known  as  Moore's  test,  Trommer's  test,  and  the  Fermen- 
tation test.  Moore's  test  consists  in  boiling  urine  for  five  minutes  in  a 
tube,  with  half  its  bulk  of  liquor  potassse.  If  sugar  be  present,  the 
liquid  assumes  a  brownish  bistre  colour.  Trommer^s  test  consists  in 
adding  a  few  drops  of  a  solution  of  sulphate  of  copper,  so  as  to  give  the 
urine  a  pale  blue  colour  ;  liquor  potassa?  is  then  added  until  the  hydrated 
oxide  of  copper  thrown  down  is  again  dissolved,  which  will  happen  if 
the  urine  be  saccharine.  Tlie  clear  deep  blue  solution  which  is  formed 
must  now  be  boiled  ;  when,  if  sugar  be  present  in  very  minute  quantity, 
it  will  be  indicated  by  the  mixture  assuming  a  yellowish-red  opalescent 
tint ;  but  if  in  large  amount,  by  its  becoming  pertectly  opaque  from  the 
formation  and  precipitation  of  the  yellow  sub-oxide  of  copper.  If  the 
urine  contain  no  sugar,  a  dark-green  precipitate  only  is  formed  on  ebul- 
lition. Fermentation  test. — A  few  drops  of  yeast  should  be  added  to 
urine,  and  a  test  tube  completely  filled  with  the  mixture  inverted  and 
allowed  to  remain  in  a  saucer,  containing  a  little  more  of  the  urine. 
The  whole  should  then  be  put  in  a  warm  place,  of  about  70  or  80  de- 
grees, for  24  hours.  Fermentation  ensues,  and  carbonic  acid  is  formed, 
which  collects  at  the  top  of  the  tube,  displacing  the  fluid.  This  test  is 
now  but  seldom  employed,  being  tedious  of  application,  and  not  giving 
such  accurate  results  as  was  at  one  time  supposed. 

The  following  solution  is  very  useful  when  many  observations  are  to 
be  made  for  the  detection  of  grape  sugar  in  the  urine.  Take  of  bitar- 
trate  of  potash  and  crystallized  carbonate  of  soda,  of  each  150  parts,  of 
caustic  potash  80  parts,  of  sulphate  of  copper  50  parts,  and  of  water 
1000  parts ;  dissolve  the  carbonate  of  soda  and  potash  in  part  ot  the 
water  boiling,  then  add  the  sulphate  of  copper  powdered.     ^^  hen  all 


96  EXAMINATION   OF   THE   PATIENT. 

the  bitartrate  is  dissolved,  add  the  rest  of  the  water,  and  fiher.  A  few 
drops  of  this  solution  added  to  a  little  urine  in  a  test  tube  will,  under 
the  action  of  heat,  throw  down  a  dirty  green  or  yellow  precipitate  of 
sub-oxide  of  copper,  if  sugar  be  present. 

To  detect  Chlorides  in  the  Urine. — Add  to  urine  in  a  test  tube,  about 
a  sixth  part  of  its  bulk,  of  strong  nitric  acid,  and  then  a  few  drops  of  a 
solution  of  nitrate  of  silver.  If  any  soluble  chloride  be  present,  the 
chlorine  will  be  thrown  down  in  combination  with  the  silver  as  a  white 
precipitate  ;  but  if  none  exist,  the  fluid  will  remain  clear.  From  the 
degree  of  turbidity  or  haziness  occasioned  by  the  addition  of  the  silver 
solution,  a  rough  estimate  may  be  made  of  the  amount  of  chlorides  con- 
tained in  the  urine. 

In  concluding  this  subject,  allow  me  to  impress  upon  you  the  great 
importance  of  making  yourselves  acquainted  with  all  the  modes  of  ex- 
amination I  have  brought  before  you,  rather  than  one  or  more  of  them. 
It  too  frequently  happens  that  exclusive  attention  to  a  particular  method 
of  exploration,  has  rendered  some  medical  men  good  observers  of  symp- 
toms, whilst  they  are  unacquainted  with  physical  diagnosis  ;  and  again, 
among  those  who  have  cultivated  the  latter,  there  are  some  who  can 
percuss  and  use  the  stethoscope  with  skill,  who  are  ignorant  of  the  use 
of  the  microscope.  Now  you  should  regard  all  instruments  only  as  a 
means  to  an  end.  In  themselves  they  are  nothing,  and  can  no  more 
confer  the  power  of  observing,  reflecting,  or  of  advancing  knowledge, 
than  a  cutting  instrument  can  give  the  judgment  and  skill  necessary  tor 
performing  a  great  operation.  We  should  learn  to  distinguish  between 
the  mechanical  means  necessary  for  arriving  at  truths,  and  those  powers 
of  observation  and  mental  processes  which  enable  us  to  recognise,  com- 
pare, and  arrange  the  truths  themselves.  In  short,  rather  endeavour  to 
observe  carefully  and  reason  correctly  on  the  facts  presented  to  you, 
than  waste  your  time  in  altering  the  fashion  and  improving  the  physical 
properties  of  the  means  by  which  facts  are  ascertained.  At  the  same 
time,  these  means  are  absolutely  necessary  in  order  to  arrive  at  the  facts 
on  which  all  correct  reasoning  is  based ;  and  perhaps  no  kind  of  know- 
ledge has  been  so  much  advanced  in  modern  times  by  the  introduction 
of  instruments,  and  by  physical  means  of  investigation,  as  that  of  medi- 
cine. These  enable  the  practitioner  to  extend  the  limits  to  which  other- 
wise his  senses  would  be  confined.  Chest  measurers,  pleximeters,  ste- 
thoscopes, microscopes,  specula,  probes,  etc.  etc.,  are  all  useful,  and  in 
particular  cases  indispensable.  I  do  not  say  employ  one  to  the  exclu- 
sion of  the  other,  but  be  equally  dexterous  in  the  use  of  each.  Do  not 
endeavour  to  gain  a  reputation  as  a  microscopist,  as  a  stethoscopist,  or 
as  a  chemist ;  but  by  the  appropriate  application  of  everi/  instrument 
and  means  of  research,  seek  to  arrive  at  the  most  exact  diagnosis  and 
knowledge  of  disease,  so  as  to  earn  for  yourselves  the  title  of  enlightened 
medical  practitioners.  x\bove  all,  do  not  be  led  away  by  the  notion 
that  any  kind  of  reasoning  or  theory  will  enable  you  to  dispense  with 
the  careful  observation  of  facts.  What  is  called  tact  and  skill  is  not  a 
peculiar  intuition,  or  a  superior  power  of  intelligence  possessed  by  cer- 
tain persons,  but  is  always  the  result  of  constant  and  laborious  examina- 
tion of  symptoms  and  signs  in  the  living,  combined  with  careful  research 
into  the  nature  of  morbid  changes  discovered  in  the  dead. 


SECTION  11. 


PRINCIPLES   OF  MEDICINE. 

Every  animated  being  lias  a  limited  period  of  existence,  during  ^vliich 
it  is  constantly  undergoing  a  change.  So  long,  however,  as  this  change 
takes  place  uniformly  in  the  ditferent  parts  ot^  which  it  is  composed,  its 
physiological  or  healthy  condition  is  preserved.  But  immediately  the 
action  of  one  organ  becomes  excessive  or  weak  in  proportion  to  the 
others,  disease,  of  a  pathological  state,  is  occasioned.  This  state  may 
be  induced  by  direct  mechanical  violence,  but  may  also  occur  from  the 
continued  or  irregular  influence  of  several  physical  agents  upon^  the 
bodv,  such  as  temperature,  moisture  or  dryness,  certain  qualities  of  the 
atmosphere,  kinds  of  food,  etc.  etc.  These  are  always  acting  upon  the 
vital  powers  of  the  individual  as  a  whole,  as  well  as  incessantly  stimu- 
latino-  the  various  organs  to  perform  their  functions.  Life,  then,  may  be 
defined  in  the  wordsof  Beclard — "  organization  in  action."  Health  is 
the  regular  or  normal,  and  disease  the  disturbed  or  abnormal  condition 
of  that  action. 

While  such  mav  be  assumed  to  he  our  notion  of  disease  in  the  abstract, 
what  constitutes  disease  in  particular  has  been  much  disputed.  From 
the  time  of  Hippocrates  to  that  of  Cullen  and  his  followers,  the  external 
manifestation  or  symptoms  constituted  the  only  means  of  recognising 
diseased  action,  and  gradually  came  to  be  regarded  as  the  disease  itself. 
Then  these  symptoms  were  arranged  into  groups,  divided,  subdivided, 
and  named,  according  to  the  predominance  of  one  or  more  of  them,  or 
the  mode  in  which  they  presented  themselves.  These  artificial  arrange- 
ments are  the  nosologies  of  former  writers.  All  philosophical  phy- 
sicians, however,  have  "recognised  that  the  true  end  of  medical  inquiry 
is,  if  possible,  to  determine  rather  the  altered  condition  of  the  organs 
which  produces  the  disordered  function,  than  to  be  contented  with  the 
study  of  the  eftects  it  occasions.  But  the  difliculty  of  this  inquh'v  has 
been  so  great,  and  a  knowledge  of  the  means  of  prosecuting  it  so  limited, 
that  it  is  only  within  the  last  "thirty  years  that  medicine  has  been  enabled 
to  build  up  for  herself  anything  like  a  solid  scientific  foundation.  "\^  hat 
has  hitherto  been  accomplished  in  this  way  has  been  brought  about  by 

7 


VQ  PRINCIPLES   OF   MEDICINE. 

the  conjoined  cultivation  of  morbid  anatomy,  patlioloijy,  and  clinical 
observation,  greatly  assisted,  however,  by  the  advance  of  numerous  col- 
lateral branches  of  science,  and  especially  in  recent  times  by  chemical 
and  histological  investigation.  The  result  has  been  a  complete  over- 
throw of  nosological  systems.  We  now  attempt  to  trace  all  maladies  to 
their  organic  cause;  and  just  in  proportion  as  this  has  been  successfully 
accomplished  has  medicine  become  less  empirical  and  more  exact.  The 
organic  changes,  however,  which  produce  or  accompany  manv  diseases 
have  not  yet  been  discovered,  and  consequently  a  classilication  of  all 
maladies  on  this  basis  cannot  be  strictly  carried  out.  The  organic  cause 
of  epilepsy,  hydrophobia,  and  of  many  fevers,  for  example,  is  as  yet 
unknown.  In  the  present  state  of  medicine,  therefore,  when  the  morbid 
change  in  an  organ  is  unequivocally  tlie  origin  of  the  symptoms,  we 
employ  the  name  of  the  lesion  to  designate  the  disease  ;  but  when  there 
is  disturbance  of  function,  without  any  obvious  lesion  of  a  part,  we  still 
make  use  of  the  principal  derangement  to  characterise  the  malady. 
Thus  as  regards  the  stomach  we  say  a  cancer  or  an  ulcer  of  that  viscus, 
and  thereby  express  all  the  phenomena  occasioned.  But  if  we  are  unable 
to  detect  such  cancer  or  ulcer,  we  denominate  the  affection  after  its 
leading  symptom,  dyspepsia,  or  difficulty  of  digestion. 

In  endeavouring  to  carry  out  this  distinction,  however,  modern  2^hv- 
sicians  have  fallen  into  a  great  error,  inasmuch  as  they  have  continued 
to  employ  the  nomenclature  of  our  forefathers,  and  use  words  simph* 
expressive  of  the  presence  of  symptoms  to  indicate  the  altered  condition 
of  organs  which  are  the  cause  of  those  symptoms.  Formerly  the  term 
inflammation  meant  the  existence  of  pain,  heat,  redness,  and  swellino-; 
it  now^  represents  to  us  certain  changes  in  the  ner\'ous,  vascular,  and 
parenchymatous  tissues  of  a  part.  Formerly,  apoplexy  meant  sudden 
unconsciousness  origiuating  in  the  brain  ;  now,  it  is  frequently  used  to 
express  lifiemorrhage  into  an  organ,  and  hence  the  terms  apoplexy  of  the 
lung  and  of  the  spinal  cord.  The  two  ideas  are  essentially  distinct,  and 
bear  no  reference  to  each  other,  because  the  same  word  may  be,  and 
often  is,  employed  under  circumstances  where  its  original  meaning  is 
altogether  inapplicable.  Hence  it  is  incumbent  on  every  one  who  ap- 
plies to  organic  changes,  terms  which  liave  been  long  employed  in 
medicine,  to  define  exactly  what  he  means  by  them.  In  this  way  old 
indefinite  expressions,  though  still  retained,  Avill  have  a  more  precise 
meaning  attached  to  them.  If,  for  instance,  it  be  asserted  that  bleeding- 
cuts  short  an  inflammation,  let  it  be  explained  what  is  cut  short — whether 
the  symptoms,  the  physical  signs,  a  congestion  of  the  vessels,  or  an  exu- 
dation of  the  liquor  sanguinis. 

But  notwithstanding  the  confusion  in  our  nosological  systems,  and  the 
frequent  change  of  ideas  with  regard  to  the  nature  of  morbid  actions, 
which  have  necessarily  resulted  from  the  rapid  advance  of  medicine  in 
late  years,  it  still  follows  that  disease  is  only  an  alteration  in  the  healthy 
function  of  organs.  Hence  all  scientific  classification  of  maladies  must 
be  founded  on  physiology,  which  teaches  us  the  laws  that  regulate  those 
functions.  Therefore  I  venture  to  divide  all  diseases,  in  the  first  place, 
into  two  great  classes,  viz. — 1,  Diseases  of  nutrition ;  and  2,  Diseases  of 
innervation. 


HEALTHY   AND   DISEASED   NUTRITION.  99 


ON  THE   GENERAL   LAWS   OF   NUTRITION   AND    OF 
INNERVATION  IN  HEALTH  AND  DISEASE. 

There  have  not  been  wanting  some  pathologists  who  have  ascribed 
the  origin  of  all  diseases  to  an  altered  condition  of  nutrition  and  of  the 
blood,  whilst  others  have  rcgaixled  even  this  function  as  subservient  to 
that  of  innervation.  In  man,  it  is  true,  we  find  them  inextricabl}-  united, 
and  it  becomes  exceedingly  difficult  at  all  times  to  separate  with  exacti- 
tude what  are  the  purely  mrtritive,  and  what  the  purely  nervous  pheno- 
mena. But  a  consideration  of  animated  nature  at  large  must  satisfy  us, 
that  in  the  vegetable  world,  as  well  as  in  some  forms  of  animal  life,  nutri- 
tion may  proceed  independcntl}'  of  a  nervous  system.  We  also  feel 
satisfied  that  in  theory  as  well  as  in  fact,  the  function  of  nutrition  is  capa- 
ble of  being  separated  from  that  of  innervation.  Doubtless  there  is  no 
lesion  whatever  which  does  not  in  the  higher  class  of  animals  involve 
both  nutritive  and  nervous  changes,  but  the  only  method  of  arriving  at 
a  knowledge  of  their  conjoint  action,  of  their  mutual  influence,  or  the 
manner  in  which  sometimes  one  predominates  over  or  mingles  with  the 
other,  is  by  studying  in  the  first  instance  tlie  laws  by  which  each  seems 
to  be  governed. 

FuXCTION    OF    NuTRITIOX. 

The  various  modes  in  Avhich  nutrition  becomes  impaired,  and  the 
blood  diseased,  can  only  be  understood  by  passing  in  review  the  different 
steps  of  the  nutritive  process.  "We  have  already  pointed  out  how  patho- 
looT  and  practical  medicine  must  be  based  upon  anatomy  and  physiology, 
and  there  is  no  one  subject  perhaps  which  is  so  well  capable  of  illustrat- 
ing; this  proposition  as  the  one  we  are  about  to  consider.  For  ages 
medical  men  have  been  in  the  habit  of  considering  the  blood  to  be  the 
primary  source  of  numerous  maladies.  It  will  be  our  endeavour  to  shew, 
bv  an  analysis  of  the  process  of  nutrition,  that  the  changes  of  the  blood, 
and  the  diseases  which  accompany  them,  are  for  the  most  part  not  pri- 
marv,  but  secondary — that  is  to  say,  they  are  dependent  on  previously 
existing  circumstances,  to  the  removal  of  which  the  medical  practitioner 
must  look  for  the  means  of  curing  his  patient. 

For  the  sake  of  convenience  of  description  and  reference,  we  shall  di- 
vide the  process  of  nutrition  in  man  into  five  stages.  1.  The  introduction 
into  the  stomach  and  intestinal  canal  of  appropriate  alimentary  matters, 
2.  The  foi'mation  from  these  of  a  nutritive  fluid,  the  blood,  and  the 
changes  it  undergoes  in  the  lungs.  3.  Passage  of  fluid  fi'om  the  blood 
to  be  transformed  into  the  tissues.  4.  The  disappearance  of  the  trans- 
formed tissues  and  their  re-absorption  into  the  blood.  5.  The  excretion 
of  these  effete  matters  from  the  body,  in  various  forms  and  by  different 
channels. 

These  different  stages  comprehend  not  only  growth,  but  the  processes 
of  assimilation,  absorption,  secretion,  and  excretion  ;  and  we  believe  that 
it  is  only  bv  understandino-  the  function  in  this  enlarged  sense  that  we 


100  PRINCIPLES   OF   MEDICINE. 

can  obtain  a  correct  explanation  of  those  important  affections,  whicliniay 
appropriately  be  called  diseases  of  nutrition.  We  shall  first,  however, 
consider  each  of  these  stages  separately. 

1 .  The  introduction  into  the  stomach  and  intestinal  canal  of  appropri- 
ate alimentary  matters. — Alimentary  matters  have  been  divided  into 
several  groups.  The  chemist  has  divided  them  into  azotized  and  non- 
azotized  substances.  The  most  important  azotized  principles  are  fibrin, 
albumen,  and  caseine ;  the  most  important  non-azotized  are  fat,  starch, 
gum,  and  sugar.  Both  animal  and  vegetable  aliments  are  capable  of 
yielding  similar  proximate  principles,  although  in  ditl'erent  proportions. 
Those  which  are  most  subservient  to  nutrition  are  albumen  and  oil.  Dr. 
Ascherson  of  Berlin  was  the  fii-st  to  point  out  the  effects  produced  by  a 
union  of  these,  and  their  importance  in  the  formation  of  every  organized 
tissue.  When  we  regard  the  proportions  in  which  these  principles  enter 
into  our  food,  their  presence  in  milk  (the  natural  food  of  young  animals), 
tlieir  univei-sality  in  every  blastema  and  organized  tisiue,  and  the  nume- 
rous experiments  which  prove  that  they  are  capable,  when  united,  although 
not  alone,  of  furnishing  the  conditions  necessary  for  the  support  of  living- 
animals,  we  are  at  once  led  to  the  conviction  that  albumen  and  oil  are 
the  cliief  alimentary  mattei-s  destined  for  nutrition. 

Whilst  albumen  and  oil  may  be  considered  as  types  of  the  chemical 
division  of  nutritive  substances  into  nitrogenized  and  non-nitrogenize<l, 
they  prove  that  other  conditions  than  cliemical  ones  are  necessary  for 
nutrition.  When  mingled  together  thev  produce  an  emulsion,  identical 
in  structure  with  milk,  that  is,  containing  numerous  globules  composed 
of  a  minute  drop  of  oil,  enclosed  in  an  albuminous  membrane.  The  func- 
tion of  the  stomach  and  intestines  consists  in  separating  or  converting 
from  the  contents  submitted  to  them,  albuminous  and  fatty  matters  in  a 
fluid  state,  which,  being  absorbed,  constitute  that  emulsion  observed  within 
the  extremities  of  the  villi  when  they  are  called  into  activity,  as  well  as 
the  fatty  basis  of  tlie  chyle. 

But  fluid  fat  and  albumen,  together  with  the  various  kinds  of  drink, 
also  hold  in  solution  a  third  class  of  alimentarv  matters  no  less  essential 
to  nutrition — viz.,  mineral  substances,  such  as  phosphorus,  sulphur,  iron, 
potassium,  sodium,  calcium,  and  magnesium.  These  in  difterent  states 
of  combination  form  a  necessary  constituent  of  every  tissue  and  fluid,  and 
some  textures,  as  bone  and  teeth,  are  principally  composed  of  them. 

It  is  from  the  albuminous,  fatty,  and  mineral  groups  of  alimentary 
principles  that  all  the  various  tissues  and  organs  are  formed.  The  three 
enter  into  the  composition  of  every  texture  and  every  fluid,  but  are  dif- 
ferently proportioned  in  each.  The  fibrous  tissues  abound  in  the  albu- 
minous, the  adipose  tissue  in  the  fatty,  and  the  osseous  in  the  mineral 
principle.  The  excess  or  diminution  of  these  three  substances  not  only 
stamps  certain  features  on  the  whole  economy,  but  the  morbid  lesions 
of  individual  organs  and  textures  are  intimately  connected  with  fibrous, 
fattv,  and  mineral  formations. 

It  is  unnecessary  to  dwell  at  any  length  upon  the  fact  that  of  all  the 
causes  of  disease,  irregularity  of  diet  is  the  most  common.  Neither  need 
I  do  more  than  merely  allude  to  the  equally  well-known  circumstance, 
that  of  all  the  means  of  cure  at  our  disposal,  attention  to  the  quantity 


HEALTHY  AND   DISEASED   NUTRITION.  101 

and  quality  of  the  ingesta  is  by  far  the  most  powerful.  The  peculiar 
kind  of  interference  with  the  aliment,  which  various  diseases  require, 
Avill  be  illustrated  as  we  proceed  further. 

2,  The  formation  from  alimentary  matters  of  a  nutritive  fluid — tlie 
blood,  and  the  changes  it  undergoes  in  the  lungs. — The  exact  process  by 
which  blood  is  formed  from  alimentary  matters  has  now  been  accurately 
tiaced  by  physiologists.  During  mastication,  the  food  is  mingled  with 
the  saliva,  an  alkaline  viscous  fluid.  In  the  stomach  it  is  subjected  to 
constant  trituration  and  to  the  action  of  the  gastric  juice — an  acid  fluid, 
supposed  to  operate  especially  on  the  albuminous  constituents  of  the 
food.  On  passing  through  the  pylorus  the  whole  is  reduced  to  a  pulpy 
matter  called  chyme.  In  the  duodenum  the  chyme  becomes  mixed 
with  bile,  which  produces  important  changes  in  it,  but  the  nature  of 
these,  and  the  true  uses  of  the  bile,  are  subjects  which  have  not  yet 
been  positively  determined.  The  fatty  constituents  of  the  food  are,  by 
the  conjoint  action  of  heat,  trituration  with  fluid  albumen,  and  the  influ- 
ence of  the  Brunnerian,  pancreatic,  and  other  glands,  which  pour  out  an- 
other alkaline  fluid,  reduced  to  an  exceedingly  flne  state  of  division.  The 
chyme  thus  operated  upon  is  now  gently  propelled  along  the  intestinal 
canal,  by  vermicular  contractions,  and  its  more  fluid  parts  pass  through 
the  villi  into  the  lacteals.  The  matter  so  absorbed  forms  chyle,  which, 
being  brought  into  contact  with  the  cells  elaborated  by  a  series  of  lym- 
phatic or  blood  glands,  is  transformed  into  corpuscles  floating  in  a  fluid. 
^Vhen  at  length  the  chyle  enters  the  torrent  of  the  circulation,  the  cor- 
puscles are  at  once  carried  to  the  lungs,  and  become  coloured  in  conse- 
quence of  the  action  of  the  oxygen  to  which  they  are  there  exposed, 
and  the  fluid  presents  all  the  characters  of  blood. 

The  blood  must  be  examined  structurally  and  chemically.  In  struc- 
ture it  consists  of  numerous  yellow  corpuscles,  a  small  number  of  colour- 
less corpuscles,  and  a  few  granules,  floating  in  a  yellowish  fluid,  the  liquor 
sanguinis.  The  liquor  sanguinis  consists  of  fibrin  dissolved  in  serum, 
which  has  the  property,  when  drawn  from  the  body,  or  under  certain 
other  circumstances,  of  coagulating.  The  facts  connected  with  this  sub- 
ject it  is  unnecessary  to  describe  minutely  here. 

It  is  exceedingly  difficult  to  ascertain  the  exact  chemical  composition 
of  healthy  blood,  but  from  the  analyses  wliich  have  been  made,  we  may 
for  practical  purposes  consider  its  various  constituents  to  be  present  in 
1000  parts  in  the  following  proportions :  AVater  varies  from  760  to  800 
parts  ;  Fibrin  from  1  to  3  parts ;  Albumen  from  60  to  70  parts ;  Cor- 
puscles from  130  to  150  parts;  Extractive  matters  and  fat  from  1  to  4 
parts;  Salts  from  5  to  10  parts. 

We  know  from  the  results  of  numerous  analyses,  that  the  relative 
proportions  of  these  constituents  are  greatly  changed  in  various  diseases. 
What  we  are  desirous  of  alluding  to  now,  however,  is  the  well-known 
fact  that  one  of  the  most  common  causes  of  derangement  in  the  blood 
is  the  difterent  kinds  of  food.  M.  Denis  mentions  that  in  the  blood  of 
a  young  girl  of  good  health  the  globules  were  represented  by  the  pro- 
portion of  132.  After  15  days  of  rigorous  diet  they  were  represented 
by  85.  The  other  constituents,  but  more  especially  the  water,  albumen, 
fat,  and  salts,  are  modified  to  a  like  extent  by  changes  in  the  diet. 


102  PRINCIPLES  OF   MEDICINE. 

The  alterations  which  the  blood  undergoes  in  the  lungs  are  the  recep- 
tion of  a  large  amount  of  oxygen,  which  is  thus  conveyed  through  the 
arteries  to  all  parts  of  the  economy,  and  the  giving  off  a  quantity  of 
carbonic  acid  gas,  which  is  brought  to  the  lungs  by  the  venous  blood 
through  the  pulmonary  aiiery.  Hence  the  importance  not  only  of 
dietetic  regulations  to  furnish  the  material  of  the  blood,  but  of  a  con- 
stant supply  of  fresh  air  to  purify  it  and  render  it  fit  for  the  performance 
of  its  functions.  The  constant  relation  which  exists  between  diet  and 
the  quantity  and  quality  of  the  air  breathed,  is  observable  in  the  con- 
dition of  people  inhabiting  different  parts  of  the  world. 

3.  The  jMssar/e  of  fluid  from  the  blood  to  be  transformed  into  the  tinsxes. 
— From  the  blood  a  fluid  blastema  is  continually  passing  through  the 
capillaries  for  the  formation  and  sustentation  of  the  different  tissues  of 
the  economy.  It  is  necessary  that  this  sliould  take  place  to  an  amount 
proportionate  to  tlie  matter  supplied  to  the  blood  by  assimilation  on 
the  one  hand,  and  that  dissipated  by  waste  on  the  other.  If  more  or 
less  be  given  off,  a  morbid  condition  is  occasioned.  Thus,  an  increased 
amount  in  a  part  gives  I'ise  to  hypertrophies,  a  diminished  amount  pro- 
duces atrophy. 

This  important  function  is  now  considered  to  depend  upon  an  inherent 
vital  property  peculiar  to  the  tissues  themselves,  which  exercise  a  force 
at  the  same  time  attractive  and  selective.  By  its  agency  each  tissue 
and  gland  attracts  from  the  blood  that  amount  of  matter  which  is  neces- 
sary to  maintain  its  bulk,  and  at  the  same  time  selects  from  it  the  pecu- 
liar substance  necessary  for  itself,  or  for  the  secretion  it  is  destined  to 
produce.  Hence  the  liver  keeps  up  its  own  nutrition,  and  at  the  same 
time  selects  the  materials  from  the  blood  which  serve  to  form  bile.  The 
kidney  also  is  nourished,  and  forms  urea ;  and  so  in  like  manner  is  it 
with  all  the  glandular  organs.  In  this  way  the  matter  drawn  off  from 
the  blood  is  made  subservient  in  numerous  ways  to  the  wants  of  the 
economy,  here  furnishing  substance  for  growth  or  for  replacing  waste, 
and  there  giving  material  to  supply  the  various  secretions. 

It  often  happens  that  this  attractive  and  selective  power  in  the  tissues 
Is  deranged,  so  as  to  produce  increase  or  diminution  in  growth  or  in 
secretion,  general  or  partial.  Not  unfrequently  the  selective  power 
appears  to  be  lost,  and  the  attractive  power  so  much  increased,  that  the 
liquor  sanguinis  is  drawn  out  through  the  vessels,  so  that  its  fibrin  coa- 
gulates in  a  mass  outside  them.  This  result,  preceded  or  accompanied 
by  certain  changes  in  the  vessels  themselves,  and  more  or  less  stag- 
nation of  the  current  of  blood,  constitutes  the  phenomena  hitherto 
described  as  inflammation.  Under  these  circumstances,  other  cells  and 
tissues,  altogether  foreign  to  the  healthy  condition  of  the  economy,  are 
produced  in  what  is  now  called  the  exudation,  although  the  same  gene- 
ral laws  of  growth  and  transformation  preside  over  the  abnormal  as  over 
the  normal  products.  In  this  manner  pus  and  cancer  cells  may  be 
formed,  or  fibrous,  cartilaginous,  osseous,  and  other  tissues  causing  dif- 
ferent kinds  oi  morbid  growth. 

4.  The  disap2)earance  of  the  transformed  tissues,  and  their  re-ahsorp- 
tion  into  the  blood. — During  life,  whilst  new  tissue  and  new  cells  are 


HEALTHY  A>'D  DISEASED  NUTRITIOX,  103 

continually  being  formed,  the  old  ones  disappear.  The  manner  in 
Avbifh  this  is  accomplished  in  certain  adult  tissues,  such  as  muscle,  bone, 
and  areolar  texture,  has  not  yet  been  demonstrated,  as  the  intermediate 
stages  of  growth  have  in  them  only  been  seen  in  the  embryo.  There  is 
every  reason  to  believe  that  individual  particles,  as  they  are  dissolved 
and 'absorbed,  are  replaced  by  other  particles  derived  from  the  blood, 
without  necessarily  passing  through  the  stage  of  cell  formation.  Secret- 
ing surfaces,  however,  are  continually  producing  new  cells,  in  which  the 
especial  secretion  is  elaborated,  and  this  either  serves  some  definite  pur- 
pose in  the  economy,  as  in  the  case  of  the  gastric  juice,  or  is  separated 
from  the  body,  as  is  the  case  with  urea.  The  result  is,  that  a  large 
quantity  of  matter  which  has  answered  its  purpose,  breaks  doAvn,  is  dis- 
solved, and  again  passes  into  the  blood.  A  quantity  of  effete  matter  is 
thus  continually  entering  the  circulation,  arising  from  the  decay  of  all 
the  tissues,  but  more  especially  from  the  muscular,  osseous,  nervous,  adi- 
pose, and  areolar  tissues.  The  blood  globules  themselves  dissolve  after 
having  performed  their  functions,  and  serve  to  swell  the  amount  of  effete 
matter  in  the  blood. 

So  long  as  the  matters  absorbed  from  the  tissues  correspond  in  quan- 
tity and  quality  to  tlie  matters  exuded  and  transformed,  the  physiolo- 
gical or  healthy  state  of  the  blood  is  preserved.  We  know,  however, 
that  this  is  continually  liable  to  be  disordered  from  any  of  the  causes 
we  have  formerly  noticed  which  derange  nutrition.  In  some  cases,  ab- 
sorption takes  place  with  great  rapidity,  as  is  occasionally  observed  after 
starvation  or  the  formation  of  large  abscesses.  In  others,  this  process  is 
in  no  way  proportionate  to  the  quantity  of  matters  exuded,  as  in  ple- 
thora, hypertrophy,  and  morbid  growths. 

The  effete  matters  thus  absorbed  into  the  blood  circulate  with  it,  and 
always  form  an  inherent  part  of  its  composition.  It  Avas  first  main- 
tained by  Zimmermann  that  they  constitute  the  fibrin  of  the  blood,  which, 
instead  of  being  exuded  to  form  the  tissues,  as  has  been  generally  sup- 
posed, is  excreted  from  the  body  by  the  difierent  glands.  It  may  be 
well  to  recapitulate  some  of  the  arguments  in  favour  of  this  opinion. 

There  is  no  fibrin  in  chyme,  and  very  little  in  the  chyle,  and  what  is 
remarkable,  much  less  in  the  chyle  of  carnivorous  than  of  herbivorous 
animals,  as  horses  and  sheep.  Ilunger  does  not  diminish  its  quantity  in 
the  chyle  of  horses,  but,  on  the  contrary,  rather  increases  it,  if  we  can 
rely  upon  the  experiments  of  Tiedemann  and  Gmelin,  who  concluded  that 
the  fibrin  must  get  into  the  chyle  through  the  lymphatics.  Since,  then, 
there  is  no  fibrin  in  the  chyme  of  carnivorous  animals,  whilst  it  consti- 
tutes so  large  a  portion  of  their  food,  the  object  of  digestion  must  be  the 
transformation  of  fibrin  into  albumen.  Further,  the  blood  of  carnivora 
contains  less  fibrin  than  the  blood  of  herbivora,  and  in  the  egg  there  is 
no  fibrin,  although  organization  is  proceeding  rapidly  in  it.  These  facts 
are  sufficient  to  prove  that  fibrin  is  in  no  way  necessary  to  cell  develop- 
ment and  formation  of  the  tissues.  On  the  other  hand,  all  those  circum- 
stances that  cause  exhaustion  of  the  textures,  or  increase  the  amount  of 
absorption  from  them,  augment  the  amount  of  fibrin  in  the  blood,  as 
after  inflammatory  or  other  exudations,  starvation,  violent  fatigue,  preg- 
nancy, and  frequent  bleeding  or  hfemorrhage.  Both  Xasse  and  Zim- 
mermann found  the  fibrin  far  more  abundant  in  weak  lymphatic  persons, 


10-i  PRINCIPLES   OF   MEDICINE. 

than  in  those  who  are  strong  and  vigorous.  Again,  'fthile  there  is  little 
fibrin  in  the  chyle  of  the  lacteals,  it  exists  in  great  quantity  in  the 
lymph  of  the  lymphatics,  as  determined  by  Xasse  in  man,  and  by  Miiller 
in  frogs.*  It  follows  from  these  facts,  that  the  pi-imary  digestion  must 
transform  fibrin  into  albumen,  rather  than  the  latter  into  the  former ; 
and  such  is  very  probably  also  the  result  of  the  secondary  digestion. 
flow  otherwise  could  so  small  a  quantity  of  fibrin  as  from  one  and 
a  half  to  three  parts  in  a  thousand,  exist  in  healthy  blood — an  amount 
altogether  disproportionate  to  what  would  be  requii-ed,  did  this  consti- 
tuent as  such  build  up  the  tissues?  It  appears,  therefore,  probable  that 
the  fibrin  is  formed  partly  from  a  solution  of  blood  corpuscles,  and  partly 
from  the  effete  matters  of  the  tissues.  Hence  we  may  understand  why 
absorption  of  exudations,  or  of  the  textures  from  exhausting  causes,  as 
well  as  anything  that  favours  the  disintegrating  process  of  the  blood 
corpuscles  themselves,  will  produce  an  increase  of  this  constituent  in  the 
blood. 

It  has  been  maintained  by  some  that  fibrin  is  secreted  by  the  blood 
corpuscles.  Dr.  Carpenter  supposed  this  to  be  the  especial  function  of 
the  colourless  ce]ls,f  and  Mr.  Wharton  Jones  of  the  coloui'ed  nuclei.^ 
But  there  are  facts  proving  that  fibrin  must  have  a  double  origin,  as  I 
have  stated,  one  in  the  solution  of  both  kinds  of  corpuscles,  another 
from  the  tissues,  of  which  its  increase  during  inflammation  and  in  rheu- 
matism are  examples,  although  in  these  morbid  states,  increase  of  the 
colourless  or  coloured  corpuscles  is  certainly  not  essential.  Hence  fibrin 
must  be  referred  in  its  origin  to  a  process  of  disintegration,  rather  than 
to  one  of  evolution, — but  even  in  this  capacity,  it  may  serve  to  produce 
higher  elaboration  of  that  complex  fluid,  the  blood.§ 

The  pathological  changes  which  take  place  in  the  blood,  as  far  as  they 
have  been  ascertained  by  Andral  and  Gavarret,  Simon,  and  numerous 
other  investigators,  may  be  summed  up  in  the  words  of  Becquerel  and 
Rodier,  who  ascertained — 1st,  That  the  simple  fact  of  the  development 
of  a  disease  almost  always  modifies  in  a  notable  manner  the  composition 
of  that  fluid.  2d,  That  venesection  exercises  a  remarkable  influence  on 
the  composition  of  the  blood — the  more  marked  the  oftener  it  is  re- 
peated. Under  these  circumstances  the  blood  is  impoverished  and  ren- 
dered more  watery — the  albumen  is  slightly  diminished — the  fibrin, 
extractive  matters,  and  free  salts,  are  not  influenced,  but  there  is  a 
decided  diminution  of  the  blood  corpuscles.  3d,  That  in  a  plethoric 
condition  of  the  system  there  is  no  relative  increase  in  the  number  of 
the  corpuscles,  or,  in  fact,  any  other  change  in  the  composition  of  the 
blood ;  it  is  simply  the  mass  of  the  blood  that  is  increased.  4th,  That 
anemia  is  characterized  by  a  diminution  in  the  amount  of  the  corpuscles. 
5th,  That  inflammation  induces  an  increase  of  the  fibrin  and  of  the  cho- 

*  Zur  Analysis  und  Synthesis  des  pseudoplastischen  Processe.    Berlin,  1844.  P.  19. 

■f-  British  and  Foreign  Medical  Review,  vol.  xv.,  jjp.  272,  278. 

:j:  Ibid,  vol.  xiv.  p  597. 

g  I  have  carefully  read  the  argument  of  an  able  writer  in  the  British  and  Foreign 
Medical  Review,  vol.  vii.  pp.  153,  473,  and  vol.  x.  p.  200,  in  opposition  to  the  view 
of  Ziminermann,  and  in  favour  of  the  old  doctrine ;  but  I  beheve  that  all  the  facts 
he  adduces  may  readily  be  shewn  to  favour,  rather  than  overthrow,  what  appears  to 
me  the  correct  theor3% 


HEALTHY  AND   DISEASED   NUTRITION.  105 

lesterine — the  former  varying  from  4  to  10,  and  tlie  latter  being  almost 
doubled.  The  albumen  is  diminished.  6th,  That  the  amount  of 
fibrin  is  diminished,  and  possibly  its  physical  conditions  altered  under 
two  classes  of  circumstances — the  first  embraces  fevers,  exanthematous 
disease,  and  intoxication ;  the  second  starvation  and  purpura  haemor- 
rhagica.  7th,  That  when  any  of  the  secretions  are  checked,  their  essen- 
tial principles  are  contained  in  the  blood  in  excess.  For  instance,  when 
the  secretion  of  the  urine  is  suppressed,  urea  is  found  in  the  blood ; 
when  the  bile  is  not  excreted,  it  also  abounds  in  the  blood,  etc.  8th, 
That  there  are  three  diseases  in  which  the  albumen  of  the  blood  is 
notably  diminished,  viz.,  in  Bright's  disease,  in  certain  aft'ections  of  the 
heart  accompanied  b}'  dropsy,  and  in  severe  cases  of  puerperal  fever. 

5.  The  excretion  of  the  effete  matters  from  the  body  in  various  forms 
and  by  d[ferent  channels. — The  circulating  fluid  having  received  the 
effete  matters  in  the  manner  we  have  described,  again  parts  with  them 
through  the  agency  of  the  glands,  in  the  form  of  certain  secretions  and 
excretions.  Glands  are  nourished  like  all  other  textures,  but  their  cells 
are  endowed  with  the  property  of  secreting  difterent  substances  from 
the  blood.  Thus  the  cells  of  the  liver  secrete  bile  ;  those  of  the  kidney, 
urea ;  those  of  the  mamma,  milk ;  those  of  the  testis,  the  spermatic 
fluid,  etc.,  etc.  In  this  way  the  carbonized  and  nitrogenized  matters, 
as  well  as  the  albuminous  and  fatty  principles,  whether  received  from 
the  assimilation  of  alimentary  substances,  or  from  the  transformation 
of  the  tissues  themselves,  are  again  excreted  from  the  system,  as  bile, 
urea,  carbonic  acid,  etc. 

The  mineral  matters  received  into  the  blood  pass  through  the  same 
process.  The  lime  and  phosphorus  absorbed  from  the  alimentary  canal, 
unite  to  form  the  constituents  of  bone,  and  when  re-absorbed  are  ex- 
creted under  new  combinations  in  the  urine  and  foeccs.  The  muriate  of 
soda  is  decomposed  in  the  tissues.  The  acid  is  found  in  the  gastric  juice 
or  is  exhaled  by  the  skin,  Avhile  the  soda  is  excreted  largely  with  the 
bile  by  the  liver.  Sulphur,  phosphorus,  and  the  other  minerals,  also 
pass  out  of  the  system  in  various  states  of  combination. 

To  complete  the  physiological  changes  connected  with  the  function 
of  nutrition,  it  is  only  necessary  to  remember  that  carbonic  acid  gas,  the 
result  of  decompositions  in  the  tissues,  and  water,  are  contiiuially  given 
off  by  the  lungs  and  skin  ;  and  that  oxygen,  which  enters  the  blood 
through  the  lungs,  is  continually  entering  into  new  combinations  with  the 
bases  of  the  solids  and  fluids.  These  chemical  combinations  and  ex- 
changes are  accompanied  by  the  evolution  of  heat,  whereby  the  animal 
temperature  is  kept  up. 

Thus  we  may  consider  that  there  are  two  kinds  of  digestion  continu- 
ally going  on  in  the  body — one  in  the  stomach  and  intestines,  the  other 
in  the  tissues  ;  that  the  blood  is  the  recipient  of  both,  distributing  the 
results  of  the  first  to  build  up  the  tissues,  and  of  the  second  to  consti- 
tute the  various  excretions.  In  this  manner  the  circulation  of  the  blood 
may  be  compared  to  a  river  flowing  through  a  populous  city,  which 
serves  at  the  same  time  to  supply  the  wants  of  its  inhabitants,  and  to 
remove  all  the  impurities  that  fi'om  numerous  channels  find  their  way 
into  its  stream. 


106  PKIXCIPLES   OF   MEDICINE. 

From  the  foregoing  considerations,  it  follows  that  an  eliminative  func- 
tion is  to  a  certain  extent  brought  about  by  all  the  processes  of  growth 
referred  to,  and  that  there  can  be  no  change,  however  limited,  that  is  not 
necessarily  associated  with  a  general  one  in  the  system  at  large.  As  all 
the  nutritive  functions  are  connected  with  one  another,  an  excess  or 
diminution  of  local  growth,  by  subtracting  from  or  adding  to  the  consti- 
tuents of  the  blood,  must  produce  an  alteration  in  that  fluid  both  as  to 
quantity  and  quality.  The  idea  of  Treviranus,  viz.,  "that  each  single 
part  of  the  body,  in  respect  of  its  nutrition,  stands  to  the  whole  body  in 
the  relation  of  an  excreted  substance,"  has  been  ably  shewn  by  Mr. 
Paget  to  account  for  various  processes  in  health,  under  the  name  of 
"  complemental  nutrition."*  The  same  notion  has  been  still  further 
extended  by  Dr.  William  Addison,  who  correctly  points  out,  thatin  the 
distinctive  eruptive  fevers,  such  as  small-pox,  the  numerous  minute 
abscesses  in  the  skin  eliminate  the  morbid  poison,  which  formerly  existed 
in  the  blood,  and  are  in  this  way  essential  to  the  cure.  This  provident 
action  he  denominates  "  cell  therapeutics."!  Hence  there  are  fixed  pro- 
cesses in  abnormal  as  in  normal  nutrition,  with  which  it  is  essential  for 
the  medical  practitioner  to  be  acquainted,  in  order  that,  instead  of  ope- 
rating blindly  or  empirically,  he  may  act  scientifically,  or  in  accordance 
■with  natural  laws. 

Further,  we  cannot  avoid  observing  that  the  process  of  nutrition  is  a 
continuous  round,  which  in  the  natural  world  may  be  said  to  commence 
"with  the  reception  and  terminate  with  the  preparation  of  aliment,  vege- 
table or  animal;  that  this  is  observable  not  only  in  the  "chemical 
balance  of  organic  nature,"  so  beautifully  described  by  Dumas,  but  in 
the  incessant  cliemical  compositions  and  decompositions,  as  well  as 
structural  formations  and  disintegrations,  which  are  peculiar  to  all  vital 
entities.  If  so,  it  must  be  apparent  that  our  knowledge  of  the  animal 
economy  and  of  the  diseases  to  which  it  is  liable,  can  only  be  elucidated 
by  investigating  the  nature  of  such  chemical  and  structural  changes, 
together  with  the  necessary  relations  that  each  one  bears  to  the  others, 
and  that  it  is  on  such  kind  of  knowledge  alone  that  medicine,  as  a 
scientific  art,  can  ever  repose  in  security. 

We  can  noAv  readily  understand  how  derangement  in  one  stage 
of  the  nutritive  process  more  or  less  affects  the  others,  Tlius,  if 
alimentary  matters  are  not  furnished  in  sufiicient  quantity,  and  of 
a  proper  quality,  the  blood  is  rendered  abnormal,  and  it  necessarily 
follows  that  the  matters  it  gives  off  will  be  abnormal  also,  and  its  subse- 
quent transformations  more  or  less  modified.  Again,  if  secretion  be 
checked,  the  blood  is  not  drained  of  its  effete  matter ;  and  if  excretion 
be  prevented,  the  secretions  themselves  may  enter  the  blood,  and  act 
upon  it  as  a  poison. 

A  diseased  or  morbid  state  of  the  blood,  therefore,  may  arise  from 
either  of  the  stages  of  nutrition  which  we  have  described,  being  rendered 
irregular,  or  otherwise  abnormal.  In  Avhatever  part  of  the  circle  inter- 
ruption takes  place,  it  will,  if  long  continued,  aftect  the  whole.     Thus,  a 

*  Lectures  on  Surgical  Pathology.     Lecture  2. 
f  Addison  on  Cell  Therapeutics.     1856. 


HEALTHY   AND   DISEASED   NUTRITION.  107 

bad  assimilation  of  food  produces  througli  tlic  lilood  bad  secretions  and 
excretions,  whilst  an  accidental  arrest  of  one  of  the  latter  reacts  through 
the  blood  on  the  assimilating  jjowers.  The  forms  of  disease  thus  arising 
may  be  endless,  but  as  regards  nutrition,  they  may  all  be  traced  to  the 
following  causes : — 

1.  An  improper  quantity  or  quality  of  the  food. 

2.  Circumstances  preventing  assimilation  or  impeding  respiration. 

3.  Altered  quantity  or  quality  of  nutritive  mattei's  passing  out  of  the 
blood. 

4.  The  accumulation  of  effete  matters  in  the  blood. 

5.  Obstacles  to  the  excretion  of  these  from  the  body. 

Examples  in  which  each  of  these  causes,  separately  or  combined. 
Las  occasioned  disease,  must  have  occui'red  to  every  pi'actitioner.  It 
is  true  that  all  general  diseases  are  accompanied  by  certiiin  changes  in 
the  blood,  but  "these  changes  are  to  be  removed,  not  by  operating  on 
that  fluid  directly,  but  by  obviating  or  removing  those  circumstances 
which  liave  deranged  the  stage  of  nutrition  primarily  affected.  For 
instance,  a  very  intense  form  of  disease  may  be  produced  in  infants, 
through  improper  lactation.  The  remedy  is  obvious ;  we  procure  a 
healthy  nurse.  Ischuria  is  followed  by  coma,  in  consequence  of  the 
accumulation  of  urea  in  the  blood ;  we  give  diuretics  to  increase  the 
flow  of  urine,  and  the  symptoms  subside.  In  the  one  case  we  furnish 
the  elementary  principles  necessary  for  nutrition  ;  in  the  other,  we 
remove  the  residue  of  the  process.  In  both  cases  the  blood  is  dis- 
eased, but  its  restoration  to  health  is  produced  by  acting  on  a  know- 
ledge of  the  causes  which  led  to  its  derangement. 

In  the  same  manner  we  might  illustrate  the  indications  for  correct 
practice  in  the  other  classes,  of  causes  tending  to  derange  the  blood. 
Thus,  although  there  be  a  proper  quantity  or  quality  of  food,  there 
may  be  circumstances  which  impede  its  assimilation ;  for  instance,  a 
too  great  acidity  or  irritability  of  the  stomach — the  use  of  alcoholic 
drinks — inflammation  or  cancer  of  the  organ.  It  is  the  discovery  and 
removal  of  these  that  constitute  the  chief  indications  for  the  scientific 
practitioner.  Again,  the  capillary  vessels  become  over-distended  with 
blood,  and  the  "exudation  of  liquor  sanguinis  to  an  unusual  amount 
takes  place,  constituting  inflammation,  llow  is  this  to  be  treated  ?  In 
the  early  stage  topicat  bleeding,  if  directly  applied  to  the  part,  may 
diminish  the  congestion,  and  the  application  of  cold  will  check  the 
amount  of  exudatton.  But  the  exudation  having  once  coagulated  out- 
side the  vessels,  acts  as  a  foreign  body,  and  the  treatment  must  then  be 
directed  to  furthering  the  transformations  which  take  place  in  it,  and 
facilitating  the  absorption  and  excretion  of  effete  matter.  This  is 
accomplished  by  the  local  application  of  heat  and  moisture — the  inter- 
nal use  of  neutral  salts  to  dissolve  the  increase  of  fibrin  in  the  blood, 
and  the  employment  of  diuretics  and  purgatives  to  assist  its  excretion  by 
urine  or  stool. 

The  general  principle  we  are  anxious  to  establish  from  this  general^ 
sketch  of  the  nutritive  functions  is— that  diseases  of  nutrition  and  of 
the  blood  are  only  to  be  combated  by  an  endeavour  to  restore  the 
deranged  processes  to  their  healthy  state,  in  the  order  in  which  they 
were  impaired  ;  that  a  knowledge  of  the  process  of  nutrition  is  a  pre- 


108  PRINCIPLES   OF   MEDICINE. 

liminary  step  to  the  proper  treatment  of  these  affections ;  that  the 
theory  of  acting  directly  on  the  blood  is  incorrect;  and  that  an  expect- 
ant system  is  as  bad  as  a  purely  empirical  one. 


Function  of  Innervation. 

The  function  of  innervation  is  also  made  up  of  the  performance  of 
various  actions,  widely  ditfercnt  from  each  other,  although  associated 
together.  These  actions  lead  to  the  manifestation  of  intelligence,  sensa- 
tion, and  combined  motion.  But  as  the  connection  between  these  is  not 
capable  of  exhibiting  such  an  order  of  sequence,  as  has  been  made  appa- 
rent among  the  nutritive  processes,  it  Avill  be  necessary  to  describe  them 
in  a  different  manner. 

General  Anaiomi/  and  PhysioJogi/  of  the  Nervous   System. 

Structure  and  Arrangement  of  the  Nervous  System. — To  the  eye,  the 
nervous  system  appears  to  be  composed  of  two  structures — the  grey  or 
ganglionic,,  and  the  white  or  fibrous.  The  ganglionic,  when  examined 
under  high  powers,  may  be  seen  to  be  composed  of  nucleated  cells, 
varying  greatly  in  size  and  shape,  mingled  with  a  greater  or  less  number 
of  nerve  tubes,  also  varying  in  calibre.  One  important  fact,  with  regard 
to  these  corpuscles,  is,  that  many  of  them  may  be  demonsti-ated  to  throw 
out  prolongations,  which  are  in  direct  con",munication  with,  or  constitute, 
the  central  band  or  axis  of  Remak  and  Purkinje  witliin  the  fibres.  The 
fibres,  indeed,,  may  be  shewn  to  consist  of  minute  tubes,  which  are 
smallest  towards  the  periphery  of  the  cerebrum,  larger  towards  its  base, 
and  largest  in  the  nerves.  They  are  of  three  kinds — 1st,  Finely  cylin- 
drical, as  observed  in  the  optic  and  auditory  nerves ;  2d,  Varicose,  as  in 
the  white  substance  of  the  cerebral  lobes  and  of  the  spinal  cord ;  and 
3d,  Larger  and  of  regular  size  throughout,  as  in  the  nerves.  There  are 
also  bundles  of  gelatinous  or  flat  fibres,  the  nature  of  which  is  much  dis- 
puted, very  common  in  the  olfactory  nerve  and  sympathetic  system  of 
nerves.  There  can  be  no  doubt  that  some  nerve  tubes  run  into  the 
ganglionic  corpuscles,  whilst  others  originate  from  them.  (Wagner, 
Kolliker.)  It  is  also  now  rendered  certain  that  the  same  ganglionic  cell 
may  receive  and  give  off  nerve  tubes,  each  having  distinct  properties, 
the  one  of  conveying  the  influence  of  impressions  to,  and  the  other  of 
conveying  influences  from,  the  nervous  centres.  The  peripheral  termi- 
nation of  the  nerves  is  in  loops  or  arcs. 

The  general  arrangement  of  the  two  kinds  of  structures  should  be 
known.  By  cerebrum,  or  brain  proper,  ought  to  be  understood  that 
part  of  the  encephalon  constituting  the  cerebral  lobes,  situated  above 
and  outside  the  corpus  callosum ;  by  the  spinal  cord  all  the  parts  situ- 
ated below  this  great  commissure,  consisting  of  the  corpora-striata,  optic 
thalami,  corpora  quadrigemina,  cerebellum,  pons  varolii,  medulla 
oblongata,  and  medulla  spinalis.  In  this  way,  we  have  a  cranial  and  a 
vertebral  portion  of  the  spinal  cord. 

In    the    cerebrum,  or  brain    proper,   the    ganglionic   or  corpuscular 


HEALTHY   AND   DISEASED   IXNERVATIOX, 


109 


structure  is  external  to  tlie  fibrous  or  tubular.     It  presents  on  the  sur- 
face  numerous  anfractuosities,   -whereby  a   large  quantity  of  matter  is 


capable  of  being  contained  in  a  small  space.  This  crumpled  up  sheet  of 
grev  substauce  has  beeu  appropriately  called  the  hemispherical  ganglion. 
(Solly.)  In  the  cranial  portion  of  the  spinal  cord,  the  grey  matter 
exists  in  masses,  constituting  a  chain  of  ganglia  at  the  base  of  the  ence- 
phalon,  more  or  less  connected  with  each  other  and  with  the  white  mat- 
ter of  the  brain  proper  above,  and  the  vertebral  portion  of  the  cord 
below.  In  this  last  part  of  the  nervous  system  the  grey  matter  is  inter- 
nal to  the  white,  and  on  a  transverse  section  presents  the  form  of  the 
letter  x,  having  two  posterior  and  two  anterior  cornua, — an  arrangement 
which  allows  the  latter  to  be  distributed  in  the  form  of  nerve  tubes  to 
all  parts  of  the  frame. 

The  white  tubular  structure  of  the  vertebral  portion  of  the  cord  is 
divided  by  the  anterior  and  posterior  horns  of  grey  matter,  together 
with  the  anterior  and  posterior  sulci,  into  three  divisions  or  columns 
on  each  side.  On  tracing  these  upwards  into  the  medulla  oblongata, 
the  anterior  and  middle  ones  may  be  seen  to  decussate  there  with  each 


Fig.  94  Transverse  section  of  the  spinal  cord  of  the  Sahno  salar,  about  two  inches 
from  the  brain. — A,  anterior ;  B.  posterior  groove ;  C,  central  canal  lined  with  epi- 
thelium ;  D.  areolar  tissue  surrounding  the  central  canal,  continuous  with  tlie  ante- 
rior and  posterior  grooves;  E,  anterior  root:  F,  commissural  fi))res;  G.  po-sterior 
root :  H,  areolar  tissue ;  I,  vertical  fibres  of  the  white  substance  cut  acros.s  in  the 
transverse  section ;  K.  openings  of  blood-vessels  cut  across :  L,  ganglionic  cells. — 
(  Owsjannikow.)  100  dium. 


110 


PEIXCIPLES   OF   MEDICINE. 


other,  whilst  the  posterior  columns  do  not  decussate.     On  tracing  the 
columns  up  into  the  cerebral   lobes,  we  observe  that  the  anterior,  or 


pyramidal  tracts,  send  oiF  a  bundle  of  fibres,  which  passes  below  the 
olivary  body,  and  is  lost  in  the  cerebellum — {Arciform  hand  of  Solly). 
The  principal  portion  of  the  tract  passes  through  the  coipns  striatum, 
and  anterior  portion  of  the  optic  thalamus,  and  is  ultimately  lost  in  the 
white  substance  of  the  cerebral  hemispheres.  The  middle  colunm,  or 
olivary  tract,  may  be  traced  through  the  substance  of  the  optic  thalamus 
and   corpoia   quadrigemina,  to  be  in  like  manner  lost  in  the  cerebral 


Fig.  95.  Longitudinal  section  of  the  spinal  cord  of  the  Salmo  solar  cut  obhqueh- 
from  before  inwards,  in  tlie  course  of  the  fibres  of  the  anterior  root. — A,  blood-ves- 
sels filled  with  blood  corpuscles ;  B,  areolar  texture ;  C,  central  canal ;  D,  ganglionic 
cells ;  E,  fibres  of  the  white  substance  originating  in  the  cells  and  going  to  the  brain : 
F,  fibres  of  the  anterior  root  which  pass  througli  the  white  substance  and  pass  into 
the  cells:  G,  pia  mater. — {Owsjannikoic)  lOO  diam. 

Fig.  96.  Longitudinal  section  of  the  spinal  cord  of  the  Pdromyzon  fluviatilis. 
The  right  half — A,  areolar  tissue  between  the  broad  fibres  of  the  cord ;  B,  areolar 
tissue  between  the  ganglionic  cells,  which  exist  in  large  numbers ;  C,  broad  fibres ; 
D,  bipolar  ganglionic  cells  on  a  level  with  the  broad  fibres,  the  extremities  of  which 
divide  into  a  countless  number  of  minute  branches.  The  upper  one  is  seen  to  commu- 
nicate Avith  a  spindle-shaped  cell  by  a  continuous  fibre;  E,  fibres  of  medium  width ; 
F.  spindle-shaped  ganglionic  cells,  containing  a  nucleus  and  nucleolus;  longitudinal 
fibres  of  the  white  substance,  passing  upwards;  a,  a  fibre  going  from  the  cell  into 
the  posterior  root ;  h,  a  fibre  cut  across  which  passes  into  the  anterior  root ;  c,  com- 
missural fibre ;  d.  a  fibre  very  difficult  to  follow,  which  was  once  seen  to  communi- 
cate with  a  round  ganglionic  cell  in  the  centre  of  the  cord ;  e,  a  fibre  passing  out  of 
the  cell  and  running  upwards. — {Oicsjannikow.)  100  diam. 


HEALTHY  AND   DISEASED   INNERVATION.  Ill 

hemispheres.     The  posterior  cohimn,  or  restiform  tract,  passes  ahnost 
entirely  to  the  cerebelhun. 

In  addition  to  the  diverging  fibres  in  the  cerebral  hemispheres  which 
may  be  traced  from  below  upwards,  connecting  the  hemispberical  ganglion 
with  the  structures  below,  the  brain  proper  also  possesses  bands  of 
transverse  fibres,  constituting  the  commissures  connecting  the  two  hemi- 
spheres of  the  brain  together,  as  well  as  longitudinal  fibres  connecting 
the  anterior  with  the  posterior  lobes.  In  the  spinal  cord  it  results  from 
the  investigations  of  Lockhart  Clarke,  that  there  is  a  decussation  of 
various  bundles  of  fibres  throughout  its  whole  extent.  It  is  now  also 
determined,  that  many  of  the  fibres  in  the  nei'ves  may  be  traced  directly 
into  the  grey  substance  of  the  cord— a  fact  originally  stated  by  Grainger, 
but  confirmed  by  Budge  and  Kulliker.  Furtlier,  it  has  recently  been 
shewn  that  by  means  of  these  fibres  an  anastoiuosis  is  kept  up  between 
the  various  columns,  even  those  on  both  sides  of  the  cord,  through  the 
medium  of  nerve  cells  in  the  grey  matter,  an  important  fact  principally 
demonstrated  by  the  labours  of  Stilling,  Remak,  Van  der  Kolk,  Schilling, 
Kupifer,  and  Owsjannikow. 

These  later  observations  indeed  open  up  to  us  the  probability  that  the 
numerous  actions  hitherto  called  reflex,  are  truly  direct,  and  are  carried 
on  by  a  series  of  nervous  filaments  running  in  ditFerent  directions,  which 
have  yet  to  be  described.  There  can  be  no  doubt  that  they  pass  and 
operate  through  the  cord,  and  hence  the  term  diastaltic  proposed  by 
Marshall  Hall  instead  of  reflex,  is  in  every  way  more  appropriate.  The 
importance  of  this  view  appears  to  me  so  great,  that  I  would  refer  to  the 
figures,  pp.  109,  110,  from  the  Thesis  of  Owsjannikow,*  showing  what 
he  thinks  to  be  the  connection  of  nerves  and  ganglionic  cells  in  the 
spinal  cord  of  certain  fishes,  as  indicative  of  probably  similar  relations 
yet  to  be  discovered  in  man. 

Functions  of  the  N^ervous  Si/stem. — The  great  difterence  in  structure 
existing  between  the  grey  and  white  matter  of  the  neiwous  sytem  would 
d  priori  lead  to  the  supposition  that  they  performed  separate  functions. 
The  theory  at  present  entertained  on  this  point  is,  that,  while  the  grey 
matter  eliminates  or  evolves  nervous  power,  the  white  matter  simply 
conducts  to  and  from  this  ganglionic  structure  the  influences  which  are 
sent  or  originate  there. 

The  brain  proper  furnishes  the  conditions  necessary  for  the  manifesta- 
tion of  the  intellectual  faculties  properly  so  called,  of  the  emotions,  pas- 
sions, and  volition,  and  is  essential  to  sensation.  That  the  evolution  of 
the  power  especially  connected  with  mind  is  dependent  on  the  hemi- 
spherical ganglia  is  rendered  probable  by  the  following  facts: — 1.  In 
the  animal  kingdom  generally,  a  correspondence  is  observed  between 
the  quantity  of  grey  matter,  depth  of  convolutions,  and  the  sagacity  of 
the  animal.  2.  At  birth,  the  grey  matter  of  the  cerebrum  is  very  defec- 
tive, so  much  so,  indeed,  that  the  convolutions  are,  as  it  were,  in  the 
first  stage  of  their  fonuation,  being  only  marked  out  by  superficial 
fissures  almost  confined  to  the  surface  of  the  brain.  As  the  cineritious 
substance  increases,  the  intelligence  becomes  developed.  3.  The  results 
of  experiments  by  Flourens,  Rolando,  Hertwig,  and  others,  have  shewn 

*  Disquisitiones  microscopical  de  medullte  spinalis  textura,  1854. 


112  PRINCIPLES   OF   MEDICIXE. 

that,  on  slicing  away  the  brain,  the  animal  becomes  more  dull  and  stupid 
in  proportion  to  the  quantity  of  cortical  substance  removed.  4.  Clinical 
observation  points  out,  that  in  those  cases  in  which  the  disease  has  been 
afterwards  found  to  commence  at  the  circumference  of  the  brain  and 
proceed  towards  the  centre,  the  mental  faculties  are  affected  first; 
whereas  in  those  diseases  which  commence  at  the  central  parts  of  the 
organ  and  proceed  towards  the  circumference,  they  are  affected  last. 

The  white  tubular  matter  of  the  brain  proper  serves,  by  means  of 
the  diverging  fibres,  to  conduct  the  influences  originating  in  the  two 
hemispherical  ganglia  to  the  nerves  of  the  head  and  trunk,  whilst 
they  also  conduct  the  influence  of  impressions  made  on  the  trunk,  in 
an  inverse  manner,  up  to  the  cerebral  convolutions.  The  other 
transverse  and  longitudinal  fibres  which  connect  together  tlie  two 
hemispheres,  and  various  parts  of  the  hemispherical  ganglia,  are  proba- 
bly subservient  to  that  combination  of  the  mental  faculties  which  cha- 
racterises thought. 

The  spinal  cord,  both  in  its  cranial  and  vertebral  portions,  furnishes 
the  conditions  necessary  for  combined  movements ;  and  that  the 
nervous  power  necessary  for  that  purpose  depends  upon  the  grey 
matter,  is  rendered  probable  by  the  following  facts: — 1st,  Its  universal 
connection  with  all  motor  nerves.  2d,  Its  increased  quantity  in  those 
portions  of  the  spinal  cord  from  whence  issue  large  nervous  trunks. 
3d,  Its  collection  in  masses  at  the  origin  of  such  nerves  in  the  lower 
animals  as  furnish  peculiar  organs  requiring  a  large  quantity  of  nervous 
power,  as  in  the  triglia  volitans,  raia  torpedo,  silurus,  etc.  4th,  Clinical 
observation  points  out  that,  in  cases  where  the  central  portion  of  the 
cord  is  afl"ected  previous  to  the  external  portion,  an  individual  retains 
the  sensibility  of,  and  power  of  moving,  the  limbs,  but  wants  the 
power  to  stand,  walk,  or  keep  himself  erect,  when  the  eyes  are  shut ; 
whereas,  when  diseases  commence  in  the  meninges  of  the  cord  or 
externally — pain,  twitchings,  spasms,  numbness,  or  paralysis,  are  the 
symptoms  present,  dependent  on  lesion  of  the  white  conducting 
matter. 

The  white  matter  of  the  cord  acts  as  a  conductor,  in  the  same 
manner  that  it  does  in  the  brain  proper,  and  there  can  be  no  doubt  that 
the  influence  arising  from  impressions  is  carried  not  only  along  the 
fibres,  formerly  noticed,  which  connect  the  brain  and  two  portions  of 
the  spinal  cord  together,  but  along  those  more  recently  discovered, 
"which  decussate  or  anastomose  in  the  cord  itself  (Brown-Sequard),  and 
are  connected  with  the  ganglionic  cells  of  the  grey  matter. 

The  various  nerves  of  the  body  consist  for  the  most  part  of 
nerve  tubes,  running  in  parallel  lines.  Yet  some  contain  ganglionic 
corpuscles,  as  the  olfactory  and  the  ultimate  expansion  of  the  optic 
and  auditoi-y  nerves,  whilst  the  sympathetic  nerve  contains  in  various 
places,  not  only  ganglia,  but  gelatinous  flat  fibres.  The  posterior  roots 
of  the  spinal  nerves  possess  a  ganglion,  the  function  of  which  is  quite 
unknown.  These  roots  are  connected  with  the  posterior  horn  of  grey 
matter  in  the  cord,  while  the  anterior  roots  are  connected  with  the 
anterior  horns.  As  regards  function,  the  nerves  may  be  considered  as 
— 1st,  Nerves  of  special  sensation,  such  as  the  olfactory,  optic,  auditory, 
part  of  the  glosso-pharyngeal    and   lingual   branch  of  the  fifth.      2d, 


HEALTHY   AND   DISEASED   INNERVATION.  113 

Nerves  of  common  sensation,  such  as  tlie  greater  portion  of  the  fifth, 
and  part  of  the  glosso-pharyngeal.  3d,  Nerves  of  motion,  such  as  the 
third,  fourth,  lesser  division'  of  the  fifth,  sixth,  facial,  or  portio  dura  of 
the  seventh,  and  the  hypo-glossal.  4th,  Senso-motory  or  mixed 
nerves,  such  as  the  pneumo-gastric,  the  accessory,  and  the  spinal  nerves. 
5th,  Sympathetic  nerves,  including  the  numerous  ganglionic  nerves  of 
the  head,  thorax,  and  ahdomen, — the  exact  function  of  which  has  not 
been  determined,  although  they  seem  to  influence  nutrition  and  the  pro- 
duction of  animal  heat,  through  their  connection  with  the  blood-vessels. 

All  nerves  are  endowed  with  a  peculiar  vital  property  called  sensi- 
bility, inherent  in  their  structure,  by  virtue  of  which  they  may  be 
excited  on  the  application  of  appropriate  stimuli,  so  as  to  transmit  the 
influence  of  the  impressions  they  receive  to  or  from  the  brain,  spinal 
cord,  or  certain  ganglia,  which  may  be  considered  as  nervous  centres. 
The  nerves  of  special  sensation  convey  to  their  nervous  centres  the 
influence  of  impressions  caused  by  odoriferous  bodies,  by  light,  sound, 
and  by  sapid  substances.  The  nerves  of  common  sensation  convey  to 
their  nervous  centres  the  influence  of  impressions  caused  by  mechanical 
or  chemical  substances.  The  nerves  of  motion  c&ny  from  the  nervous 
centres  the  influence  of  impressions,  whether  psychical  or  physical. 
(Todd.)  The  mixed  nerves  carry  the  influence  of  stimuli  both  to  and 
from,  combining  in  themselves  the  functions  of  common  sensation  and 
of  motion.  Although  the  sympathetic  nerves  also  undoubtedly  carry 
the  influences  of  impressions,  the  direction  of  these  cannot  be  ascer- 
tained, from  their  numerous  anastomoses,  as  well  as  from  the  ganglia 
scattered  over  them,  all  of  which  act  as  minute  nervous  centres.  But 
there  are  cases  where  certain  psychical  stimuli  (as  the  emotions)  act 
on  organs  through  these  nerves,  and  where  certain  diseases  (as  colic, 
gallstones,  etc.)  excite  through  them  sensations  of  pain. 

Sensation  may  be  defined  to  be  the  consciousness  of  an  impression, 
and  that  it  may  take  place,  it  is  necessary, — 1st,  That  a  stimulus 
should  be  applied  to  a  sensitive  nerve,  which  receives  an  impression  ; 
2d,  That,  in  consequence  of  this  impression,  a  something  which  we 
designate  an  influence,  should  be  generated,  and  conducted  along  the 
nerve  to  the  hemispherical  ganghon  ;  3d,  On  arriving  there,  it  calls 
into  action  that  faculty  of  the  mind  called  consciousness  or  perception, 
and  sensation  is  the  result.  It  follows  that  sensation  may  be  lost  by 
any  circumstance  which  destroys  the  sensibility  of  the  nerve  to  impres- 
sions;— which  impedes  the  progress  of  the  influence  generated  by 
these  impressions,  or,  lastly,  which  renders  the  mind  unconscious  of 
them.  Illustrations  of  how  sensation  may  be  affected  in  all  these  ways 
must  be  familiar  to  you,  from  circumstances  influencing  the  ultimate 
extremity  of  a  nerve,  as  on  exposing  the  foot  to  cold, — from  injury  to 
the  spinal  cord,  by  which  the  communication  with  the  brain  is  cut  off", 
or  from  the  mind  being  inattentive,  excited,  or  suspended. 

The  independent  endowment  of  nerves  is  remarkably  well  illustrated 
by  the  fact,  that  whatever  be  the  stimulus  which  calls  their  sensibility 
into  action,  the  same  result  is  occasioned.  Mechanical,  chemical,  gal- 
vanic, or  other  2)ki/sical  stimuli,  when  applied  to  the  course  or  the  extre- 
mities of  a  nerve,  cause  the  very  same  results  as  may  originate  from 
suggestive  ideas,  perverted  imagination,  or  other  psychical  stimuli.     Thus 


114 


PEIXCIPLES   OF   MEDICIXE. 


a  chemical  irritant,  galvanism,  or  pricking  and  pinching  a  nerve  of  mo- 
tion, will  cause  convulsion  and  spasms  of  the  muscles  to  which  it  is  dis- 
tributed. The  same  stimuli  applied  to  a  nerve  of  common  sensation  -will 
cause  pain,  to  the  optic  nerve  Hashes  of  light,  to  the  auditory  nerve  ring- 
ing sounds,  and  to  the  tip  of  the  tongue  peculiar  tastes.  Again,  we 
have  lately  had  abundant  opportunities  of  seeing  that  suggestive  ideas, 
or  stimuli  arising  in  the  mind,  may  induce  peculiar  effects  on  the  muscles, 
give  rise  to  pain  or  insensibility,  and  cause  perversion  of  all  the  special 
senses. — (See  Diseases  of  the  Nervous  System.) 

Motion  is  accomplished  through  the  agency  of  muscles,  which  are 
endowed  with  a  peculiar  vital  property,  called  contractility,  in  the  same 
way  that  nerve  is  endowed  with  the  property  of  sensibility.  Contractility 
may  be  called  into  action  altogether  independent  of  the  nerves  (Haller), 
as  by  stimulating  an  isolated  muscular  fasciculus  directly.  (AYeber.)  It 
may  also  be  excited  by  a  physical  or  psychical  stimulus,  operating  through 
the  nerves.  Physical  stimuli  (as  pricking,  pinching,  galvanism,  etc.) 
applied  to  the  extremities  or  course  of  a  nerve,  may  cause  convulsion  of 
the  parts  to  which  the  motor  filaments  are  distributed  directly,  or  they 
may  induce  combined  movements  in  other  pails  of  the  hody  diastalti- 
cally  (Marshall  Hall), — that  is,  through  the  spinal  cord.  In 'this  latter 
case  the  following  series  of  actions  take  place  : — 1st,  The  influence  of  the 
impression  is  conducted  to  the  spinal  cord  by  the  afferent  or  enoclic  fila- 
ments which  enter  the  grey  matter,  2d,  A  motor  influence  is  transmitted 
outwards  by  one  or  more  efferent  or  exodic  nerves.  3d,  This  stimu- 
lates the  contractility  of  the  muscles  to  which  the  latter  are  distributed, 
and  motion  is  the  result.  Lastly,  contractility  may  be  called  into  action 
by  'psychical  stimuli  or  mental  acts — such  as  by  the  will  and  by  certain 
emotions.  Integrity  of  the  muscular  structure  is  necessary  for  contractile 
movements;  of  the  spinal  cord,  for  diastaltic  or  reflex  movements;  and 
of  the  brain  proper,  for  voluntary  or  emotional  movements.* 


*  Diagram  illustrative  of  voluntary  and  reflex  motions.  Fig.  97  refers  to  volun- 
tary motion  and  sensation.  Tlie  first  originates  in  a  psychical  stimulus — the  wiU — 
in  the  liemispherical  ganglion,  the  influence  of  which  is  propagated  downwards  through 

the  fibres  of  the  brain,  a,  to  the  spinal  cord, 
and  outwards  by  a  motor  filament  in  a  com- 
pound nerve,  b,  to  the  muscles.  The  last 
originates  in  aphysical  stimulus,  say  the  prick 
of  a  needle,  at  the  extremity  of  the  nerve, 
b,  the  influence  of  which  travels  in  the  op- 
posite direction,  along  a  sensitive  filament  of 
that  compound  nerve,  through  the  spinal  cord, 
up  to  the  hemispherical  ganglion,  there  ex- 
citing the  mental  act  of  consciousness,  and, 
as  a  result,  sensation.  In  both  cases  the 
nerve  fibres  are  continuous. 

Fig.  98  explains  reflex  or  more  properly 
diastaltic  motions  {Sta,  through,  oteXAu,  I 
contract).  They  originate  in  a  physical  sti- 
mulus applied  to  the  extremity  of  a  sensitive 
filament,  a,  the  influence  of  which  travels  in- 
wards to  the  spinal  cord,  and  through  its 
grey  matter  again  outwards  along  a  motor 
filament,  b,  to  the  muscles,  without  neces- 


\ 

Fig.  97. 


\ 


Pig.  9S. 


sarily  being  propagated  to  the  hemispherical  ganglion,  and  thereby  exciting  con- 


HEALTHY  A^D  DISEASED  INNERVATION".  115 

Thus,  tben,  we  may  consider  that  the  brain  acting  alone  furnishes  the 
conditions  necessary  for  intelligence ;  the  spinal  cord  acting  alone  fur- 
nishes the  conditions  essential  for  the  co-ordinate  movements  necessary  to 
tlie  vital  functions;  and  the  brain  and  spinal  cord  acting  together  fur- 
nish the  conditions  necessaiy  for  voluntary  motion  and  sensation. 

The  following  aphorisms  will  be  found  useful,  in  endeavouring  to  rea- 
son correctly  on  the  functions  of  the  nervous  system  : — 

1.  The  brain  proper  is  that  portion  of  the  encej^halon  situated  above 
the  Corpus  Callosum. 

2.  The  spinal  cord  is  divided  into  a  cranial  and  a  vertebral  portion. 

3.  The  grey  matter  evolves  and  the  white  conducts  nervous  power. 

4.  ContructiUty  is  the  property  peculiar  to  fibrous  texture,  whereby 
it  is  capable  of  shortening  its  fibres.  Motion  is  of  three  kinds,  contrac- 
tile, dependent  on  muscle — diastalttc,  dependent  on  muscle  and  spinal 
cord — voluntary,  dependent  on  muscle,  spinal  cord,  and  brain. 

5.  Sensibility  is  the  property  peculiar  to  nervous  texture,  whereby  it 
is  capable  of  receiving  impressions.  Sensation  is  the  consciousness  of 
receiving  such  impressions. 

A  more  detailed  account  of  the  various  cerebral,  spinal,  and  cerebro- 
spinal functions,  as  they  are  performed  separately  or  coujointl}',  belongs 
to  the  course  of  the  Institutes  of  Medicine,  and  with  these  you  are  sup- 
posed to  be  familiar.  It  is  important,  however,  that  we  dwell  more  at 
length  on  the 

General  Pathology  of  the  Nervous  System. 

For  the  purposes  of  diagnosis  and  treatment,  it  is  a  matter  of  great 
importance  to  attend  to  the  following  pathological  laws  which  regulate 
diseased  action  of  the  nervous  centres. 

(1.)  The  amount  of  fluids  tvithin  the  cranium  must  always  be  the 
same  so  long  as  its  osseous  walls  are  co'pable  of  resisting  the  j^ressure  of 
the  atmosphere.  There  are  few  principles  in  medicine  of  greater  prac- 
tical importance  than  the  one  we  are  about  to  consider, — the  more  so, 
as  many  able  .practitioners  have  lately  abandoned  their  former  opinions 
on  this  head,  and  on  what  I  consider  to  be  very  insufticient  grounds. 
On  this  point,  therefore,  I  cannot  do  better  than  condense  and  endeavour 
to  put  clearly  before  you  the  forcible  arguments  of  the  late  Dr.  John 
Reid,  with  such  other  considerations  as  have  occurred  to  myself. 

That  the  circulation  within  the  cranium  is  different  from  that  in  other 
parts  of  the  body,  was  first  pointed  out  by  the  second  Monro.  It  was 
tested  experimentally  by  Dr.  Kellie  of  Leith,  ably  illustrated  by  Dr. 
Abercrombie,  and  successfully  defended  by  Dr.  John  Reid.  The  views 
adopted  by  these  distinguished  men  were,  that  the  cranium  forms  a 
spherical  bony  case  capable  of  resisting  the  atmospheric  pressure,  the 
only  openings  into  it  being  the  difterent  foramina  by  which  the  vessels, 
nerves,  and  spinal  cord  pass.  The  encephalon,  its  membranes,  and 
blood-vessels,  Avith  perhaps  a  small  portion  of  the  cerebro-spinal  fluid, 

sciousness  and  sensation.  The  nature  of  the  communication  through  the  grey  matter 
instead  of  being  broken  or  reflected,  we  have  seen  to  be  probably  continuous  and 
direct  through  the  medium  of  ganglionic  cells.     (Fig.  94.) 


116  PRIXCIPLES   OF   MEDICINE. 

completely  fill  up  the  interior  of  the  cranium,  so  that  no  substance  can 
be  dislodged  from  it  without  some  equivalent  in  bulk  takino;  its  place. 
Dr.  Monro  used  to  point  out,  that  a  jar,  or  other  vessel  similar  to  the 
cranium,  with  unyielding  walls,  if  filled  with  any  substance,  cannot  be 
emptied  without  air  or  some  substance  taking  its  place.  To  use  the 
illustration  of  Dr.  "Watson,  the  contents  of  the  cranium  are  like  beer  in 
a  barrel,  which  will  not  flow  out  of  one  opening  unless  provision  be 
made  at  the  same  time  that  air  rushes  in.  The  same  kind  of  reasoning 
applies  to  the  spinal  canal,  which,  with  the  interior  of  the  cranium,  may  be 
said  to  constitute  one  large  cavity,  incompressible  by  the  atmospheric  air. 

Before  proceeding  furthei-,  we  must  draw  a  distinction  between  pres- 
sure on,  and  compression  of,  an  organ.  Many  bodies  are  capable  of  sus- 
taining a  great  amount  of  pressure  without  undergoing  any  sensible 
decrease  in  bulk.  By  compression  must  be  understood,  that  a  substance 
occupies  less  space  from  the  application  of  external  force,  as  when  we 
squeeze  a  sponge,  or  compress  a  bladder  filled  with  air.  Fluids  gene- 
rally are  not  absolutely  incompressible,  yet  it  requires  the  weight  of  one 
atmosphere,  or  fifteen  pounds  in  the  square  inch,  to  produce  a  diminu- 
tion equal  to  2 o.Wotli  part  of  the  whole.  Now  this  is  so  exceedingly 
small  a  change  upon  a  mass  equal  in  bulk  to  the  brain,  as  not  to  be 
appreciable  to  our  senses.  Besides,  the  pressure  on  the  internal  surface 
of  the  blood-vessels  never  exceeds  ten  or  twelve  pounds  on  the  square 
inch,  during  the  most  violent  exertion,  so  that,  under  no  possible  circum- 
stances, can  the  contents  of  the  cranium  be  diminished  even  the  jo.Wotti 
part.  When  the  brain  is  taken  out  of  the  ci'anium,  it  may,  like  a 
sponge,  be  compressed,  by  squeezing  fluid  out  of  the  blood-vessels ;  but 
during  life,  surrounded,  as  it  is,  by  unyielding  walls,  this  is  impossible. 
For  let  us,  with  Abercrombie,  say,  that  the  whole  quantity  of  blood  cir- 
culating within  the  cranium  is  equal  to  10,  this  is  5  in  the  veins,  and  5 
in  the  arteries ;  if  one  of  these  be  increased  to  6,  the  other  must  be 
diminished  to  4,  so  that  the  same  amount,  10,  shall  always  be  preserved. 
It  follows,  that  when  fluids  are  eft'used,  blood  extravasated,  or  tumours 
grow  within  the  cranium,  a  corresponding  amount  of  fluid  must  be 
pressed  out,  or  of  brain  absorbed,  from  the  physical  impossibility  of  the 
cranium  holding  more  matter.  At  the  same  time,  it  must  be  evident 
that  an  increased  or  diminished  amount  of  pressure  may  be  exerted  on 
the  brain,  proportioned  to  the  power  of  the  heart's  contraction,  the  eftect 
of  which  will  be,  not  to  alter  the  amount  of  fluids  within  the  cranium, 
but  to  cause,  using  the  words  of  Abercrombie,  "  a  change  of  circulation" 
there.  This  is  all,  it  seems  to  me,  that  is  shown  by  the  ingenious  experi- 
ments of  Donders,  who  saw  venous  congestion  through  glass  plates,  fixed 
in  the  crania  of  rabbits.* 

Dr.  Kellie  performed  numerous  experiments  on  cats  and  dogs,  in  order 
to  elucidate  this  subject.  Some  of  these  animals  were  bled  to  death  by 
opening  the  carotid  or  femoral  arteries,  others  by  opening  the  jugular 
veins.  In  some  the  carotids  were  first  tied,  to  diminish  the  quantity  of 
blood  sent  to  the  brain,  and  the  jugulars  were  then  opened,  with  "the 
view  of  emptying  the  vessels  of  the  brain  to  the  greatest  possible  extent ; 
while,  in  others,  the  jugulars  were  first  secured,  to  prevent  as  much  as 

*  Nederlandeche. — Laucet,  1850. 


HEALTHY  AND   DISEASED   INNERVATION.  117 

possible  the  return  of  the  blood  from  the  brahi,  and  one  of  the  carotids 
was  then  opened.  He  inferred,  from  the  whole  inquiry,  which  was  con- 
ducted with  extreme  care,  "  That  we  cannot,  in  fact,  lessen,  to  any  con- 
siderable extent,  the  quantity  of  blood  within  the  cranium  by  arterio- 
tomy  or  venesection  ;  and  that  when,  by  profuse  haemorrhages,  destruc- 
tive of  life,  we  do  succeed  in  draining  the  vessels  within  the  cranium  of 
any  sensible  portion  of  red  blood,  there  is  commonly  found  an  equivalent 
to  this  spoliation  in  the  increased  circulation  or  effusion  of  serum,  serv- 
ing to  maintain  the  plenitude  of  the  cranium." 

Dr.  Kellie  made  other  experiments  upon  the  effects  of  position  imme- 
diately after  death  from  strangulation  or  hanging.  He  also  removed 
a  portion  of  the  unyielding  walls  of  the  cranium  in  some  animals,  by 
means  of  a  trephine,  and  then  bled  them  to  death ;  and  the  difference 
between  the  appearances  of  the  brain  in  these  cases,  and  in  those  where 
the  cranium  was  entire,  was  very  great.  One  of  the  most  remark- 
able of  these  differences  was  its  shrunk  appearance,  in  those  animals 
in  which  a  portion  of  the  skull  was  removed,  and  the  air  allowed  to 
gravitate  upon  its  inner  surface.  He  says: — "The  brain  was  sensibly 
depressed  below  the  cranium,  and  a  space  left,  which  was  found  capable 
of  containing  a  teaspoonful  of  water." 

It  results  from  these  inqiiiries,  that  there  must  always  be  the  same 
amount  of  fluids  within  the  cranium  so  long  as  it  is  uninjured.  In  morbid 
conditions  these  fluids  may  be  blood,  serum,  or  pus ;  but  in  health,  as 
blood  is  almost  the  only  fluid  present  (the  cerebro-spinal  fluid  being  verj^ 
trifling),  its  quantity  can  undergo  only  very  slight  alterations.  There  are 
many  circumstances,  however,  which  occasion  local  congestions  in  the 
brain,  and  consequently  unequal  pressure  on  its  structure,  in  which  case 
another  portion  of  its  substance  must  contain  less  blood,  so  that  the 
amount  of  the  whole  as  to  quantity,  is  always  preserved.  These  circum- 
stances are  mental  emotions,  haemorrhages,  eftusions  of  serum,  and  mor- 
bid growths.  Such  congestions,  or  local  hyperhemias,  in  themselves 
constitute  morbid  conditions  ;  and  nature  has,  to  a  great  extent,  provided 
against  their  occurrence  under  ordinary  circumstances,  by  the  tortuosity 
of  the  arteries  and  the  presence  of  the  cerebro-spinal  fluid,  described  by 
Magendie. 

The  views  now  detailed,  had  been  very  extensively  admitted  into  patho- 
logy, when  Dr.  Burrows,  of  St.  Bartholomew's  Hospital,  endeavoured 
to  controvert  them,  first  in  the  Lumleian  Lectures  of  1843,  and  subse- 
quently in  a  work  published  in  1846,  entitled  "  On  Disorders  of  the  Cere- 
bral Circulation,  and  on  the  connections  between  Affections  of  the  Brain 
and  Diseases  of  the  Heart."  Dr.  Burrows,  however,  evidently  misunder- 
stood the  doctrine  we  are  advocating.  Thus,  he  is  always  combating 
the  itlea  that  blood-letting,  position,  strangulation,  etc.,  cannot  affect  the 
hlood  in  the  brain  ;  whereas  the  real  proposition  is,  that  they  cannot 
alter  the  fluids  within  the  cranium.  By  thus  confounding  blood  with 
fluid,  and  brain  with  cranium,  he  has  only  contrived  to  overthrow  a  doc- 
trine of  his  own  creation. 

Dr.  Burrows  has  brought  forward  several  observations  and  experi- 
ments, which  he  considers  opposed  to  the  theory  now  advocated.  His 
facts  are  perfectly  correct.  I  myself  have  repeated  his  experiments  on 
rabbits,  and  can  confirm  his  descriptions.     It  is  the  inferences  he  draws 


118  PRINCIPLES   OF  MEDICINE. 

from  them  that  are  erroneous.  For  the  paleness  which  results  from 
haemorrhage,  and  the  dift'erence  observable  in  the  colour  of  the  brain, 
when  animals,  immediately  after  death,  are  suspended  by  their  ears  or 
by  their  heels,  is  explicable  by  the  diminished  number  of  coloured  blood 
particles  in  the  one  case,  and  by  their  gravitation  downwards  in  the 
other.  That  the  amount  of  fluid  within  the  cranium  was  in  no  way 
affected,  is  proved  by  the  plump  appearance  of  the  brains  figured  by  Dr. 
Burrows,  and  the  total  absence  of  that  shrunken  appearance  so  well 
described  by  Dr.  Kellie. 

Neither  does  our  observation  of  what  occurs  in  asphyxia  or  apna?a, 
oppose  the  doctrine  in  question,  as  Dr.  Burrows  imagines,  but  rather  con- 
firms it.  On  this  point  the  following  observations  by  Dr.  John  Reid  are 
valuable.  He  says : — If  any  circumstance  could  produce  congestion  of 
the  vessels  within  the  cranium,  it  would  be  that  of  death  by  hanging;  for 
then  the  vessels  going  to  and  coming  from  the  brain  are,  with  the  ex- 
ception of  the  vertebral  arteries,  compressed  and  then  obsti'ucted.  These 
two  ai'teries,  which  are  protected  by  the  peculiarity  of  their  course 
through  the  foramina  of  the  transverse  processes  of  the  cervical  vertebra?, 
must  continue  for  a  time  to  force  their  blood  upon  the  brain,  while  a 
comparatively  small  quantity  only  can  escape  by  the  veins.  Indeed,  the 
greater  quantity  of  blood  carried  to  the  encephalon  by  the  vertebrals 
returns  by  the  internal  jugulars  and  not  by  the  vertebral  veins,  which 
are  supplied  from  the  occipital  veins  of  the  spinal  cord ;  and  the  anasto- 
moses, between  the  cranial  and  vertebral  sinuses,  could  carry  off  a  small 
quantity  of  the  blood  only,  transmitted  along  such  large  arteries  as  the 
vertebrals.  And  yet  it  is  well  known  that  there  is  no  congestion  of  the 
vessels  within  the  cranium  after  death  by  hanging,  however  gorged  the 
external  parts  of  the  head  may  be  by  blood  and  serum."  This  is  admitted 
by  Dr.  Burrows,  although  he  endeavours  to  get  rid  of  so  troublesome  a 
fact  by  a  gratuitous  hypothesis,  which  will  not  bear  a  moment's  exami- 
nation, but  for  the  refutation  of  which  I  must  refer  to  the  works  of 
Dr.  Reid.* 

On  the  whole,  whether  we  adopt  the  terms  of  local  congestion,  of 
change  of  circulation  within  the  cranium  (Abercrombie),  or  of  unequal 
pressure  (Burrows),  our  explanation  of  the  pathological  phenomena  may 
be  made  equally  correct,  because  each  of  these  modes  of  expression  im- 
plies pretty  much  the  same  thing.  But  if  we  imagine  that  venesection 
will  enable  us  to  diminish  the  amount  of  blood  in  the  cerebral  vessels,  the 
theory  points  out  that  this  is  impossible,  and  that  the  eftects  of  bleeding- 
are  explained  by  the  influence  produced  on  the  heart,  the  altered  pres- 
sure on  the  brain,  exercised  by  its  diminished  contractions,  and  the 
change  of  circulation  within  the  cranium  thereby  occasioned. 

I  have  entered  somewhat  fully  into  this  theory,  because,  independent 
of  its  vast  importance  in  a  practical  point  of  view,  it  is  one  which  origi- 
nated in  the  Edinburgh  School  of  Medicine.  Singular  to  say,  notwith- 
standing the  obvious  errors  and  fallacies  in  Dr.  Burrows'  work,  no  sooner 
did  it  appear,  than  the  whole  medical  press  of  England  and  Ireland 
adopted  its  conclusions,  and  even  Dr.  Watson,  in  the  two  last  editions  of 
his  excellent  work,  also  abandoned  the  theory  of  Monro,  Kelly,  and 

*  Physiological,  Anatomical,  and  Pathological  Researches,  No.  XXV. 


HEALTHY  AND   DISEASED   INNERVATION.  119 

Abercrombie.  But  so  far  is  this  theory  concerning  the  circnlation  with- 
in the  cranium  from  being  shaken  by  the  attack  of  Dr.  Burrows,  that  it 
may  be  said  now  to  stand  on  a  firmer  basis  than  ever,  owing  to  that 
attack  having  drawn  forth  the  convincing  reasoning  and  unanswerable 
arguments  of  so  sound  an  anatomist,  physiologist,  and  pathologist,  as  the 
late  Dr.  John  Reid. 

(2.)  A.II  the  functions  of  the  nervous  system  may  be  increased,  per- 
verted, or  destroyed,  accordiay  to  the  degree  of  stinialus  or  disease  ope- 
rating on  its  various  parts. — Thus,  as  a  general  rule  it  may  be  said,  that 
a  sligiit  stimulus  produces  increased  or  perverted  action;  whilst  the  same 
stimulus,  long  continued  or  much  augmented,  causes  loss  of  function. 
All  the  various  stimuli,  whether  mechanical,  chemical,  electrical,  or 
psychical,  produce  the  same  effects,  and  in  ditferent  degrees.  Circum- 
stances influencing  the  heart's  action,  stimulating  drinks  or  food,  act  in 
a  like  manner.  Thus  if  we  take  the  effects  of  alcoholic  drink,  for  the 
purpose  of  illustration,  we  observe  that,  as  regards  combined  movements, 
a  slight  amount  causes  increased  vigour  and  activity  in  the  muscular 
system.  As  the  stimulus  augments  in  intensity,  we  see  irregular  move- 
ments occasioned,  staggering,  and  loss  of  control  over  the  limbs.  Lastly, 
when  the  stimuhis  is  excessive,  there  is  complete  inability  to  move,  and 
the  power  of  doing  so  is  temporarily  annihilated.  With  regard  to  sen- 
sibility and  sensation,  we  observe  cephalalgia,  tingling,  and  heat  of  skin, 
tinnitus  aurium,  confusion  of  vision,  muscte  volitantes,  double  sight,  and 
lastly,  complete  insensibility  and  coma.  As  regards  intelligence,  we 
observe  at  first  rapid  flow  of  ideas,  then  confusion  of  mind,  delirium,  and 
lastly,  sopor  and  perfect  unconsciousness.  In  the  same  manner  pressure, 
mechanical  irritation,  and  the  various  organic  diseases,  produce  aug- 
mented, perverted,  or  diminished  function,  according  to  the  intensity  of 
the  stimulus  applied,  or  amount  of  structure  destroyed. 

Then  it  has  been  shewn  that  excess  or  diminution  of  stimulus,  too 
much  or  too  little  blood,  very  violent  or  very  weak  cardiac  contractions, 
and  plethora  or  extreme  exhaustion,  will,  so  far  as  the  nervous  functions 
are  concerned,  produce  similar  alterations  of  motion,  sensation,  and  intel- 
ligence. Excessive  haemorrhage  causes  muscular  weakness,  convulsions, 
and  loss  of  motor  power,  perversions  of  all  the  sensations,  and  lastly, 
unconsciousness  from  syncope.  Hence  the  general  strength  of  the  frame 
cannot  be  judged  of  by  the  nervous  symptoms,  although  the  treatment 
of  these  will  be  altogether  difterent,  according  as  the  individual  is  robust 
or  weak,  has  a  full  or  small  pulse,  etc.  These  similar  effects  on  the 
nervous  centres  from  apparently  such  opposite  exciting  causes,  can,  it 
seems  to  me,  only  be  explained  by  the  peculiarity  of  the  circulation 
previously  noticed.  A  change  of  circulation  within  the  cranium  takes 
place,  and,  whether  arterial  or  venous  congestion  occurs,  pressure  on 
some  portion  of  the  organ  is  equally  the  i-esult.  The  impoilance  of 
paying  attention  to  this  point  in  the  treatment  must  be  obvious. 

(3.)  The  seat  of  the  disease  in  the  nervous  system  influences  the  nature 
of  the  jyhenomena  or  symptoms  produced. — It  is  a  matter  of  very  great 
importance  to  ascertain  how  far  certitude  in  diagnosis  may  be  arrived 
at,  and  the  seat  of  the  disease  ascertained.     On  this  subject  it  may  be 


120  PRINCIPLES   OF   MEDICINE. 

affirmed  that,  altliongh  clinical  observation  combined  with  pathology 
has  done  much,  more  reqnires  to  be  accomplished.  As  a  general  rule, 
it  may  be  stated,  that  disease  or  injury  of  one  side  of  the  encephalon, 
especially  influences  the  opposite  side  of  the  body.  It  is  said  that  some 
very  striking  exceptions  have  occurred  to  this  rule,  but  these  at  any  rate 
are  remaikably  rare.  Besides,  it  has  always  appeared  to  me  probable 
that,  inasmuch  as  extensive  organic  disease,  if  occurring  slowlv,  may  exist 
without  producing  sj-mptoms,  whilst  it  is  certain  most  important  symp- 
toms may  be  occasioned  without  organic  disease,  even  these  few  excep- 
tional eases  are  really  not  opposed  to  the  general  law.  Then,  as  a  s'eneral 
rule,  it  may  be  said  that  diseases  of  the  brain  proper  are  more  especially 
connected  with  perversion  and  alteration  of  the  intelligence ;  whilst 
disease  of  the  cranial  portion  of  the  spinal  cord  and  base  of  the  cranium, 
are  more  particularly  evinced  by  alterations  of  sensation  and  motion.  In 
the  vertebral  portion  of  the  cord,  the  intensity  of  pain  and  of  spasm,  or 
else  the  want  of  conducting  power,  necessary  to  sensation  and  voluntary 
motion,  indicates  the  amount  to  which  the  motor  and  sensitive  fibres  are 
atFected.  Further  than  this  we  can  scarcely  generalise  with  prudence, 
although  there  are  some  cases,  as  we  shall  subsequently  see,  where  careful 
observation  has  enabled  us  to  arrive  at  more  positive  results. 

The  fatality  of  lesions  afliecting  various  parts  of  the  nervous  centres 
varies  greatly.  Thus  the  hemispheres  may  be  extensively  diseased, 
often  without  injury  to  life,  or  even  permanent  alteration  of  function. 
Convulsions  and  paralysis  are  the  common  results  of  disease  of  the 
ganglia,  in  the  cranial  portion  of  the  cord.  The  same  results  from 
lesion  of  the  pons  varolii.  But  if  the  medulla  oblongata,  where  the 
eighth  pair  originates,  be  aflfected,  or  injury  to  this  centre  itself  occur,  it 
is  almost  always  immediately  fatal. 

(4.)  The  rapidity  or  slowness  with  tvhich  the  lesion  occurs  influences  the 
phenomena  or  symptoms  produced. — It  may  be  said  as  a  general  rule, 
that  a  small  lesion  {for  instance,  a  small  hemorrhagic  extravasation), 
occurring  suddenly,  and  with  force,  produces,  even  in  the  same  situation, 
more  violent  etfects  than  a  very  extensive  organic  disease  which  comes 
on  slowly.  This,  however,  will  depend  much  upon  the  seat  of  the  lesion. 
Very  extraordinary  cases  are  on  record,  where  large  portions  of  the 
nervous  centres  have  been  much  disorganized,  without  producing  any- 
thing like  the  violent  symptoms  which  have  been  occasioned  at  other 
times  by  a  small  extravasation  in  the  same  place.  Here  again  the 
nature  of  the  circulation  within  the  cranium  otters  the  only  explanation, 
for  the  encephalon  must  undergo  a  certain  amount  of  pressure,  if  no 
time  be  allowed  for  it  to  adapt  itself  to  a  foreign  body ;  whereas  any 
lesion  coming  on  slowly  enables  the  amount  of  blood  in  the  vessels  to 
be  diminished  according  to  circumstances,  whereby  pressure  is  avoided. 

(5.)  The  various  lesions  and  injuries  of  the  nervous  system  produce 
p)henomena  similar  in  kind. — The  injuries  which  may  be  inflicted  on  the 
nervous  system,  asAvell  as  the  morbid  appearances  discovered  after  death, 
are  various.  For  instance,  there  may  be  an  extravasation  of  blood, 
exudation  of  lymph,  a  softening,  a  cancerous  tumour,  or  tubercular 
deposit,  and  yet  they  give  rise  to  the  same  nervous  phenomena,  and 


HEALTHY  AND  DISEASED   INNERVATION.  121 

are  modified  only  by  the  circumstances  formerly  mentioned,  of  degree, 
seat  suddenness,  etc.  Certain  nervous  phenomena  also  are  of  a  parox- 
ysmal character,  whilst  the  lesions  supposed  to  occasion  them  are  sta- 
tionary or  slowly  increasing.  It  follows,  that  the  effects  cannot  be 
explained  by  the  nature  of  the  lesions,  but  by  something  which  they 
all  have  in  common;  and  this,  it  appears  to  me,  may  consist  of— 1st, 
Pressure  with  or  without  organic  change ;  2d,  more  or  less  destruction 
or  disorganization  of  nervous  texture.  Further,  wlien  we  consider  that 
the  same  nervous  symptoms  arise  from  irregularities  in  the  circulation ; 
from  increased  as  well  as  diminished  action ;  sometimes  when  no  appre- 
ciable change  is  found,  as  well  as  v^'hen  disorganization  has  occurred — 
the  theory  of  local  congestions  to  explain  functional  alterations  of  the 
nervous  centres  seems  to  me  the  most  consistent  with  known  facts.  That 
such  local  congestions  do  frequently  occur  during  life,  without  leaving 
traces  detectable  after  death,  is  certain ;  whilst  the  occurrence  of  mole- 
cular changes,  or  other  hypothetical  conditions  which  have  been  sup- 
posed to  exist,  has  never  yet  been  shown  to  take  place  under  any 
circumstances. 

While  such  appear  to  me  to  be  some  of  the  generalizations  which  are 
important  to  the  physician  with  regard  to  the  nutritive  and  nervous 
functions,  viewed  separately,  it  should  never  be  forgotten  that  he  has 
constantly  to  do  with  their  conjoint  action.  Indeed,  the  derangement 
of  one  order  of  functions  exercises  a  constant  influence  over  the  other, 
so  that  in  every  disease  the  effects  of  disordered  nutrition  are  visiblein 
perverted  innervation,  and  the  converse.  Thus  an  improper  quantity 
or  quality  of  food  produces  sometimes  excitement,  at  others  dulness  of 
intellect.  Various  articles  of  diet  have  been  known  to  cause  violent 
headache,  and  different  kinds  of  nervous  phenomena ;  while  starvation,  if 
long  continued,  excites  delirium,  paroxysms  of  mania,  and  lastly,  stupor. 
In  "children,  derangement  of  the  alimentary  canal  is  the  most  common 
cause  of  spasm  and  convulsion,  and  in  the  aged  it  often  leads  to  apo- 
plexies and  palsy.  Again,  impeded  respiration,  poverty  of  the  blood, 
accumulation  of  "^effete  matters  in  the  system,  suppressed  secretions  and 
obstructed  excretions,  are  all  accompanied  or  followed  by  disorders  of 
innervation.  On  the  other  hand,  the  influence  of  the  nervous  system  on 
nutrition  is  equally  apparent.  Syncope  and  even  death  itself  have  been 
occasioned  by  mental  emotions.  Anxiety  and  suppressed  grief  predispose 
to  diseases  of  the  stomach,  and  thereby  to  altered  nutrition,  terminating 
in  various  maladies.  The  reception  of  joyful  or  distressing  intelligence, 
it  is  well  known,  invigorates  or  depresses  the  bodily  energies.  Various 
organs  are  excited  to  action  by  particular  trains  of  thought  or  desires, 
and  the  countenance  is  reddened  by  modesty,  and  blanched  by  fear.  As 
a  general  rule,  it  may  be  said,  while  slight  emotions  increase  the  secre- 
tions, very  violent  ones,  particularly  if  suppressed,  completely  suspend 
them,  and  are  most  dangerous  to  life.*  Direct  mechanical  injury  to  the 
large  nervous  trunks,  in  addition  to  causing  paralysis,  is  now  recognised 
in  some  cases  to  produce  increased  heat  and  redness  in  parts,  often  fol- 

*  "  Give  sorrow  words ;  the  grief  that  will  not  speak, 

Whispers  the  o'erfraught  heart,  and  bids  it  hveak."—Shaks2)eare. 


122  PRINCIPLES  OF  MEDICINE. 

lowed  by  exudation  and  ulceration.  In  chronic  cases,  such  paralysis 
leads  to  atrophy,  and  withering  of  a  limb,  or  some  other  portion  of  "the 
body.  Very  rarely,  injuiy  of  a  great  sympathetic  trunk  produces  similar 
loss  of  nutrition  without  impairment  of  sensibility  or  motion,  of  Avhich 
the  most  remarkable  example  I  am  acquainted  with  is  recorded  by  Pro- 
fessor Romberg  of  Berlin.  It  was  that  of  an  unmarried  woman,  ao-ed 
28,  in  whom,  as  the  result  of  extensive  suppuration  on  the  left  side  of 
the  neck,  which  burst  through  the  tonsil,  the  features  on  the  correspond- 
ing side  of  the  face  gradually  became  atrophied,  without  any  diminution 


Fig.  99. 

of  sensibility  or  motion.  Looking  at  the  two  halves  of  the  face  sepa- 
rately, it  appeared  as  if  the  one  belonged  to  a  young,  and  the  other  to 
an  old  woman.  By  some  it  was  supposed  that  the  diseased  side  was 
sound,  and  that  the  other  was  swollen.  The  hair,  eyebrows,  and  eye- 
lashes were  very  thin  on  the  affected  side,  and  she  was  in  the  habit  of 
dividing  her  hair  towards  the  right,  so  as  to  equalize  the  quantity. 
Every  feature,  including  the  brow,  eye,  nostril,  lips,  cheek,  and  chin,  as 
well  as  the  left  half  of  the  tongue  and  left  palatine  arch,  was  smaller  than 
those  on  the  opposite  one,* 

Further  illustrations  of  the   general   principles  now  detailed  will  be 
constantly  met  with  under  the  head  of  special  diseases. 

*  Klinische  Ergebnisse.     Berlin,  18-16. 


Fig.  99.   Remarkable  atrophy  of  the  left  side  of  the  face,  in  a  woman  aged  28, 
without  loss  of  sensibility  or  motion  in  the  affected  parts. — (Romberg.) 


SIMPLE,    CANCEROUS,    AXD   TUBERCULAR   EXUDATIONS.      123 


SIMPLE,  CAXCEROUS,  AXD  TUBERCULAR  EXUDATIONS— 
THEIR  PATHOLOGY  AXD  GEXERAL  TREATMEXT. 

Tliere  are  three  varieties  of  exudation,  which,  occurring  as  they  do 
in  one  or  other  of  the  textures,  occasion  the  great  majority  of  those 
diseases  we  are  called  upon  to  treat.  A  knowledge  of  the  manner  in 
which  these  are  produced,  of  the  characters  of  each,  of  their  specific 
differences  and  natural  progress,  constitutes  the  foundation  of  modern 
medicine,  I  propose,  then,  in  the  first  place,  to  describe  them  to  you 
generally,  and  then  to  direct  your  attention  to  the  special  peculiarities 
which  they  present  in  individual  cases. 

The  term  exudation  has  been  introduced  into  pathology,  not  only  to 
express  the  act  of  the  liquor  sanguinis  passing  through  the  walls  of  the 
blood-vessels,  but  also  to  denominate  the  coagulation  of  the  fibrinous 
portion  of  the  liquor  sanguinis  itself,  upon  the  surface,  or  in  the  substance 
of  any  tissue  or  organ  of  tlie  body.  The  use  of  this  term  removes  a 
difficulty*  which  morbid  anatomists  have  long  experienced ;  and  hence 
it  has  of  late  years  been  extensively  used  to  indicate  various  kinds  of 
morbid  deposits.  Thus  it  has  been  applied  to  all  those  processes  hitherto 
termed  intiaramatorv,  tubercular,  and  cancerous ;  it  may  be  associated 
with  ever}-  form  of  morbid  growth ;  it  often  gives  rise  to  concretions, 
and  frequently  constitutes  the  soil  in  which  grow  those  parasitic  vegeta- 
tions or  cryptogamic  plants  of  a  low  type,  which  communicate  essential 
characters  to  certain  diseases.  Under  the  head  of  exudation,  indeed, 
considered  as  a  morbid  process,  is  comprised  the  greater  part  of  organic, 
as  distinguished  from  functional  diseases ;  of  lesions  of  nutrition,  as  sepa- 
rated from  lesions  of  innervation. 


I.  Production  of  Exudatiox. 

Exudation  is  in  every  case  preceded  by  a  series  of  changes  which 
have  taken  place  in  the  capillary  vessels,  and  in  the  blood  contained  in 
them.  These  changes,  as  we  are  enabled  to  follow  them  in  the  trans- 
parent parts  of  animals  under  the  microscope,  are  seen  to  occur  in  the 
following  oi'der : — 1st,  The  capillary  vessels  are  narrowed,  and  the  blood 
flows  through  them  with  greater  rapidity.  2d,  The  same  vessels  become 
enlarged,  and  the  current  of  blood  is  slower,  although  even.     3d,  The 

*  Of  inflammation,  Andral  says.  "  created  in  the  infancy  of  science,  this  expres- 
sion, altogether  metaphorical,  was  destined  to  represent  a  morbid  state,  in  wliich 
the  parts  appeared  to  bum,  to  be  inflamed,  etc.  Received  into  general  language 
without  any  precise  idea  having  ever  been  attached  to  it,  in  the  triple  relation  of 
symjrtoms  wliich  announce  it,  of  the  lesions  which  characterize  it,  and  of  its  intimate 
nature,  the  expression  inflammation  is  become  so  very  vague,  its  interpretation  is  so 
very  arbitrary,  that  it  has  really  lost  its  value ;  it  is  like  an  old  coin  without  an 
impression,  which  ought  to  be  removed  from  circulation,  as  it  only  causes  error  and 
confusion."  On  the  other  hand,  exudation  of  the  liquor  sanguinis  is  a  demonstra- 
tive fact,  and  gives  rise  to  a  definite  idea.  Hence,  for  all  scientific  and  practical 
purposes,  the  expression  '•  exudation"  may  be  substituted  for  that  of  inflammation. 


124  PRINCIPLES   OF   MEDICINE. 

flow  of  blood  becomes  irregular.  4th,  All  motion  of  the  blood  ceases, 
and  the  vessel  appears  fully  distended.  5th  and  lastly,  The  liquor  san- 
guinis is  exuded  through  the  walls  of  the  vessel ;  and  sometimes  there  is 
extravasation  of  blood  corpuscles,  owing  to  rupture  of  the  capillaries. 

The  first  step  in  the  process,  viz.,  narrowing  of  the  capillaries,  is 
readily  demonstrated  on  tlie  application  of  acetic  acid  to  the  web  of  the 
frog's  foot.  If  the  acid  be  weak,  the  capillary  contraction  occurs  more 
slowly  and  gradually.  If  it  be  very  concentrated,  the  phenomenon  is 
not  observed,  or  it  passes  so  quickly  into  complete  stoppage  of  blood  as 
to  be  imperceptible.  Although  we  cannot  see  these  changes  in  man  under 
the  microscope,  certain  facts  indicate  that  the  same  phenomena  occur. 
The  operations  of  the  mind,  for  instance,  as  fear  and  fright,  and  the  appli- 
cation of  cold,  produce  paleness  of  the  skin,  an  effect  which  can  only  arise 
from  contraction  of  the  capillaries,  and  a  diminution  of  the  quantity  of 
blood  they  contain.  In  the  majority  of  instances,  also,  this  paleness  is 
succeeded  by  increased  redness,  the  same  result  as  follows  from  direct 
experiment  on  the  web  of  the  frog's  foot,  and  which  constitutes  the 
second  step  of  the  process.  In  other  cases,  the  redness  may  arise  pri- 
marily from  certain  mental  emotions,  or  from  the  application  of  heat ; 
and  in  both  instances  depends  on  the  enlargement  of  the  capillaries,  and 
the  greater  quantity  of  blood  which  is  thus  admitted  into  them.* 

The  variation  in  the  size  of  the  capillaries,  and  of  the  amount  of 
blood  in  them,  is  conjoined  with  changes  in  the  movement  of  that  fluid. 
AVhilst  the  vessels  are  contracted,  the  blood  may  be  seen  to  flow  with 
increased  velocity.  After  a  time  the  blcod  flows  more  and  more  slowly, 
without,  however,  the  vessel  being  obstructed ;  it  then  oscillates,  that 
is,  moves  forwards  and  backwards,  or  makes  a  pause,  which  is  evi- 
dently synchronous  with  the  ventricular  diastole  of  the  heart.  At 
length  the  vessel  appears  quite  distended  with  yellow  or  coloured  cor- 
puscles, and  all  movement  ceases. 

Again,  these  changes  in  the  movement  of  the  blood  induce  variations 
in  the  relations  which  the  blood  corpuscles  bear  to  each  other,  and  to 
the  walls  of  the  vessel.  In  the  natural  circulation  of  the  frog's  foot,  the 
yellow  corpuscles  may  be  seen  rolling  forward  in  the  centre  of  the  tube, 
a  clear  space  being  left  on  each  side,  which  is  filled  only  with  liquor 

*  It  has  been  asserted  that  instead  of  contraction  of  the  capillaries,  the  first 
changes  observable  are  enlargement  with  an  increased  flow  of  blood.  To  determine 
positively  the  question  of  contraction  or  dilatation,  I  have  recently  made  a  series  of 
careful  observations  on  the  web  of  a  frog's  foot.  Having  fixed  the  animal  in  such 
a  way  that  it  could  not  move,  I  carefully  measured  with  Oberha^user's  ej-e  micro- 
meter the  diameter  of  various  vessels  before,  during,  and  after  the  application  of 
stimuli.  The  results  were,  that  immediately  hot  water  was  applied,  a  vessel  that 
measured  13  spaces  of  the  eye  micrometer  contracted  to  10;  another  that  measured 
10  contracted  to  7 ;  a  third  that  measured  7  contracted  to  5  ;  a  fourth,  which  was  a 
capillary  carrying  blood  globules  in  single  file,  and  measured  5,  was  contracted  to 
4 ;  and  another  one  of  the  smallest  size  which  measured  4  was  contracted  to  3. 
"With  regard  to  the  ultimate  capillaries,  it  was  frequently  observed  that  if  filled  with 
corpuscles,  they  contracted  little,  but  if  empty,  the  contraction  took  place  from  4  to 
2,  so  that  no  more  corpuscles  entered  them,  and  they  appeared  obliterated.  This 
was  especially  seen  after  the  addition  of  acetic  acid.  It  was  also  observed  that 
minute  vessels  that  contracted  from  4  to  3,  afterwards  became  dilated  to  6  before 
congestion  and  stagnation  occurred.  The  smaller  veins  were  seen  to  contract  as 
much  as  the  arteries  of  the  same  size. 


PRODUCTIOX   OF   EXUDATION. 


125 


sanguinis  and  a  few  lymph  corpuscles.  There  are  evidently  two  cur- 
rents, one  at  the  centre,  which  is  very  rapid,  and  one  at  the  sides  (in  the 
lymph  spaces,  as  they  are  called),  much  slower.  The  coloured  cor- 
puscles are  hurried  forward  in  the  centre  of  the  vessel,  occasionally 
mixed  with  some  lymph  corpuscles.  These  latter,  however,  may  fre- 
quently be  seen  clinging  to  the  sides  of  the  vessel,  or  slowly  proceeding 
a  short  distance  along  it  in  the  lymph  space,  and  then  again  stopping. 
Occasionally  the  lymph  corpuscles  get  into  the  central  torrent,  whence 
they  are  carried  off  with  great  velocity,  and  accompany  the  yellow 
corpuscles.  It  has  been  said  that  these  corpuscles  augment  in  number, 
accumulate  in  the  lymph  spaces,  and  obstruct  the  flow  of  blood.     In 


Fig.  100. 

young  frogs  their  number  is  often  very  great ;  but  then  they  constitute  a 
normal  part  of  the  blood,  and  in  no  way  impede  the  circulation.  In  old 
frogs,  on  the  other  hand,  all  these,  and  subsequent  changes,  may  be  ob- 


Fig.  100.  An  exact  copy  of  a  portion  of  the  web  in  the  foot  of  a  young  frog,  after 
a  drop  of  strong  alcohol  had  been  placed  upon  it.  The  view  exhibits  a  deep-seated 
artery  and  vein,  somewhat  out  of  focus ;  the  intermediate  or  capillary  plexus  run- 
niHg  over  them,  and  pigment  cells  of  various  sizes  scattered  over  the  whole.  On 
the  left  of  the  figure,  the  circulation  is  still  active  and  natural.  About  the  middle  it 
is  more  slow,  the  column  of  blood  is  oscillating,  and  the  corpuscles  crowded  together. 
On  the  right,  congestion,  followed  by  exudation,  has  taken  place. 

a,  A  deep-seated  vein,  partially  out  of  focus.  The  current  of  blood  is  of  a  deeper 
colour,  and  not  so  rapid  as  that  in  the  artery.  It  is  running  in  the  opposite  direc- 
tion. The  lymph  space  on  each  side,  filled  with  slightly  yellowish  blood  plasm,  is 
very  apparent,  containing  a  number  of  colourless  corpuscles,  clinging  to,  or  slowly 
movuig  along,  the  sides  of  the  vessel. 

6,  A  deep-seated  artery,  out  of  focus,  the  rapid  current  of  blood  allowing  nothing 
to  be  perceived  but  a  reddish  yellow  broad  streak,  with  lighter  spaces  at  the  sides. 

Opposite  c,  laceration  of  a  capillary  vessel  has  produced  an  extravasation  of  blood, 
which  resembles  a  brownish-red  spot. 

At  fZ,  congestion  has  occurred,  and  the  blood  corpuscles  are  apparently  merged 
into  one  semi-transparent,  reddish  mass,  entirely  filling  the  vessels.  The  spaces  of 
the  web,  between  the  capillaries,  are  rendered  thicker  and  less  transparent,  partly 
by  the  action  of  the  alcohol,  partly  by  the  exudation.  This  latter  entirely  fills  up 
the  spaces,  or  only  coats  the  vessel.  200  diam. 


126  PRDfCIPLES   OF   MEDICIXE. 

served,  without  the  presence  of  colourless  corpuscles.  When  the  capil- 
laries enlarge,  however,  the  central  coloured  column  in  the  smaller  ves- 
sels maybe  seen  to  enlarge  also,  and  gradually  approach  the  sides  of  the 
tube,  thus  encroaching  on  the  lymph  spaces.  The  slower  the  motion 
of  the  blood,  the  more  the  lymph  spaces  are  encroached  on,  until  at 
length  the  coloured  corpuscles  come  in  contact  with  the  sides  of  the 
vessel,  and  are  compressed  and  changed  in  form.  The  vessel  is  at 
length  completely  distended  with  coloured  corpuscles,  the  original  form 
of  which  can  no  longer  be  discovered,  so  that  the  tube  appears  to 
be  filled  with  a  homogeneous  deep  crimson  fluid.  This  is  congestion. 
If  the  morbid  process  continue,  the  vessel  may  burst,  causing  haemor- 
rhage, or  the  liquor  sanguinis  may  transude  through  its  walls,  without 
rupture,  into  the  surrounding  texture.     This  last  is  exudation. 


II.    Theory  of  Exudation. 

It  is  of  the  utmost  importance  in  pathological  inquiries  to  separate 
facts  fi'om  theories.  Our  facts  may  be  correct,  although  the  conclusions 
derived  from  them  are  wrong.  This  proposition,  however  generally 
admitted,  is  seldom  adhered  to  in  practice ;  for,  in  medical  writings  and 
statements,  we  frequently  find  fact  and  hypothesis  so  mingled  together, 
that  it  often  requires  considerable  critical  and  anah*tical  power  to  sepa- 
rate the  one  from  the  other.  AVe  are,  however,  in  all  cases,  insensibly 
led  to  theorise — that  is,  to  attempt  an  explanation  of  the  phenomena 
observed,  in  order  that  we  may  derive  from  them  some  general  principle 
for  our  guidance.  Such  speculation  is  always  legitimate,  so  long  as  we 
consider  opinions  to  be  mere  generalizations  of  known  facts,  and  are 
ready  to  abandon  them  the  moment  other  facts  point  them  out  to  be 
erroneous.  Tlie  phenomena  of  exudation,  previously  described,  may 
easily  be  demonstrated — they  constitute  the  facts.  Let  us  now  examine 
how  they  have  been  attempted  to  be  explained — in  other  w^ords,  what 
is  the  theory. 

1.  The  contraction  and  dilatation  of  the  capillaries  are  explicable,  by 
supposing  them  to  be  endowed  with  a  power  of  contractility  analogous 
to  that  existing  in  non-voluntary  muscles.  John  Hunter  thought  they 
were  muscular,  from  the  results  of  his  observations  and  experiments ; 
and  they  may  be  shown  by  the  histologist  to  consist  of  a  delicate  mem- 
brane, in  which  permanent  nuclei  are  imbedded.  Mr.  Lister  has  recent- 
ly shown  that  much  of  the  contractility  is  dependent  on  fusiform  cells, 
which  have  the  property  of  shortening  themselves,  and  which  run  trans- 
versely round  the  vessels.  In  structure,  then,  they  possess  elements 
closely  resembling  the  muscular  fibres  of  the  intestine,  and  we  know 
that,  like  them,  they  may  be  contracted  or  dilated  by  emotions  of  the 
mind  (that  is,  through  the  nerves),  or  by  local  applications,  that  is  di- 
rectly. The  narrowing  of  these  tubes,  therefore,  may  be  considered,  as 
Cullen  thought  it  was,  analogous  to  spasm,  while  their  dilatation  may 
be  referred  either  to  the  relaxation  which  follows  such  spasm,  or  to  mus- 
cular paralysis.  The  recent  observations  of  CI.  Bernard  and  others  as 
to  the  eftects  produced  by  dividing  the  large  nervous  trunk  of  the  sym- 
pathetic in  the  neck,  have  singularly  confirmed  this  theory. 


THEORY   OF   EXUDATIOX,  127 

2.  The  rapid  and  slow  movement  of  the  blood  is  explicable  on  the 
hydraulic  principle,  that  when  a  certain  quantity  of  fluid  is  driven  for- 
ward with  a  certain  force  through  a  pervious  tube,  and  the  tube  is  nar- 
rowed or  widened,  while  the  propelling  force  remains  the  same,  the  fluid 
must  necessarily  flow  quicker  in  the  first  case  and  slower  in  the  second. 
It  has  been  supposed,  from  the  throbbing  of  large  vessels  leading  to  con- 
gested parts,  that  they  pump  a  larger  quantity  of  blood  than  usual  into 
them.  This  was  called  "  determination  of  blood  "  by  the  older  patho- 
logists, and  is  now  known  not  to  be  a  cause,  but  a  result,  of  the  changes 
going  on  in  the  capillary  vessels  and  tissues  of  the  affected  part.  The 
oscillatory  movement,  seen  later  in  the  transparent  parts  of  small  ani- 
mals, has  not  been  observed  in  man,  and  probably  depends,  in  the  former, 
on  a  weakened  power  of  the  heart. 

3.  It  is  the  stoppage  of  the  blood  and  exudation  of  the  liquor  sangui- 
nis, however,  which  it  is  most  diflicult  to  explain  ;  for  why,  so  long  as 
there  is  no  mechanical  obstruction  (and  during  thig  process  none  has 
ever  been  seen)  should  the  circulation  through  the  capillaries  of  a  part 
cease  ?  It  has  been  endeavoured,  indeed,  of  late  years,  to  account  for 
this  stoppage  by  referring  it  to  a  mechanical  obstruction,  which  is  sup- 
posed to  result  from  the  formation  of  colourless  corpuscles,  which  cling 
in  large  numbers  to  the  sides  of  the  capillaries,  and  so  cause  interruption 
of  the  stream.  But  this  hypothesis  is  negatived  by  the  following  facts  : 
— 1st,  In  young  frogs,  the  vessels  may  be  seen  to  be  crowded  witli  colour- 
less corpuscles,  while  the  circulation  is  in  no  way  aftected.  2d,  In  old 
frogs,  oscillation  and  gradual  stoppage  of  the  stream  may  be  seen, 
without  any  colourless  corpuscles  being  present.  3d.  The  colourless  cor- 
puscles, as  shown  by  Remak,  are  increased,  after  large  venesections,  in 
the  horse,  without  ever  causing  active  congestion,*  And,  4th,  In  Leu- 
cocythemia  all  the  vessels  are  crowded  with  colourless  corpuscles,  and  yet 
no  active  congestion  in  these  vessels,  nor  exudation  of  any  kind,  takes 
place.     (See  Leucocythemia.) 

We  cannot  ascribe  the  stoppage  of  the  circulation  in  the  capillaries 
to  venous  obstruction,  or  to  mechanical  pressure  of  any  kind,  because 
all  observation  proves  that  such  causes,  while  they  induce  eft\ision  of 
serum,  never  occasion  exudation  of  liquor  sanguinis.  Neither  can  we 
suppose  it  to  depend  on  endosmose,  nor  on  a  vis  a  tergo^  as  such  physical 
causes  cannot  be  shewn  to  apply  in  all  cases.  We  are  compelled,  there- 
fore, to  attribute  the  vital  force  producing  these  changes,  not  to  anything 
residing  in  the  blood,  or  in  the  vessels,  but  to  the  tissues  which  lie  out- 
side the  vessels.  That  these  do  possess  a  power  attractive  and  selective, 
whereby  matters  are  drawn  from  the  blood  to  carry  on  nutrition  and 
secretion,  is  now  generally  admitted  in  physiology.  A  modification  of 
this  power,  whereby  the  attractive  property  is  augmented,  and  the 
selective  one  diminished,  at  least  offers  us  an  explanation  consistent  with 
all  known  facts,  and  seems  to  be  the  only  active  agency  to  Avhich  we  can 
ascribe  the  approach  of  the  coloured  particles  to  the  capillary  walls,  and 
the  passage  through  them  of  the  exudation. 

*  Diagnostische  und  Pathognetische  Untersuchungen,  &c.,  1845.  He  also  found 
that  in  man  the  colourless  corpuscles  of  the  blood  were  few  iu  number  during  inflam- 
mations, and  were  augmented  during  successive  bleedings,  so  that  he  concluded  the 
fewer  there  are  of  these  the  higher  is  the  degree  of  inflammation. 


128  PRINCIPLES   OF   MEDICINE. 

AMien  the  liquor  sanguinis  is  exuded,  it  generally  coagulates,  and  con- 
stitutes a  foreign  body  in  the  texture  of  the  parts  affected  ;  and  then  it 
becomes  the  object  of  nature  either  to  remove  it  from  the  system,  or  so 
to  modify  it  that  its  presence  may  be  rendered  conducive  to  the  wants 
of  the  economy.  In  order  to  accomplish  this,  two  kinds  of  changes 
take  place  in  it — 1st,  The  exudation  serves  as  a  blastema,  in  which  new 
vital  structures  originate  and  are  developed  ;  2d,  It  exhibits  no  power  of 
becoming  organised,  and  the  exuded  matters,  together  with  the  textures 
involved  in  them,  die.  In  the  first  case,  corpuscles  spring  up  in  the  exu- 
dation, which  differ  in  form,  size,  constitution,  and  power  of  further  deve- 
lopment, and  give  rise  to  these  various  appearances  and  changes  which, 
in  some  cases,  have  been  denominated  the  results  of  inflammation,  iu 
others,  various  kinds  of  deposits.  In  the  second  case,  death  of  the  exu- 
dation takes  place — slowly,  constituting  ulceration ;  or  rapidly,  producing 
gangrene. 


III.  Vital  Transformations  of  the  Exudation. 

"We  find  that  the  peculiar  constitution  of  the  blood,  or  the  general 
vital  power  of  the  organism,  exercises  a  very  powerful  influence  on  the 
development  of  the  exudation.  This  has  been  long  recognised  by  patho- 
logists in  certain  conditions,  denominated  respectively  diathesis,  dj'scrasia, 
or  cachexia.  I  propose  at  present  to  direct  your  attention  to  some  of 
the  facts  connected  with  exudation  as  it  occurs  in  the  body  during 
health,  as  well  as  when  connected  with  cancerous  and  scrofulous  consti- 
tutions. I  shall  call  the  former  simple  exudation,  to  distinguish  it  from 
what  may  be  denominated  cancerous  and  tuboxulur  exudation. 

Simple   Exudation. 

Simple  exudation  presents  four  principal  forms — 1,  As  it  occurs  on 
serous  membranes,  where  it  exhibits  a  finely  fibrous  structure,  and  has  a 
strong  tendency  to  be  developed  into  molecular  fibres  ;  2,  As  it  occurs 

on  mucous  membranes,  or  in  areolar  tissue, 
where  it  is  generally  converted  into  pus 
corpuscles ;  3,  When  it  occurs  in  dense 
parenchymatous  organs,  such  as  the  brain, 
where  it  assumes  a  granular  form,  and  is 
associated  with  numerous  compound  gra- 
nular corpuscles  ;  4,  As  it  is  poured  out  after 
wounds  or  injuries,  and  occurs  on  granulating 
sores.  In  this  last  case  the  superficial  por- 
tion is  transformed  into  pus  corpuscles, 
while  the  deeper  seated  is  converted,  by 
means  of  nuclei  and  cells,  into  nucleus  and 
'^'  ^^  ■  cell  fibres,  which  ultimately  form  the  cicatrix. 

1.  On  examining  the  minute  structure  of  the  exudation  on  a  serous 

Fig.  101.  Molecular  fibres  and  plastic  corpuscles,  in  simple  exudation  on  a  serous 
surface,     a,  The  latter  after  the  addition  of  acetic  acid.  250  diam. 


VITAL   TRANSFORMATIONS   OF   THE   EXUDATION.  129 

surfacG  when  recently  formed,  and  when  it  presents  a  gelatinous  semi- 
transparent  appearance,  it  will  be  found  to  be  made  up  of  minute  fila- 
ments mingled  with  corpuscles  (Fig.  101).  The  filaments  are  not  the 
result  of  the  development  of  either  a  nucleus  or  a  cell,  but  are  formed 
by  the  simple  precipitation  of  molecules,  which  arrange  themselves  in 
a  linear  manner,  in  the  same  way  as  they  may  be  seen  to  form  in 
the  bufty  coat  of  the  blood.  As  the  exudation  becomes  firm,  the 
filaments  appear  more  distinct  and  consolidated,  varying  from  y^io  gth 
to  --i_^th  of  an  inch  in  diameter.  Bundles,  or  difterent  layers 
of  them,  often  cross  each  other;  and  as  the  lymph  becomes  older, 
they  assume  more  and  more  the  character  of  those  in  dense  fibrous 
tissue.  The  corpuscles,  when  newly  formed,  are  delicate  and  trans- 
parent, but  in  a  short  time  become  more  distinct,  and  are  then  seen 
to  be  composed  of  a  distinct  cell-wall,  enclosing  from  three  to  eight 
granules.  They  vary  in  size  from  yaVot^i  to  ToVot'i,  and  the  enclosed 
granules  from  y^-io  o^^^  to  joio  o^h  of  an  inch  in  diameter.  On  the 
addition  of  water  and  acetic  acid,  the  corpuscles  undergo  no  change, 
although  sometimes  the  latter  re-agent  causes  the  cell-wall  to  contract 
and  thicken ;  and  at  others,  to  be  somewhat  more  transparent.  In 
1842,  I  separated  these  bodies  from  pus  cells,  and  called  them  plastic 
corpuscles,  from  the  frequency  of  their  occurrence  in  plastic  lymph. 
Lebert,  in  1845,  confirmed  my  description,  and  called  iham  2)yoid,  from 
their  resemblance  to  pus. 

These  corpuscles  after  a  time  melt  away  among  the  fibres,  but  seve- 
ral of  them  remain,  constituting,  as  shown  \y  Dr.  Drummond,  perma- 
nent nuclei.      After  a  time,  blood-vessels  grow  in  the  exuded  lymph 


3-    '   ■ 


ii«iii     Y\:.'^^    -''H    ^iSli 


Fig.  102.  Fig.  103.  Fig.  104.  Fig.  105.  Fig.  106. 

(see  Vascular  Growths),  the  surface  of  which  becomes  villous.  Into  the 
villi  loops  of  vessels  penetrate,  and  by  these  the  fluid,  contained  in  the 
interior  of  shut  sacs,  is  absorbed.  The  fluid  thus  gradually  diminishes, 
and,  when  the  villous  surfaces  are  brought  into  contact,  they  unite,  and 
ultimately  form  the  dense  chronic  adhesions  so  common  between  serous 
membranes. 

2.  Exudation  poured  out  on  a  mucous  membrane  sometimes  presents 
a  fibrous  mass,  as  in  cases  of  croup  and  diphtheritis,  but  more  gene- 
rally it  passes  into  an  opaque,  unctuous,  straw-coloured  fluid,  long  known 

Fig.  103.  A  portion  of  recent  Ij'mph  from  the  pleura. 
Fig.  103.  Another  portion  of  the  same,  further  developed. 
Fig.  104.  Portion  of  firm  pleural  adhesion. 
Fig.  105.  Another  portion  of  the  same,  further  developed. 
Fio-.  106.  The  last  acted  on  by  acetic  acid. — {Drummond.)  180  dmm. 

9 


130  PRIXCIPLES   OF   MEDICINE. 

under  the  name  of  pus.  "When  poured  into  the  meshes  of  areolar 
tissue,  and  occasionally  into  the  substance  of  the  brain,  the  same  trans- 
formation occurs,  and  then  forms  an  abscess.  On  examining  the 
minute  structure  of  pus,  it  is  seen  to  be  composed  of  numerous  corpus- 
cles floating  in  a  clear  fluid.  These  corpuscles  are  perfectly  globular  in 
form,  and  vary  in  size  from  the  g^oVo't'i  to  the  y aVo^li  ^^  'I'l  "^ch  in 
diameter.  Their  surface  is  finely  granular.  They  have  a  regular  well- 
defined  edge,  and  roll  freely  in  the  liquor  puris  upon  each  other.  On 
the  addition  of  water,  they  become  much 
f^,^     A-^v  i'pj^fS^!     increased  in  size  and  more  transparent,  their 

,Vf'"N^  ^^l^         '^^'^     finely  granular  surface  disappearing.     Weak 
'^^J^^ ^^^\'     ^P%\'-^'-'-''     acetic   acid    partially,   and  the   strong    acid 
£0^^f^       '  ■■-'U^^     completely,  dissolves  the  cell-wall,  and  brings 
n^*  >ii-  ■-       jiito  view  an  included  body,  generally  com- 

Fig.  loT.  Fig.  108.  poscd  of  two  or  three  granules  close  toge- 
ther, and  rarely  four  or  five,  each  with  a  central  shadowed  spot.  These 
are  usually  about  the  g  oVo^li  of  an  inch  in  diameter.  (Figs.  107,  108, 
also  Figs. '39,  40.) 

In  some  cases  the  pus  corpuscles  now  described  are  surrounded  by 
an  albuminous  layer  closely  resembling  a  delicate  cell-wall  (Fig.  41), 
which  I  first  described  in  1847.  It  is  about  the  toVot^  or  g^gth  of 
an  inch  in  diameter,  and  is  highly  elastic,  assuming  different  shapes, 
according  to  the  degree  and  direction  of  the  pressure  to  which  it  is 
subjected.  Water  and  acetic  acid  cause  it  at  once  to  dissolve,  whilst 
the  included  pus  corpuscle  exhibits  the  usual  body  composed  of  two  or 
three  granules. 

In  what   is    called  scrofulous  pus,  the   corpuscles,  instead  of  being 

round  and   rolling  freely  on  each   other,  are   misshapen  and  irregular 

.--7-,.  „  _        (Fig.  42),  and,  on  the  addition  of  acetic  acid, 

;0\K<^^)  '"-■'' ^'^ ■r^!  the    granular    nuclei    are    found    to    be    ill- 

^y^\^       ('^^/p  ^^  formed  or  absent  (Figs.  109,  110). 

-^'''^■^'^'^^)         y?'i /^i         -P^^*  cells,  if  not  evacuated  externally,  ulti- 

'-^'  '^  Vi°>^  ''^^     mately    dissolve,  their    walls    disappear,  the 

Fig.  109.  Fig.  110.     included   nuclei  and   granules  separate,  and 

are  converted  into  a  fluid.     This  passes  into  the  blood,  increases  for  a 

time  its  effete  constituents,  but  is  at  length  excreted  by  the  emunctories. 

Meanwhile  the  original  abscess,  or  collection  of  matter,  is  said  to  be 

resolved. 

3.  In  parenchymatous  organs,  the  exudation  insinuates  itself  among 
the  elementary  tissues  of  which  they  are  composed,  so  that,  when  it 
coagulates,  these  are  imprisoned  in  a  solid  plasma,  like  stones  in  the 
mortar  of  a  rough  cast  wall ;  thus  constituting  a  firm  mass,  and  giving 
increased  density  to  certain  organs.  This  is  Avell  observed  in  the  lung, 
where,  however,  a  mucous  surface  extensively  prevails,  and  where  the 
exudation  is  commonly  transformed  into  pus.  In  the  brain,  spinal 
cord,  and  placenta,  we  find  the  exudation  deposited  in  the  fonn  of 
minute  molecules  and  granules,  which  are  frequently  seen  coating  the 

Fig.  107.  Pus  cells.     Four  cells  have  been  acted  on  by  acetic  acid. 

Fig.  108.  Pus  cells  containing  fatty  molecules,  after  adding  acetic  acid.       250  di. 

Fig.  109.  Scrofulous  pus  cells  after  the  addition  of  acetic  acid. 

Fig.  110.  The  same.     In  both  specimens  the  nuclei  are  irregular  or  absent. 


VITAL  TRANSFORMATIONS   OF   THE   EXUDATION.  131 


the   6  oVo^'^  *^^'  ^^  ^'^*^^^ 


vessels  externally,  and  filling  up  the  intervascular  spaces   (Fig.   Ill) 
The  granules  var}^  in  size  from  the  ja.oo  o^^i  to 
in  diameter.     They  always  contain  among 
them  round  transparent  globules,  varying 
in  size  from  the  5  oVo^^i  to  -soVot^   ^^  ^^ 
inch  in  diameter.     These  are  the  nuclei  of 
round  or  oval  cells  which  may  frequently 
be  observed  in  various  stages  of  develop-   ^j 
ment.     When  fully  formed,  the  cells  vary    ff? 
greatly  in  size,  for  the  most  part  measur- 
ing from  the  yoVo'th  to  the  7 jo^th  of  an 
inch  in  diameter.     They  sometimes  con- 
tain a  few   oil   granules  only,   at    others 
they  are  so   completely   filled  with  them 
as  to  assume  a  brownish-black  appearance. 

Water  and  acetic  acid  cause  no  change   in  them,  although  the  latter 
re-agent,  on  some  occasions,  renders  the   cell- 
walls    more    transparent.     They    are    readily 
soluble  in  a;ther,  and  break  down  into  a  mole- 
cular mass  on  the  addition  of  potash  and  am- 
monia.    These    are   granule    cells   (Fig.  112). 
Masses  of  these  granules  may  be  occasionally 
seen  floating  about,  of  ii-regular  shape,  without 
any  cell-wall.     They  are   produced   either  by 
the  solution  of  the  cell-wall  in  which  they  are 
contained,  or  from  the  separation,  or  peeling 
off  of  such  masses  from  the  external  wall  of 
the  vessels;  and  form  granular  masses  (Fig.  112   a). 
these  granules  to  coalesce,  or  the  oil  to  be  forced  through  the  cell-wall. 
Occasionally  also  the  cell-wall  is  ruptured. 

The  granules,  masses,  and  cells  just  described  are  found  in  the  colos- 
trum secreted  by  the  mammary  glands ;  in  the  exudative  softening  of 
parenchymatous  organs ;  on  the  surface  of  granulations  and  pj^ogenic 
membranes  ;  in  the  pus  of  chronic  abscesses ;  combined  with  cancerous, 
tubercular,  and  all  other  forms  of  exudation;  in  the  tubes  of  the  kidney 
when  affected  with  Bright's  disease ;  and  in  the  contents  of  encysted 
tumours.  In  fact,  there  is  no  form  of  cell-growth,  whether  healthy  or 
morbid,  that  may  not,  under  certain  conditions,  accumulate  oil  or  fatty 
granules  in  its  interior,  become  a  compound  granular  corpuscle,  and  thus 
be  rendered  abortive.  The  granule  cells  in  an  exudation,  however,  are 
the  results  of  a  vital  transformation  of  that  exudation,  and  not  of  a  mere 
fatty  degeneration  of  the  vessels,  as  some  have  supposed.  In  some 
instances  I  have  seen  them  in  all  stages  of  development  coating  the 
blood-vessels,  as  in  Fig.  113. 

That  softening  from  the  formation  of  granules  and  granular  cells  may 
occasionally  disappear,  and  the  new  structures  be  absorbed,  is  rendered 
probable  by  the  history  of  several  well-recorded  cases;  but  the  changes 


Fig.  112. 

Pressure  causes 


Fig.  111.  Granular  exudation  and  granular  masses,  from  cerebral  softening.  250  di. 
Fig.  112.  Granular  cells  and  masses  from  cerebral  softening.  « 


132 


PEINCIPLES  OF  MEDICINE. 


thereby  produced,  especially  in  nervous  textures,  have  not  hitherto  been 
made  the  subject  of  special  investigation. 

4.  If  a  recently-formed  granulation  on  the 
surface  of  a  healing  sore  be  examined,  nume- 
rous cells  will  be  observed,  of  various  shapes, 
and  in  different  stages  of  development.  Some 
are  round,  others  caudate,  spindle-shaped,  elon- 
gated, or  splitting  into  fibres,  as  originally 
described  by  Schwann  (Fig.  114).  In  many 
cases  there  may  be  seen  a  number  of  free 
nuclei,  imbedded  in  a  slightly  fibrous  blastema, 
elongating  at  both  ends,  becoming  fusiform,  and 
splitting  up  the  surrounding  exudation,  as  de- 
scribed by  Henle.  Not  unfrequently  the  nuclei 
may  be  seen  developing  themselves  into  elastic 
fibres,  in  the  same  exudation  which  contains 
cells  that  are  passing  into  white  fibres.  Indeed, 
the  process  of  cicatrization  in  its  various  stages, 
and  in  different  tissues,  offers  the  best  means  of 
studying  the  manner  in  which  nucleus  and  cell 
fibres  are  respectively  formed.  As  these  fibres 
-  ii"^-  are  developed  in  the  deeper  layers  of  the  exuda- 

tion, a  villous   vascular  basis  is  formed,  and  the  superficial  pus-corpus- 


I  .s,-  un- 
cles, after  having  served  to  protect  the  more  permanent  growths,  are 
thrown  off  in  the  form  of  discharge.  When  the  fibrous  structiire 
becomes  more  consistent  and  dense,  the  amount  of  pus  diminishes,  and 
a  greater  tendency  is  manifested  by  the  exudation  to  pass  into  per- 
manent tissue.     At  length  pus  ceases  to  be  developed ;  the  whole  re- 


Fig.  113.  Two  vessels  coated  with  exudation  from  softening  of  the  spinal  cord. 
Granular  cells  may  be  seen  forming  in  it.  250  diam. 

Fig.  114.  Vertical  section  of  a  granulating  sore.  Externally,  pus  corpuscles, 
deeper,  fibre  cells  in  various  stages  of  development  into  fibre.  The  looped  blood- 
vessels are  seen  enlarged  at  their  extremities,  magnified  100  diameters  linear.  On 
the  left,  the  cells  are  magnified  250  diameters  linear. 


CANCEROUS  EXUDATION". 


133 


maining  exudatioB  is  transformed  into  fibres  ;  a  new  surface  is  produced, 
■which,  after  a  time,  contracts  and  forms  the  permanent  cicatrix. 


Cancerous  Exudation. 

Cancerous  exudation  presents  three  principal  forms,  which  result 
from  the  relative  amount  and  arrangement  of  the  cells  and  fibres  forming 
it.  1,  A  very  hard  structure,  principally  formed  of  fibres  (  scirrhus). 
2,  A  soft  structure  containing  a  copious  milky  fluid,  in  which  numerous 
corpuscles  swim  (  encephaloma).  3,  A  structure  having  a  fibrous  basis, 
so  arranged  as  to  form  areolse  or  loculi,  which  contain  a  gelatinous  gum 
or  glue-like  matter  (colloid  cancer). 

1.  Scirrhus  presents  to  the  naked  eye  a  whitish  or  slightly  yellowish 
tinge ;  is  dense  and  hard  to  the  feel,  and  oflers  considerable  resistance 

Fig.  116. 


Fig.   117.  F-.    i.-. 

to,  and  often  crunches  under,  the  knife.  On  making  a  thin  section  of 
the  growth,  it  is  seen  to  be  principally  composed  of  filaments,  which 
vary  in  size,  and  run  in  different  directions,  sometimes  forming  waved 
bands,  at  others  an  inextricable  plexus,  among  which,  however,  nucleated 
cells  (cancer  cells)  may  be  seen  to  be  infiltrated.  Occasionally  the 
fibrous  structure  forms  loculi  or  cysts,  enclosino-  similar  cells. 

The  so-called  cancer-cells  may  be  round,  oval,  caudate,  spindle-shaped, 
oblong,  square,  heart-shaped,  or  of  various  indescribable  forms,  produced 
by  pressure  on  their  sides.  In  size  they  vary  from  the  ToVot^i  to  the 
^j-L^th  of  an  inch  in  diameter.  The  cell-wall,  when  young,  is  smooth 
and  distended  ;  when  old,  it  is  more  or  less  corrugated  and  flaccid. 
Each  cell  contains  at  least  one  nucleus,  often  two,  and  sometimes  as 

Fig.  115.  Section  showing  the  arrangement  of  cells  and  fibres  in  scirrhus  of  the 
mamma 
Fig.  116.  The  same,  after  the  addition  of  acetic  acid. 
Fig.  117.  Isolated  cancer-cells,  from  the  same  growth. 
Fig.  118.  The  same,  after  the  addition  of  acetic  acid.  250  diam.    * 


134 


PEIXCIPLES   OF   MEDICINE. 


many  as  nine.  Most  commonly  there  is  only  one,  wliicli  is  round,  or 
more  generally  oval,  and  contains  one  or  two  granules  or  nucleoli.  The 
nucleus  also  varies  in  size,  and  may  occupy  from  one-sixth  to  four-fifths 


-  r     R 


r?\ 


Fig.   119.  Fig.   120.  Fig.  121.  Fig.  122. 

of  the  volume  of  the  cell.  Between  the  nucleus  and  cell-wall  there  is  a 
colourless  fluid,  which,  at  first  transparent,  becomes  afterwards  opalescent, 
from  the  presence  of  molecules  and  granules.  On  the  addition  of  water, 
the  cell-wall  becomes  distended  by  endosmose,  and  is  enlarged.  "When 
acetic  acid  is  added,  the  cell-wall  is  rendered  more  transparent,  and  in 
young  cells  is  entirely  dissolved  (Fig.  120),  whilst  the  nucleus,  on  the 
other  hand,  either  remains  unafl:ected,  or  its  margin  becomes  thicker,  and 
its  substance  more  or  less  contracted. 

2.  Uncephaloma  also  presents  a  fibrous  texture,  which,  however,  is 
very  loose  when  compared  with  that  of  scirrhus.  In  the  denser  parts  of 
the  growth,  indeed,  it  closely  resembles  the  scirrhus  form  of  cancer,  but 
often  where  it  is  pulpy  and  broken  down,  no  traces  of  fibres,  or  at  most 
only  some  fragments  of  them,  are  visible  to  the  naked  eve. 

The  whitish  cut  surface  is  often  more  or  less  mottled,*  with  a  pinkish, 


■m  '■  .    A' 


'  ^ 


i^^f-: 


Fig.  123.  Fig.  124.  Fig.  125. 

reddish,  greyish,  yellowish,  or  black  colour.  The  two  first  colours  are 
owing  to  different  degrees  of  vascularity.  The  reddish  spots  are  owing 
to  extravasations  of  blood,  and  are  of  greater  or  less  extent ;  when  very 

Fig.  119.  Young  cancer-cells  from  the  lung. 
Fig.  120.  The  same,  after  the  addition  of  acetic  acid. 
Fig.  121.  Somewhat  older  cells  from  the  testicle. 
Fig.  122.  The  same,  after  the  addition  of  acetic  acid. 
Fig.  123.  Still  older  cancer-ceUs  from  a  tumour  in  the  duodeniun. 
Fig.  124.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  125.  Highest  development  of  cancer-cells,  mcluding  secondary  cells,  from  a 
tumour  of  the  toe.  250  diam. 


CANCEROUS   EXUDATION. 


135 


'~y'f 


larcje  tliev  constitute  what  has  been  called /'^Hr/us  hcematodes.  The  yel- 
lowish colour,  when  it  surrounds  extravasations  of  blood,  is  owinor  to 
imbibition  of  its  colouring  matter ;  but  when  the  colour  is  spread  in  a 
reticulated  form  over  the  surface,  or  over  the  masses,  it  generally  results 
from  fatty  degeneration  of  the  cancerous  tissue,  and  forms  the  so-called 
reticulum  {cancer  retkulare  of  MiiUer).  This  yellow  matter  is  usually  of 
cheese-like  consistence,  friable,  and  often  resembles  tubercle,  for  which  it 
has  been  mistaken.  The  blackish  tinge  is  owing  to  black  pigment  infil- 
trated among  the  cancerous  elements,  or  existing  within  the  cells,  and  con- 
stitutes the  malignant  mela- 
nosis, or  raelanic  cancer,  of  "  @*'1^  """^ 
authors.  (See  Fatty  and  Pig-  j^^^sF^\ 
mentary  Degenerations.) 

A  small  portion  of  the 
cream-like  fluid  obtained 
from  cancer-masses,  when 
examined  with  a  microscope 
presents  a  large  number  of 
the  cancer  cells  formerly 
described ;  in  some  speci- 
mens of  encephaloraa  these 
cells  reach  a  higher  degree 
of     development    than    in       N^j^         -    -rl_ 

other   forms    of   cancerous  ••.""<_"      -        ^  _j^^ 

growth    (Figs.    125,    126).  '"  -•■^^:^^:5-.;;>r4T^;rv^c;v^: -^  "^ 

They  are   mingled  with   a 

large  number  of  molecules  ^'e-  126. 

and  granules,  granular  cells,  blood  corpuscles,  and  more  or  less  of  the 
fibrous  element.  The  fibrous  structure  is  the  same  as  that  in  scirrhus, 
but  the  filaments  are  often  finer, 
and  always  more  widely  sepa- 
rated, while  the  pulpy  matter 
and  cells,  contained  in  the  in- 
terstices, are  correspondingly  in- 
creased. The  yellow  reticulum 
is  sometimes  composed  of  loose 
granules  and  granular  cells,  at 
others  of  granules  alone.  Xot 
unfrequently  it  contains  nuclei, 
disintegrated  and  altered  in 
shape  with  crystals  of  margarine 
or  of  cholesterine.  In  some 
instances  the  encephaloma  is 
more  or  less  impregnated  with 
irregular  masses  of  mineral  mat- 
ter, and  occasionally  is  almost  entirely  converted  into  a  calcareous  sub- 
Fig.  126.  Simple  and  compound  cancer-cells  from  the  duodenum. — Several  contain 
fluid  from  endosmose.  which  strongly  refracts  light. 

Fig.  127.  Colloid  tissue,  with  the  loeuli  tilled  with  molecular  matter,  in  which  cells 
are  commencing  to  form.  On  the  left  of  the  figure,  one  of  the  molecular  masses  has  been 
squeezed  from  the  fibrous  matrLs.    Below  ai'e  masses  of  mineral  matter.    250  diam. 


O®'^ 

pV^ 

^^<& 


136 


PRINCIPLES   OF  MEDICINE. 


stance.     In  this  way  cancer  is  liable  to  undergo  the  fatty  and  calcareous 
degenerations.     (See  Fatty  and  Mineral  Degenerations.) 

3.  Colloid  cancer  consists  of  a  fibrous  structure  so  arranged  as  to 
form  areolae  or  loculi,  which  are  filled  with  a  gTey  or  amber-coloured 
glutinous  matter,  sometimes  transparent,  at  others  opalescent  or  semi- 
opaque.  This  matter  is  occasionally  found  quite  structureless,  or  exhibits 
ouly  a  finely  molecular  appearance  (Fig.  127)  ;  and  in  consequence 
the  term  colloid  tissue  has  been  applied  to  it.  At  other  times  nu- 
merous nucleated  cells,  presenting  all  the  characters  of  cancer-cells,  in 


Fig.  128. 


Tig.  131. 


A,   .■-^■•>.  \ .    ><< 


Fig.  129. 


various  stages  of  development,  are  found  in  it  as  a  blastema ;  and  Ave 
observe  that  the  growth  has  a  tendency  to  spread.  In  this  colloid  can- 
cer, when  it  is  formed  on  a  free  surface,  as  on  the  peritoneum,  there  are 
often  present  small  grains  of  a  grey  colour,  resembling  coagulated  gum- 
arabic.  When  collected  in  masses,  these  grains  have  an  iiTCgularly 
nodulated  aspect.  I  have  never  seen  the  fibrous  structure  of  colloid  con- 
tain permanent  nuclei,  or  atford  any  evidence  of  being  developed  from 
nuclei  or  cells. 

All  the  three  forms  of  cancer  now  described  are  vascular,  but  in  differ- 
ent degrees.  Scirrhus  is  least  so,  but  is  still  rich  in  blood-vessels.  En- 
cephaloma  is  alwavs  very  vascular,  and  often  to  such  a  degree,  that  it 
readily  bleeds  during  life  (furu/us  hcEmatodes).  Colloid  cancer  is  also 
Avell  supplied  with  vessels,  which  ramify  among  the  fibrous  tissue.  I 
have  already  stated  that  these  forms  pass  into  each  other,  and  need  only 


Fig.  128.  Colloid  cancer.     Appearance  of  the  fibrous  areolae  filled  with  cancer- 
cells. 

Fig.  129.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  130.  Some  of  the  cells  isolated. 

Fig.  131.  Fibrous  stroma  deprived  of  the  cells  by  pressure  and  washing. 

250  diam. 


TUBERCULAR  EXUDATION. 


137 


remark  here,  tliat  this  is  often  so  gradual  in  many  specimens,  as  to  ren- 
der their  classitication  very  difficult.  This  is  especially  the  case  Avith 
scirrhus  and  encephaloma. 

Tubercular  Exudation. 

Tubercular  exudation  has  been  spoken  of  as  presenting  itself  under  a 
miliary,  infiltrated,  or  encysted  form  ;  those  distinctions,  however,  have 
no  reference  to  structure,  but  merely  to  the  extent  and  age  of  the  exuda- 
tion. It  generally  presents  a  yellowish  or  dii'ty-white  colour,  and  varies 
in  consistence  from  a  substance  resembling  tough  cheese  to  that  of  cream. 


m 


n^^ 

^A 


v\-(P.-}^. 


.0    -..yi:':'. 


ft 


Flsr.  132. 


Fie  It^ 


Sometimes  it  is  soft  at  one  place,  and  indurated  at  another.  On  section, 
Avhen  tough,  it  presents  a  smooth  or  waxy,  and  Avhen  soft,  a  slightly 
granular  surface.  On  pressure  it  is  friable,  and  ma}'  break  down  into  a 
pulpy  matter,  but  never  yields  a  milky  juice. 

A  small  portion  squeezed  between  glasses,  and  examined  under  the 


Fiar.  135. 


Fig.  132.  Corpuscles  from  firm  tubercular  exudation  into  the  lung,  a,  After  the 
addition  of  acetic  acid. 

Fig.  133.  Corpuscles,  granules,  and  debris,  from  soft  tubercular  exudation  into  the 
lung. 

Fig.  134.  The  same,  from  tubercular  infiltration  of  a  mesenteric  gland. 

Fig.  135.  Section  of  a  grey  granulation  in  the  lung,  showing  the  pulmonary  vesi- 
cles filled  with  tubercle  corpuscles. 

Fig.  136.  Section  of  a  firm  mihary  tubercle  of  the  lung.  250  diam.    ^ 


138  PRINCIPLES   OF   MEDICINE. 

microscope,  presents  a  number  of  irregularly  shaped  bodies  approaching 
a  round,  oval,  or  triangular  form,  varying  in  their  longest  diameters 
from  the  ? oVot'i  to  yTrVot^^  of  an  inch.  These  bodies  contain  from  one  to 
seven  granules,  are  unaffected  by  water,  but  rendered  very  transparent  by 
acetic  acid.  They  are  what  have  been  called  tubercle-corpuscles.  They 
are  always  mingled  with  a  multitude  of  molecules  and  granules,  which  are 
more  numerous  the  softer  the  tubercle.  Occasionally,  when  softened 
tubercle  resembles  pus,  constituting  scrofulous  purulent  matter,  we  find 
the  corpuscles  more  rounded,  and  approaching  the  character  of  pus  cells 
(Fig.  42).  They  do  not  always,  however,  on  the  addition  of  acetic  acid, 
exhibit  the  peculiar  granular  nuclei  of  pus-cells  (Figs.  10*7,  108). 

The  grey  granulations  described  by  Bayle  may  be  seen,  on  careful 
management  of  the  light,  and  after  the  addition  of  acetic  acid,  to  con- 
tain similar  bodies  to  those  described  as  tubercle  corpuscles,  being  close- 
ly aggregated  together,  having  indistinct  edges,  and  containing  few 
granules. 

Cretaceous  and  calcareous  tubercles,  on  the  other  hand,  contain  very 
few  corpuscles,  their  substance  being  principally  made  up  of  numerous 
irregular  masses  of  phosphate  of  lime,  and  a  greater  or  less  number  of 
crystals  of  cholesterine.     (See  Mineral  Degeneration.) 

Tubercle  corpuscles  may  be  associated  with  pus  and  granular  cells,  as 
well  as  with  cells  peculiar  to  glandular  organs  or  mucous  surfaces  in  vari- 
ous stages  of  fatty  transformation  and  disintegration.  AYith  all  these 
they  have  frequently  been  confounded. 


TV.    PATnOLOGT    OF    THE    ThREE    KiNDS    OF    ExUDATIOX. 

We  have  seen  that  the  liquor  sanguinis  transudes  through  the  coats 
of  the  capillaries,  and,  coagulating  outside  the  vessels,  constitutes  an 
exudation  more  or  less  solid.  Much  of  the  serum,  which  accompanied 
it,  is  rapidly  absorbed,  but  what  remains  constitutes  a  blastema,  which 
becomes  organised  in  the  various  ways  described,  according  to  the  seat 
and  nature  of  the  exuded  matter.  In  simple  exudation  we  find  diff"er- 
ences  according  as  it  is  poured  out  on  a  serous,  mucous,  or  granulating 
surface,  or  into  a  dense  parenchyma.  These  diflferences  are  dependent 
on  the  seat  of  the  exudation.  But  in  cancerous  or  tubercular  exudations, 
we  observe  no  such  distinctions,  although  it  has  been  observed  that 
fibrous  cancer  or  scirrhus  is  most  common  in  fibrous  organs,  and  cell 
cancer  or  enccphaloma  is  most  common  in  cellular  organs.  The  more 
important  characters  of  the  three  kinds  of  exudation  may  be  shortly 
stated  as  follows  : — 

A  simple  or  inflammatory  exudation  may  occur  at  all  epochs  in  life  ; 
it  may  attack  all  tissues,  and  is  most  commonly  found  in  those  which  are 
very  vascular;  it  may  be  poured  out  in  large  or  small  quantities,  and 
with  greater  or  less  rapidity — whence  the  terms  acute  and  chi'onic. 
Further,  acute  exudations  are  generally  attended  with  symptoms  of  a 
peculiar  character  (inflammatory),  and  have  a  great  tendency  to  cell  or 
temporary  formations,  which  rapidly  breaking  down,  are  absorbed  and 
excreted  by  the  emuuctories.     Chronic  simple  exudations,  on  the  other 


PATHOLOGY  OF  THE   THREE   KINDS  OF  EXUDATION.       139 

laand,  have  a  tendency  to  fibrous  or  permanent  formations,  producing 
adhesions,  strictures,  indurations,  etc. 

Cancerous  exudation  occurs  for  the  most  part  in  persons  of  adult  or 
advanced  life  ;  it  may  also  attack  every  tissue,  but  is  by  far  most  common 
in  ijlandalar  or  fatty  organs,  such  as  the  liver  or  female  mamma,  and  is 
verv  apt  to  occur  in  the  lymphatic  glands  secondarily  ;  its  progress, 
although  sometimes  slow  when  very  fibrous,  becomes  rapid  when  cor- 
puscles abound  in  it ;  there  is  in  it  a  great  tendency  to  the  formation  of 
the  most  perfect  forms  of  cell  life,  having  the  power  of  self-development, 
and  thereby  of  spreading  to  neighbouring  tissues ;  and  lastly,  when,  by 
pressure,  ulceration  is  produced  on  free  surfaces,  it  bursts  through  them 
in  exuberant  fungoid  excrescences  (Fig.  27.3). 

Tubercular  exudation  occurs  for  the  most  part  in  young  subjects, 
between  the  periods  of  dentition  and  of  adult  age ;  it  may  occur  in  all 
tissues,  but  is  by  far  most  common  primarihj  in  the  lymphatic  glands, 
and  afterwards  in  fibrous  or  albuminous  textures,  as  the  lungs  and  serous 
surfaces ;  its  progress  is  in  general  exceedingly  slow ;  there  is  no  dispo- 
sition in  it  to  the  formation  of  perfect  cell-formation,  but  abortive  cor- 
puscles are  formed  in  it  slowly,  and  slowly  break  down  ;  there  is  little 
tendency  in  it  to  absoi'ption,  but  great  liability  to  disintegration  and 
ulceration  ;  and  finally  the  local  changes  which  it  occasions  are  almost 
always  preceded  by  derangement  of  the  primse  vice,  and  a  group  of 
symptoms  known  under  the  name  of  dyspepsia. 

Taking,  then,  the  products  of  simple  exudation  (say  pus)  as  a  standard, 
we  may  remark,  that  whilst  the  cell-development  of  tubercle  is  below, 
that  of  cancer  is  above,  this  standard.  Of  the  three  kinds  of  exudation, 
tubercle  is  the  lowest,  and  cancer  the  highest,  in  the  scale. 

Of  the  ultimate  cause  producing  this  difterence  in  the  formative  power 
of  the  exudation  we  are  ignorant,  but  legitimate  reasoning  leads  us  to 
the  conclusion,  that  these  changes  and  effects  depend,  not  upon  the  vas- 
cular system,  which  is  the  mere  apparatus  for  the  production  of  exuda- 
tion ;  nor  upon  the  nervous  system,  which  conducts  impressions  to  or 
from  this  apparatus;  and  not  on  the  texture,  which  is  the  seat  of  the 
exudation,  as  that  varies  whilst  the  cancerous  or  tubercular  fonnation  is 
the  same — but  upon  the  inherent  composition  or  constitution  of  the 
exudation  itself.  On  this  point  most  pathologists  are  agreed,  and  hence 
the  supposed  existence  of  various  kinds  of  dyscrasise,  which  originate  in 
the  blood,  and  as  it  is  imagined,  explain  the  difterent  results  produced. 
And  here  pathologists  pause — having  traced  the  disease  back  to  the 
blood,  they  are  content ;  but  they  have  not  sufficiently  taken  into  con- 
sideration, that  the  blood  itself  is  dependent  for  its  constitution  on  the 
results  of  the  primary  digestion  in  the  alimentary  canal  on  the  one 
hand,  and  the  secondary  digestion  in  the  tissues  on  the  other.  Yet  it 
must  be  evident  to  every  physiologist,  that  if  it  be  the  constitution  of 
the  blood  which  determines  the  constitution  of  the  exudation,  the  causes 
which  produce  the  latter  must  be  sought  in  those  circumstances  which 
operate  on  the  composition  of  the  former  fluid. 

Xumerous  facts  render  it  probable,  that  while  the  blood  is  normal  in 
simple  exudation,  it  contains  an  excess  of  nutritive  materials  in  cancer- 
ous, and  a  deficiency  of  them  in  tubercular,  exudation  ;  but  these  are 
points  which  can  only  be  established  after  examining  instances  of  such 


1-iO  PRINCIPLES  OF  MEDICINE. 

exudations  in  detail.  But  it  must  not  be  forgotten,  however,  that  as  the 
blood  is  continually  undergoing  changes,  and  is  receiving  and  giving  off 
new  matters,  it  can  scarcely  remain  the  same  for  many'hours  together. 
An  exudation  at  one  time  may  be  very  diflferent  from  what  it  was  at 
another ;  abounding  in  elements  at  one  period  which  do  not  exist  in  it 
at  the  next.  Hence,  therefore,  it  may  often  happen  that  a  concurrence 
of  circumstances  is  necessary  to  occasion  a  certain  result.  A  cancer 
once  formed,  may  remain  local  until  such  a  concurrence  of  events  arises, 
comprising,  iirst,  the  phenomena  leading  to  and  producing  an  exudation  ; 
secondly,  the  occurrence  of  this  exudation  in  some  other  tissue  or  organ 
sufficiently  predisposed  for  the  purpose  ;  and  thirdly,  a  peculiar  consti- 
tution of  the  blood.  Hence  the  histologist  continually  finds  many 
varieties  of  intermediate  formations  between  the  three  leading  kinds  of 
exudation  ;  and  even  when  the  constitution  is  thoroughlj-  cancerous  or 
tubercular,  simple  exudations  may  be  poured  into  tissues  as  the  result 
of  recent  wounds  or  injuries.  But,  whilst  a  recent  cancerous  or  a  tuber- 
cular exudation  may  be  found  to  accompany  or  alternate  with  a  simple 
exudation,  the  two  former  are  seldom  nict  with  together — a  circumstance 
Tvhich  still  further  points  out  the  wide  difference  between  the  constitu- 
tional causes  producing  them. 

The  termination  of  all  kinds  of  exudation  may  be  the  same,  but  each 
has  its  peculiarities.  We  have  noticed  the  tendencies  of  simple  exuda- 
tion to  be  transformed  into  pus  or  fibres,  according  to  its  seat.  In  the 
one  case,  the  pus  cells  break  down,  and  are  re-absorbed  in  a  disintegrated 
and  fluid  condition  into  the  blood  ;  in  the  other,  permanent  fibrous  tis- 
sue is  produced,  constituting  chronic  adhesions  or  cicatrices.  The  cells 
of  a  cancerous  growth  may  also  degenerate  or  decay,  but  this  rarely 
takes  place  throughout  the  whole  structure.  But  it  is  not  uncommon 
to  find  in  certain  encephalomatous  tumours,  yellow  matter  eitlier  in 
masses  or  reticulated  through  its  substance — {Cancer  Heticulare  of 
Mailer).  This  is  generally  owing  to  fatty  degeneration  of  the  cancer 
cells.  (See  Fatty  Degeneration.)  The  fibrous  structure  of  cancer  may 
also  increase,  so  as  occasionally  to  produce  cicatrization.  Tubercle  pos- 
sesses no  such  fibrous  stroma,  but  is  infiltrated  among  the  elements  of 
various  organs,  the  vascularity  of  which  it  tends  to  destroy.  This, 
indeed,  is  the  reason  why  a  cancerous  tumour  increases  by  growth,  which 
tubercle  cannot  be  said  to  do  ;  the  former  is  vascular,  the  latter  is  not : 
in  the  one,  cells  are  formed  which  have  the  power  of  re-development ; 
in  the  other,  no  reproductive  cells  are  produced.  In  cancer,  the  morbid 
matter,  whatever  it  be,  circulating  in  the  blood,  is  concentrated  or 
attracted  to  the  cancerous  part ;  and  even  should  no  such  matter  be 
present,  the  healthy  blood  is  made  subservient  to  the  purpose  of  nou- 
rishing a  foreign  growth.  In  tubercle,  successive  fresh  exudations  only 
occur,  which,  by  their  accumulation,  augment  the  volume  or  amount  of 
the  morbid  product. 

All  three  forms  of  exudation  may  be  rendered  abortive,  the  animal 
matter  of  them  being  broken  down  and  absorbed,  while  the  mineral 
matter  remains,  constituting  a  cretaceous  or  calcareous  concretion.  This 
is  not  unfrequently  seen  as  the  result  of  simple  exudation  ;  it  rarely  hap- 
pens in  cancerous,  but  is  very  common  in  tubercular  exudations. 

During  the  disintegration  of  simple,  cancerous,  and  tubercular  exuda- 


DEATH   OF   THE   EXUDATION.  141 

tions,  the  animal  matter  broken  down  is  again  rendered  fluid,  repasses 
into  the  blood,  and  then  constitutes  that  excess  of  fibrin  detected  by 
chemists.  (See  p.  103.)  The  quantity  of  this  will,  of  course,  vary 
according  to  the  amount  of  the  exudation  and  the  activity  of  the  disin- 
tegrating process.  In  the  blood  this  etfete  matter  undergoes  a  series  of 
chemical  changes,  preparatory  to  its  excretion  by  the  different  emunc- 
tories,  especially  by  the  kidneys,  in  the  form  of  various  sediments.  The 
resolution  of  simple  exudation  is  generally  accompanied  by  the  presence 
of  urinary  sediments,  whose  nature  indicates  in  what  way  the  exudation, 
after  it  has  passed  through  the  phases  of  development  described,  is  at 
length  discharged  from  the  body.  In  the  same  manner  the  amount  of 
these  sediments  frequently  points  out  the  extent  of  absorption  going  on 
in  cancerous  and  tubercular  exudations. 

Another  theory  has  been  advanced  regarding  the  various  products  of 
exudation  as  we  have  described  them,  viz.,  that  instead  of  being  new 
formations  in  an  exuded  blood  plasma,  they  are  only  modifications  of 
pre-existing  texture.  According  to  this  view,  pus  cells  are  only  altered 
epithelial  ones,  cancer  cells  are  an  increased  development,  and  tubercle 
corpuscles  are  a  degeneration  or  "  necrosis,"  of  gland  or  other  cells.  The 
fallacy  of  this  theory,  though  it  has  many  facts  which  seem  to  give  it 
support,  is  easily  demonstrated.  For  instance,  pus  cells  may  occur  in 
tissues  where  there  are  no  epithelial  cells,  as  among  muscles ;  and  can- 
cer, pus  and  tubercle  are  all  found  in  the  white  substance  of  the  brain, 
where  no  cells  have  been  demonstrated  to  exist,  capable  of  increasing 
on  the  one  hand  or  deo-eneratincr  on  the  other. 


T.  Death  of  the  Exudation-. 

The  exudation,  instead  of  passing  through  the  vital  transformations 
we  have  previously  described,  may  die,  and  in  two  ways — 1st,  Rapidly 
— constituting  what  has  been  called  Mortification  or  Moist  Gangrene ; 
and,  2d,  Slowly — causing  gradual  disintegration  and  loss  of  texture,  and 
thereby  forming  what  has  been  denominated  ulceration. 

Mortification  or  Moist  Gangrene. 

Occasionally  a  very  large  amount  of  blood  plasma  is  thrown  out ;  a 
greater  or  smaller  number  of  capillaries  are  also  ruptured,  and  blood 
corpuscles  more  or  less  mixed  up  with  the  liquor  sam/uinis  exuded.  The 
exudation  thus  formed  compresses  the  part  into  which  it  is  thrown  out, 
paralyses  the  nerves,  obstructs  the  blood-vessels,  and  arrests  the  circula- 
tion in  them.  Under  these  circumstances,  instead  of  forming  a  blastema 
for  the  production  of  new  structures,  it  undergoes  chemical  changes, 
whereby  decomposition  is  induced,  and  then  the  part  is  said  to  be  mor- 
tified, or  to  be  affected  with  moist  gangrene.  This  change  commences 
first  in  the  blood  extravasated,  which  becomes  of  a  purple  colour  more 
or  less  deep  ;  the  corpuscles  break  down  and  become  disintegrated  ; 
their  hsematozine  dissolves  and  colonic  the  serum  ;  and,  should  the 
exudation  have  coagulated,  it  forms  brown,  rust-coloured,  purple,  or 
blackish  masses.     An  acid  matter  is  now  formed,  which,  acting  on  the 


142 


PRINCIPLES   OF  MEDICINE. 


neighbouring  tissues,  produces  fcetid  gases,  that  are  abundantly  given 
off  from  the  atfected  part.  Sulphuretted  hydrogen  is  evolved,  which 
causes  the  blackish  sloughs  usually  ol:)served  in  such  cases,  and  disco- 
.  lours  silver  probes  and  the  preparations  of  lead.  After  a  time,  the  ele- 
mentary tissues  surrounding  or  involved  in  the  exudation,  become  more 
or  less  atfected.  The  transverse  stria3  in  the  fasciculi  of  voluntary 
muscles  first  become  pale,  and  are  then  obliterated.  Celhilar  tissue, 
fat,  and  other  soft  substances  lose  their  connection,  and  fall  into  an 
undefined  granular  mass.  The  tendons  and  fibrous  tissues  retain  their 
characteristic  structure  for  a  long  time  after  the  other  soft  parts  have 
been  reduced  to  a  softened  pulp.     The  bones  resist  the  action  longest, 


Fig.  137. 


but  at  length,  commencing  externally,  they  become  rougli,  soft,  and  are 
more  and  more  broken  down,  and  reduced  to  the  same  pulpy  consistence 
and  granular  structure  as  the  surrounding  parts. 

As  the  tissues  thus  become  broken  down  and  fluid,  they  are  dis- 
charged from  the  system  in  the  form  of  an  ichorous  matter,  which, 
examined  microscopically,  presents  numerous  granules,  imperfect  or 
broken  dow"n  cells,  blood  corpuscles,  and  fragments  of  filamentous  tissue 
or  of  the  other  structures  involved.  If  the  morbid  action  be  seated  in 
the  subcutaneous  tissue,  the  skin  soon  becomes  aft'ected  ;  and  an  open- 
ing is  formed,  which  rapidly  enlarges,  and  gives  vent  to  the  discharge. 
In  a  similar  manner,  gangrene  of  internal  organs,  by  destroying  the 
intermediate  parts,  at  length  enables  the  fluid  to  reach  the  surface,  or  to 
find  its  way  into  the  excretory  passages,  such  as  tlie  bronchi,  the  intes- 
tinal canal,  the  meatus  auditorius,  etc.  In  this  manner,  life  may  be 
endangered,  by  the  destruction  of  organs  necessary  for  its  continuance  ; 
by  the  exhaustion  resulting  from  the  discharge  ;  and  sometimes  by  the 
absorption  of  the  ichorous  matter,  which,  entering  the  circulation,  acts 
as  a  poison  to  the  economy.  On  the  other  hand,  a  favourable  termina- 
tion may  take  place,  either  by  the  dead  substance  breaking  down,  and 
being  evacuated  externally,  or  by  its  being  separated  en  masHe  in  the 
form  of  a  slough.  In  such  case  a  process  of  regeneration  and  healing 
may  be  set  up  in  the  exposed  living  texture,  which  may  produce  a  cica- 
trix in  the  manner  formerly  spoken  of. 

It  may  be  asked,  whether  mortification  is  the  result  merely  of  a  greater 
amount  of  the  exudation  ?  or  whether  it  is  dependent  besides  on  other 
circumstances,  such  as  a  peculiar  state  of  the  atmosphere,  which  favours 


Fig.  137.  Moist  gangrene,   following  compound  fracture — all   the  injured   parts 
infiltrated  with  exudation,  which  has  died  and  mortified. — Llston. 


MORTIFICATION.  1^3 

tlie  decomposition  of  the  exudation  poured  out  ?  In  order  to  answer 
these  questions,  we  must  distinguish  between  ordinary  mortification 
arising  from  a  variety  of  circumstances,  and  moist  gangrene  properly  so 
called^  which  is  undoubtedly  the  rarest  of  all  the  terminations  of  exuda- 
tion. '  Mortification  may  be  produced  by  the  application  of  chemical  or 
mechanical  agents,  which  directly  destroy  the  tissues.  It  also  often 
arises  through" severe  and  complicated  injuries,  in  which  arteries  leading 
to  the  portions  of  structure  aft'ected  have  been  divided  or  crushed.     In 


old  persons  it  follows  obstruction  in  the  blood-vessels,  or  is  dependent 
on  circumstances  not  yet  ascertained.     In  none  of  these  cases  is  it  a 
result  of  exudation.     But  when  stasis  of  the  capillaries  is  produced  to  a 
considerable  extent,  followed  by  the  exudation  of  a  large  quantity  of 
blood-plasma,  which,  instead  of  passing  into  organization,  undergoes  the 
changes  previously  described,  then  moist  gangrene,  properly  so  called, 
is  produced.     We  sec  this  take  place  after  burns,  after  long  exposure  to 
frost,  and  in  certain  cases  of  erysipelas.     Here  the  amount  of  exudation 
is  considerable,  the  pressure  caused  by  it  extreme,  the  obstruction  to 
the  circulation  in  the  neighbouring  parts  correspondingly  great,  so  that 
these,  as  well  as  the  exudation  itself,  is  destroyed.     In  this  sense,  there- 
fore, it  may  be  said  to  depend  on  the  rapidity  and  amount  of  the  exuda- 
tion ;  but  not  in  the  sense  of  those,  who  consider  adhesion,  suppuration, 
and  gangrene  as  different  stages  of  one  process.     Suppuration,  as  w^e 
now  know,  has  no  connection  with  adhesion  ;  it  is  opposed  to  it ;  nor 
is  it  in  any  way  related  to  mortification,  which  must  be  considered  as 
a  primary  alteration  of  the  exudation.     In  mortification  the  vitality  of 
the  exudation  is  lost,  and  instead  of  passing  into  organization,  it  becomes 
subject  to  the  chemical  laws  of  dead  matter,  and  undergoes  putrefaction. 
Now^,  in  order  that  organic  substances  may  enter  rapidly  into  putre- 
faction, it  is  necessary  that  they  find  sufficient  oxygen  and  water  for  all 
their  carbon  to  be  transformed  into  carbonic  acid,  all  their  hydrogen 
into  water,  and  all  their  azote  into  ammonia.     When  these  conditions 
are  not  completely  fulfilled,  transition   or  intermediate  substances  are 
formed.     If  there  is  not  sufficient  oxygen,  for  instance,  an  excess  of  car- 
bon is  produced  in  the  debris.     There  is  also  often  developed  a  species 
of  destruction  by  contact,  which  causes  parts  undergoing  decomposition 
to  excite  it  in  neighbouring  ones  (eremacausis  of  Liebig) ;  which  does 
not  take  place  in  dry  gangrene.     A  gangrenous  stomatitis  [Cancrum 

Fig.  138.  Dry  gangrene  from  debility — being  death  of  the  pre-existing  tissues, 
unconnected  with  exudation. — Liston. 


144  PEIXCIPLES   OF   MEDICINE. 

oris)  will  tlius  destroy,  in  a  short  time,  a  large  portion  of  the  soft  parts 
of  the  lips  and  face,  and  JVoma  the  genitals  of  young  female  children. 
This  appears  to  depend  upon  the  quantity  of  destructive  fluid  or  mixture 
generated  in  the  process.  On  the  other  hand,  several  weeks  may  occur 
before  a  dry  gangrenous  foot  is  completely  separated  by  decomposition. 

There  are  sometimes  external  causes  also  which  seem  to  produce 
mortification,  independent  of  the  amount  of  exudation,  or  the  rapidity 
with  which  it  is  thrown  out.  During  the  summer  of  1836,  I  watched 
with  great  care  the  progress  of  a  sloughing  gangrene,  prevalent,  not 
onlv  in  the  Infirmary  of  Edinburgh,  but  throughout  the  city  generally. 
All  kinds  of  sores  and  wounds  were  atfected  by  it,  even  those  of  a  speci- 
fic nature,  such  as  chancres,  etc.  Neither  youth  nor  age  was  exempted 
from  it.  It  affected  not  only  those  who  were  debilitated  from  disease, 
through  intemperance  or  bad  diet,  but  those  also  apparently  in  the  most 
robust  health.  Thus  a  servant  girl,  aged  16,  who  had  never  suffered 
from  illness,  and  was  of  a  robust  constitution,  fell  down  upon  some  glass 
bottles,  and  slightly  cut  her  left  thumb.  A  week  after,  she  entered  the 
Infirmary  with  an  ulcer  the  size  of  a  shilling,  filled  with  a  brownish- 
black  slough,  discharging  a  foetid  and  sanguineous  fluid.  In  this,  as 
well  as  other  cases  which  occurred,  it  became  impossible  to  attribute 
the  gangrene  to  the  violence  of  the  injury,  the  amount  of  exudation,  a 
state  of  cachexia,  or  indeed  to  any  circumstances  connected  with  the 
individual.  It  could  not  arise  from  contagion,  as  it  originated  simul- 
taneously in  difi"erent  parts  of  the  citv  in  individuals  who  had  no  com- 
munication with  each  other,  and  was  not  confined  to  the  Infirmary, 
where  the  system  of  dressing  wounds  precluded  the  possibility  of  such 
an  occurrence.  We  are,  therefore,  compelled  to  ascribe  the  cause  to 
something  in  the  atmosphere. 

Most  writers  have  noticed  the  connection  between  a  certain  state  of 
the  atmosphere  and  the  prevalence  of  hospital  gangrene  and  of  dysen- 
tery, as  well  as  their  more  frequent  occurrence  in  summer  and  autumn 
— that  is,  at  a  period  of  the  year  when  increased  temperature  favours 
the  decomposition  of  animal  matter.  The  good  eflfects  which  result 
from  change  of  air,  when  every  kind  of  treatment  fails,  still  further  point 
out  its  connection  with  some  atmospheric  changes.  These  may  proba- 
bly depend  upon  some  peculiar  electrical  state  not  yet  explained,  power- 
fully influencing  the  chemical  combinations  of  the  diseased  part,  and 
preventing  ceil  growth.  At  least  such  is  what  we  may  reasonably  sup- 
pose, from  all  the  facts  with  which  we  are  acquainted  on  this  head. 
The  disease  is  similar  to  blight  among  vegetables,  or  the  potato  disease. 

Ulceration. 

The  process  of  ulceration  is  somewhat  similar  to  that  of  mortification, 
but  is  more  chronic  in  its  progress ;  the  exudation,  instead  of  undergo- 
ing decomposition,  exhibits  an  indisposition  to  pass  into  cell  formation. 
In  this  case  the  exudation  is  poured  out  slowly,  it  coagulates  and  presses 
upon  the  surrounding  parts,  more  or  less  obstructing  the  flow  of  blood 
to  them,  and  acts  as  a  foreign  body.  By  means  of  the  continued  pres- 
sure, the  circulation  is  obstructed,  and  death  of  the  portion  aftected 
results.     This  dead  portion  is  sometimes  imprisoned  in  fresh  exudation, 


ULCERATION.  145 

as  the  ulceration  extends,  and  the  whole  part  affected  at  length  becomes 
disintegrated.  x\ll  this  time  the  exudation  exhibits  little  of  that  ten- 
dency,"so  conspicuous  in  healthy  persons,  to  undergo  changes  in  itself, 
and  when  examined  microscopically,  is  found  to  consist  principally  of 
very  minute  granules.  These  are  occasionally  mixed  with  irregularly 
formed  cells,  usually  more  or  less  angular,  containing  one  or  more 
granules.  The  cells  are  more  numerous  in  proportion  to  the  stage  of 
the  ulceration,  and  the  healthy  powers  of  the  constitution.  The  different 
granules  and  imperfect  cells,  with  the  structures  they  involve,  at  length 
become  broken  down,  and  separated  from  each  other,  constituting  a 
serai-fluid  mass,  wdiich  has  a  tendency  to  point  where  it  can  most  readily 
be  discharged,  that  is,  towards  the  surface  of  the  skin  or  mucous  mem- 
branes. Ilere,  on  account  of  the  less  degree  of  resistance  offered,  the 
continued  pressure  and  disintegration  of  tissue  first  causes  an  aperture 
to  be  formed.  Another  portion  of  solid  exudation  is  now  broken  down, 
with  the  tissues  involved  in  it,  and  in  this  way  the  opening  is  enlarged. 
If  the  morbid  process  continue,  a  fresh  exudation  is  slowly  poured  out 
below  the  already  coagulated  blood-plasma,  which  supplies  the  loss 
thrown  off  in  the  form  of  discharge,  and  thus  chronic  ulcers  may  be 
continued  indefinitely.  The  whole  of  this  process  may  be  well  observed 
in  scrofulous  and  syphilitic  ulcers,  or  in  the  callous  sores  of  the  legs  in 
weavers  and  others  of  a  cachectic  constitution.  Indeed,  the  general 
powers  of  the  constitution  are  almost  always  in  such  cases  enfeebled, 
and  hence  the  indisposition  of  the  exudation  to  be  transformed  into 
cells. 

Ulcers  produced  by  direct  pressure  are  occasioned  in  a  similar 
manner;  only  in  such  cases  the  pressure  is  not  derived  in  the  first 
instance  from  the  solid  exudation  poured  out.  Thus,  in  stumps  not 
sufficiently  covered  by  soft  parts,  in  places  long  pressed  npon  by  lying, 
or  by  the  growth  of  tumours,  the  vitality  of  the  part  is  slowly  destroyed. 
At  the  same  time  an  exudation  is  poured  out  from  the  neighbouring 
vessels,  which  becomes  broken  up,  and  assists  in  disintegrating  the 
textures  whose  vitality  is  destroyed.  The  finely  molecular  particles 
are  thus  absorbed,  whilst  the  grosser  portions  are  thrown  oft'  in  the 
form  of  discharge. 

All  ulcerated  surfaces  are  covered  with  a  fluid,  which  varies  in 
character  according  to  the  nature  of  the  sore.  Healthy  granulations 
are  covered  with  laudable  puruleut  matter,  the  corpuscles  in  it  present- 
ing their  normal  character.  In  chronic,  scrofulous,  and  syphilitic 
sores,  the  corpuscles  are  generally  of  an  irregular  form,  constituting 
Avhat  has  been  denominated  unhealthy  purulent  matter.  Not  unfre- 
quently  the  ulcer  is  covered  with  a  discharge,  either  of  a  thin  dirty 
yellowish  tint,  or  more  or  less  sanguinolent  and  foetid.  In  the  latter 
case  the  discharge  has  received  the  name  of  sanies,  and  is  similar  in 
character  and  constitution  to  that  observed  in  the  fluid  accompanying 
moist  gangrene — that  is  to  say,  there  are  in  it  traces  of  imperfect  cell 
formation,"mixed  with  numerous  molecules,  and  the  shreds  or  debris  of 
the  structures  involved. 

Ulceration  has  by  most  writers,  since  the  time  of  Hunter,  been 
regarded  as  the  result  of  a  peculiar  operation,  which  he  denominated 
ulcerative  absorption.    No  doubt  the  process,  such  as  w^e  have  described 

10 


146  PRINCIPLES   OF  MEDICIXE. 

it,  is  peculiarly  favonrable  to  the  production  of  a  fluid  containing 
molecules  so  minute  that  they  may  readily  permeate  the  neighbouring 
vessels  bv  endosmosis.  But  it  must  not  be  overlooked  that  much  of 
the  substance  lost  in  ulceration,  especially  of  the  more  consistent  and 
tough  structures,  after  having  been  more  or  less  broken  up,  is  thrown 
oft'  from  the  surface  in  the  form  of  discharge.  This  is  proved  by  direct 
observation.  In  either  case  all  such  parts  fiist  lose  their  vitality,  from 
the  pressure  to  -which  they  are  subjected,  and  then,  being  disintegrated, 
the  fluid  and  finer  parts  may  be  absorbed,  whilst  the  coarser  are  thrown 
ofl'  from  the  surface. 

In  bones  the  processes  corresponding  to  mortification  and  ulceration 
in  soft  parts,  are  generally  denominated  JVecrosis  and  Caries. 


\1.  General  Treatment  of  Exudation. 

The  foregoing  facts  and  considerations  must  lead  us  to  the  conclusion, 
that  practically  the  medical  man  may  be  called  upon — 1st,  To  prevent 
or  diminish  the  extent  of  an  exudation ;  2d,  When  it  has  coagulated, 
to  further  its  removal  from  the  economy  ;  or,  3d,  If  this  cannot  be 
accomplished,  to  render  its  products  as  little  injurious  to  the  system  as 
possible.  In  each  case,  we  can  only  proceed  correctly  by  knowing  the 
manner  in  which  nature  operates,  and  assisting  those  curative  changes 
which  she  invariably  attempts  to  bring  about.  We  have  seen  that  exu- 
dation follows  certain  preliminary  alterations  in  the  capillary  vessels, 
and  is  immediately  dependent  on  relaxation  or  paralysis  of  their  coats, 
and  transudation  through  them  of  the  liquor  sanguinis.  Once  formed, 
it  passes  through  certain  changes  or  developments,  which  vary  according 
to  the  nature  of  the  texture  in  which  it  occurs,  its  amount,  the  rapidity 
with  which  it  is  formed,  and  its  inherent  constitution.  The  exudation, 
bv  means  of  these  changes,  is  rendered  soft,  is  more  or  less  disintegrated, 
and  is  absorbed  into  the  blood  to  be  excreted  from  the  economy.  A 
correct  treatment,  therefore,  will  be  influenced  by  the  stage  and  nature 
of  the  exudation. 

1.  To  prevent  or  diminish  the  extent  of  an  exudation,  we  must  adopt 
measures  to  overcome  the  dilatation  of  the  capillaries,  their  distension 
with  blood,  and  the  attractive  power  (whatever  that  is)  which  draws  the 
liquor  sano-uinis  into  the  surrounding  textures.  This  is  accomplished — 
1st,  Bv  local  applications  of  cold  and  astringents,  which  stimulate  the 
capillaries  to  contraction ;  2d,  By  soothing  topical  applications,  such  as 
warm  fomentations,  opiates,  etc.,  which  relieve  the  irritation  of  the  nerves 
in  the  part.  Blood-letting,  local  or  general,  has  long  been  supposed 
capable  of  meeting  this  indication,  but  theoretically  it  can  no  longer  be 
defended,  and  practically  the  use  of  the  former  has  much  diminished, 
while  that  of  the  latter  has  of  late  years  been  almost  confined  to  active 
congestion  of  the  external  tissues. 

2.  When  the  exudation  has  coagulated,  it  constitutes  a  foreign  body, 
which  either  becomes  organised,  or  is  removed  by  its  dying.  In  the 
one  case  it  acts  as  a  blastema,  in  which  cells  are  developed  that  ulti- 
mately break  down,  and  so  render  it  capable  of  being  absorbed  (resolu- 
tion), or  they  are  converted  into  a  tissue  that  becomes  permanent.     In 


CLASSinCATIOX   OF   MORBID   GROWTHS.  1-47 

the  other  case,  it  disintegrates  slowly,  constituting  ulceration — or  putre- 
fies, forming  moist  gangrene,  when  it  is  separated  from  the  economy  in 
discliarge  or  as  a  slough.  It  is  by  regulating  the  formative  power  of  the 
exudation  that  we  check  or  favour  resolution ;  and  we  can  only  do  this 
bv  employing  those  means  which  lessen  or  advance  cell  growth  in  all 
living  organisms.  Thus  locally,  cold,  dryness,  and  pressure  check — 
while  heat,  moisture,  and  room  for  expansion  favour, — growth.  And  as 
reirards  the  general  system,  the  increase  or  diminution  of  food,  nutrients 
and  stimuli,  act  for  or  against  this  object. 

With  a  view  of  diminishing  the  general  excitement  that  prevails,  tar- 
tar emetic  has  been  recommended,  and  to  assist  the  absoi-ption  of  the 
exuded  matter,  calomel  has  been  a  favourite  remedy  ;  but  the  manner  in 
which  these  act  has  been  disputed,  and  whether  it  be  as  a  solvent  of  the 
etfete  matters  in  the  blood,  or  by  operating  on  the  excretions,  is  yet 
undetermined.  The  former  probably  acts  in  both  these  ways — the  use 
of  the  latter,  as  an  antiphlogistic,  has  of  late  years  been  almost  aban- 
doned. The  action  of  counter-irritants,  although  undoubtedly  useful  in 
removinor  pain  and  in  causing  absorption  of  chronic  exudations,  is  little 
understood,  and  belongs  to  the  most  mysterious  department  of  thera- 
peutics. 

3.  In  order  to  favour  the  excretion  of  the  effete  matters  in  the  blood, 
purgatives,  diaphoretics,  and  diuretics,  alone  or  combined,  will  be  found 
very  useful.  The  influence  of  these  remedies,  indeed,  is  not  confined 
merely  to  removing  matters  which  have  been  absorbed  as  the  result  of 
the  secondary  digestion ;  but,  by  their  depurating  qualities,  they  favour 
indirectly  the  rapid  absorption  of  the  exudation. 

-4.  In  cancerous  exudations  we  must  endeavour  to  restrain  the  advance 
of  cell  growth,  by  local  cold,  dryness,  and  pressure ;  we  must  attempt  its 
eradication  by  excision  or  caustics,  if  this  can  be  appropriately  prac- 
tised ;  and  diminish  the  tendency  to  accumulation  of  nutritive  materials 
in  the  system,  by  keeping  the  excretory  functions  in  full  activity. 

5.  In  tubercular  exudation,  the  cell  development  of  wliich  is  imper- 
fect, and  tends  to  ulceration  and  wasting,  we  have  to  combat  the  preli- 
minary phenomena  of  exudation  locally,  whilst  we  improve  the  nutri- 
tive powers  of  the  economy  generally.  To  meet  the  first  indication, 
counter-irritation  and  an  equable  climate  are  useful;  whilst  for  the 
second,  we  must  overcome  the  dyspepsia  so  hostile  to  a  correct  primary 
digestion,  and  in  addition  to  exercise  and  free  air,  supply  the  system 
wi^th  easily  assimilable  animal  oils,  without  which  nutrition  cannot  pro- 
ceed. 

The  general  indications  for  treatment  now  alluded  to,  of  couree  admit 
of  infinite  variations  and  modifications  in  individual  cases.  In  the  mean- 
time, what  I  have  to  tell  you  with  respect  to  these,  will,  I  think,  be  more 
readily  comprehended  from  the  preceding  considerations. 


14:8  PRINCIPLES   OF   MEDICIXE. 


MORBID  GROWTHS  OF  TEXTURE— THEIR  GENERAL 
PATHOLOGY  AND  TREATMENT. 

The  exclusive  study  of  morbid  growtlis,  according  as  tliej^  aifect  inter- 
nal or  external  parts,  has  led  to  limited  views  of  the  subject.  The  sur- 
gical tendenc}'  to  speak  of  them  as  tumours,  and  to  regard  them  in  refer- 
ence to  the  great  practical  question  of  excision,  has  interfered  with  the 
true  pathological  doctrine,  namely,  that,  however  or  wherever  produced, 
they  are  essentially  the  same.  No  doubt  they  are  veiy  common  in  exter- 
nal parts,  simply  because  all  growth  proceeds  best  on  surfaces  where 
there  is  room  for  expansion,  but  this  accidental  circumstance  should  not 
induce  us  to  suppose  that  they  are  peculiarly  matters  for  surgical  consi- 
deration. In  truth,  their  study  belongs  to  pathology — that  science 
which  constitutes  the  basis  of  all  branches  of  the  medical  art. 

The  line  which  separates  health  from  disease  is  not  always  to  be  deter- 
mined, when  certain  tissues  or  organs  have  increased  in  size  dispropor- 
tioned  to  the  rest  of  the  body.  Exercise,  within  certain  limits,  may 
cause  the  size  of  particular  parts  to  be  relatively  increased,  as  the  legs  of 
the  dancer,  and  arms  of  the  blacksmith.  In  these  cases,  however,  such 
enlargement  is  consistent  with  health.  So  when  the  uterus  enlarges  and 
its  walls  thicken  during  pregnancy,  we  recognise  that  the  departure  from 
the  normal  type  is  absolutely  necessary  for  the  purpose  it  is  required  to 
carry  out ;  and  when  this  is  accomplished,  it  returns  to  its  natural  con- 
dition. In  like  manner,  other  hollow  viscera  enlarge  when  they  have  an 
obstruction  to  overcome.  Thus  the  urinary  bladder  becomes  greatly 
thickened,  in  consequence  of  a  stricture  in  the  urethra;  and  the  left  ven- 
tricle of  the  heart  becomes  hypertrophied  from  disease  of  the  aortic 
valves.  But  in  these  last  cases  the  increased  growth,  though  a  wise 
adaptation  of  nature,  and  even  necessary  for  the  continuance  of  life,  must 
be  regarded  as  evidence  of  permanent  disease.  Again,  a  blow  on  the 
breast,  on  the  skin,  or  over  a  bone,  may  cause  the  injured  parts  slowly 
to  enlarge,  inducing  swellings,  which  may  produce  inconvenience  from 
their  size,  or  from  their  pressure  on  neighboui'ing  nerves.  In  this  manner 
no  tissue  or  organ  of  the  body  is  exempt  from  more  or  less  increase  of 
its  extent  or  magnitude,  and  there  are  none,  consequently,  which  may 
not  occasionally  present  morbid  or  excessive  growth. 

Increased  growth  of  tissues  may  assume  various  forms.  The  organ 
or  structure  may  gradually  become  enlarged  in  whole  or  in  part,  still 
maintaining  more  or  less  of  its  original  texture,  shape,  and  function,  con- 
stituting hijpertropluj.  Membranes  may  become  preternaturally  thick- 
ened, causing  more  or  less  induration,  whereby  the  movements  of  parts 
may  be  affected,  or  the  calibre  of  tubes  and  ducts  may  be  diminished, 
producing  stricture.  The  results  of  the  healing  process  may  give  rise 
to  new  tissues  exactly  resembling  those  previously  existing  in  other 
parts  of  the  body,  as  in  cicatrices,  callus,  etc.  *,  or  such  growths  may 
assume  the  form  of  tumour.  Lastly,  we  must  not  overlook  the  fact  that 
certain  transformations  in  the  exudation,  formerly  noticed,  lead  to  increase 
of  texture,  and  produce  morbid  growths  altogether  foreign  to  the  healthy 
frame. 


CLASSIFICATION   OF   MORBID   GROWTHS,  149 

A  cultivation  of  histology  excited  the  hope  that,  by  stnclyino-  the 
ultimate  structure  and  mode  of  development  of  morbid  gi'owths,  distinc- 
tive elements,  and  thereby  a  new  foundation  for  their  classification,  would 
be  discovered.  But  extensive  researches  long  ago  convinced  me  that 
this  hope  was  vain,  and  in  a  special  work,  published  in  ]  849,*  I  pointed 
out  what  were  the  ultimate  elements  of  all  morbid  growths,  and  that  no 
one  of  these  was  characteristic  of  any  special  kind  of  organic  formation. 
The  structural  elements  of  morbid  growths  may  be  reduced  to  six,  viz. — 
1st,  molecules  and  granules  ;  2d,  nuclei ;  3d,  cells ;  4th,  fibres ;  5th, 
tubes  (especially  vascular  ones)  ;  and  6th,  crystals  or  irregular  masses 
of  mineral  matter.  Now  no  combination  of  these  elements  will  serve  to 
characterize  morbid  growths,  such  as  fibro-molecular,  fibro-nucleated, 
fibro-celiular,  fibro-vascular,  etc.,  for  the  simple  reason  that  tumours 
very  unlike  in  their  external  characters  and  natures  may  be  composed 
of  the  same  elements.  For  instance,  cystic,  glandular,  cartilaginous,  and 
cancerous  growths,  are  all  fibro-cellular.  It  is  not  then  from  its  showing 
the  existence  of  one  or  more  elementary  structures,  but  from  its  pointing 
at  their  mode  of  arranf/ement,  that  the  microscope  is  destined  to  be  of 
infinite  impoi'tance  in  pathology  and  diagnosis.  Neither  will  chemical 
composition  furnish  us  with  trustworthy  means  of  distinguishing  morbid 
gi'owths,  as  many  of  them  contain  albuminous,  fatty,  pigmentary,  and 
mineral  principles  conjoined,  although  in  variable  proportions. 

The  best  classification,  therefore,  is  one  founded  on  our  knowledge  of 
the  compound  textures  of  the  growths  themselves,  assisted  as  far  as 
varieties  are  concerned  by  their  similitude  to  well  known  objects,  which 
have  long  been  received  in  pathology  as  standards  of  comparison.  Thus 
the  following  arrangement  appears  to  me  capable  of  embracing  all  the 
known  primary  classes  of  morbid  growth  : — 

I.  Fibrous  growths  .         .         .  Fibroma  f  or  Inoma. 

II.  Fatty  growths    ....  Lipoma. 

III.  Cystic  growths  ....  Cystoma. 

IV.  Glandular  growths     .         .         .  Andenoma. 
V.  Epithelial  grow^ths     .         .         .  Epithelioma. 

YI.  Avascular  growths       .  .  .  Angionoma. 

YII.  Cartilaginous  growths  .  .  Enchondroma. 

yill.  Osseous  growths         .  .  .  Osteoma. 

IX.  Cancerous  growths     .  .  .  Carcinoma. 

All  these  primary  divisions  are  susceptible  of  being  subdivided  ac- 
cording to  the  presence  of  particular  substances,  or  to  fancied  resem- 
blances which  have  received  names.  Thus  the  varieties  of  the  above 
kinds  of  growth  have  long  been  determined  by  their  substance  present- 
ing greater  or  less  similitude  to  well-known  objects,  such  as  water,  lard, 
flesh,  brain,  etc.  etc.,  as  follows  : — 

*  On  Cancerous  and  Cancroid  Growths.     Edinburgh,  1849. 

f  The  word  Fibroma,  though  composed  of  a  Latin  root  with  a  Greek  termination, 
and  therefore  barbarous,  is  here  given  in  consequence  of  its  having  been  already 
employed  in  medicine.  Those,  however,  who  may  object  to  it  on  this  ground,  can 
employ  the  more  correct  Hovel  term  of  Inoma,  from  I's-iVos ,  a  fibre. 


150 


PRINCIPLES   OF   ilEDICIXE, 


1. 

Like  water    ..... 

.     Hygroma. 

2. 

n 

black  pigment 

Melanoma. 

3. 

5) 

green  pigment 

Chloroma. 

4. 

5J 

blood    ..... 

.     Httmatoma. 

5. 

» 

gl"e 

Colloma. 

6. 

5? 

lard 

Steatoma. 

/ . 

?J 

gruel    ..... 

Atheroma. 

8. 

r 

honer  ..... 

Meliceroma. 

9. 

» 

cholesterine 

Cholesteatoma 

3  0. 

?5 

flesh      ..... 

Sarcoma. 

11. 

?5 

nerve    ..... 

Neuroma. 

12. 

?? 

brain     ..... 

Encephaloma. 

13. 

J) 

marrow         .... 

Myeloma. 

14. 

5> 

marble           .         .         .         .         . 

Scirrhoma,  etc 

It  is  easy  to  understand  how  varieties  may  in  this  way  be  multiplied, 
and  how  new  names  may  be  scientifically  given  to  rare  forms  of  tumour, 
for  instance  Sijphonomu,  or  tubular  growth,  described  by  Henle  ;*  Cy- 
lindroma, by  Billroth  ;t  Heteradenoma  by  Eobin,|  etc.  etc. 

Further  varieties  have  been  made  to  express  one  or  more  combina- 
tions of  these  elements,  and  hence  the  terms  Fihro-cijstk,  Fibro-cartila- 
(/inous,  Fibro- Sarcoma,  Osfeo-Sarcoma,  and  so  on.  Indeed,  this  kind  of 
nomenclature  admits  of  further  extension,  and  such  terms  as  Fihro-ejn- 
thelial,  Anyio-cy^tic,  Cystk-aJcnoma^  Osteo-fibrous,  and  so  on,  might  be 
employed  with  advantage.  When,  also,  growths  have  a  certain  resem- 
blance to,  or  largely  partake  of  the  character  of  the  structures  and  sub- 
stances referred  to,  while  their  real  nature  is  not  absolutely  or  altogether 
the  same,  the  words  Fibroid,  Cystoid,  Adenoid,  Chondroid,  Osteoid,  Col- 
loid, Heematoid,  Fungoid,  Fncep}ialoid,  Myeloid,  Cancroid,  etc.,  have 
been  employed. 

All  these  words  and  modes  of  expression,  as  they  are  founded  on 
anatomical  facts,  may,  if  carefully  applied,  be  useful  in  designating  the 
structure  and  nature  of  morbid  growths.  But  other  distinctions  founded 
on  presumed  vital  properties,  are  objectionable.  "What  ideas,  for  instance, 
can  be  attached  to  the  terras  innocent  and  malignant  ?  A  fibrous  growth 
has  been  generally  classed  among  innocent  ones,  yet  the  terms  recurrent 
and  malignant  have  also  been  applied  to  it.  In  fact,  we  shall  aftei'wards 
see  that  almost  every  kind  of  growth  may  be  innocent  in  some  cases, 
and  malignant  in  others.  The  distinctions,  therefore,  sought  to  be  esta- 
blished from  such  theoretical  considerations  are  not  only  erroneous,  but 
have  proved — as  we  shall  subsequently  show — most  injurious  in  prac- 
tice. I  have  known  innocent  growths  never  operated  on  bv  the  sur- 
geon, and  allowed  to  kill,  in  consequence  of  his  believing  them  to  be 
malignant,  and  really  malignant  ones  not  touched  at  that  early  period 
when  their  removal  was  likely  to  be  beneficial,  in  the  hope  that  they 
would  go  away  of  themselves.  This  point  will  be  more  especially  dwelt 
upon,  after  giving,  as  it  is  now  proposed  to  do,  a  short  sketch  of  the 
nine  distinct  kinds  of  morbid  growths. 

*  Zeit.  fiir  Ration.  Med.  3  Bd.  1  Heft. 

f  Ueber  die  Entwickelung  der  Blutgefasse,  Berlin,  1856. 

\  Traite  d'Anat  Pathologique,  par  Lebert,  p.  339,  et  seq. 


FIBROUS   GROWTHS. 


151 


Fibrous  Growths. — Fibroma  or  Inoma. 

The  patholoo;ical  formation  of  fibrous  growths  is  the  most  common 
and  universal  which  occurs  in  the 
bod3^  It  is  essentially  of  two  kinds 
— ls<,  a  simple  increase  by  division 
or  enlargement  of  pre-existing  fibrous 
tissue  ;  2<Z,  a  new  formation  of  fibres 
in  an  exudation. 

I.  As  examples  of  the  first  kind 
of  increased  fibrous  growth,  we  may 
refer  to  what  takes  place  in  voluntary 
and  involuntary  muscle,  in  simple 
hypertrophy.  In  voluntary  muscle, 
the  fasciculi  and  fibrilloe  increase  in 
breadth,  and  there  is  a  tendency  to 
fissi parous  division,  whereby  they 
become  more  numerous.  There  may  be  also  observed  fasciculi  varying 
greatly  in  size,  but  without  cells  such  as  are  visible  in  embryonic  mus- 
cular 'formation.  The  same  thing  occurs  in  hypertrophy  of  non-volun- 
tary muscle,  where,  in  addition  to  great  increase  of  bulk  in  individual 
cells,  other  smaller  ones  in  various  stages  of  development  may  also  be 
detected.  In  the  uterus  during  pregnancy  this  is  easily  observable,  but 
in  the  thickening  of  organic  muscular  fibre  of  the  stomach  and  other 
hollow  viscera,  the  large  elongated  fusiform  cells  are  not  discoverable. 


Fig.  140. 


Fijr.  141. 


II.  With  reo-ard  to  the  second  kind  of  increased  fibrous  growth,  it 
may  be  said  to  present  various  forms. 
We  have  previously  seen  that  the  coagulation  of  liquor  sanguinis  often 


Ficr  139.  Structures  in  hypertrophied  heart,  a,  A  muscular  fosciculus  dividing 
dicliotomouslv ;  &,  a  slender  fasciculus  dividing;  c,  anastomosing  fasciculi;  d,  con- 
centric ;  e,  smooth  colloid  (amyloid  ?)  bodies.— ( Wedl.)  250  diam. 

Fig.  140.  Fibrous  structure  of  the  uteru,s. 

Fio-.  141.  The  same,  hypertrophied  from  great  increase  in  size  of  its  fusiform  cells. 


152 


PRINCIPLES   OF   MEDICINE. 


occurs  in  the  form  of  filaments  (Fig.  101),  whicli  become  more  and  more 
dense.  These  are  molecular  fibres.  Occasionally  %vlien  the  exudation 
coagulates,  it  presents  a  tendency  to  fibrillate  or  split  up,  owing  appa- 


Fifr.  143. 


Yin.  144. 


Fiir.  145. 


rentlv  to  the  formation  of  nuclei,  which  become  more  or  less  elongated. 
These  are  miclear  fibres.  At  other  times  cells  are  formed,  which  elongate, 
become  fusiform,  split  up,  and  so  produce  fibres  in  the  manner  described 
by  Schwann  in  healthy  tissues.  These  are  cell  fibres.  In  these  three 
ways,  there  may  be  produced  all  kinds  and  forms  of  fibrous  element,  from 
the  finest  and  most  delicate  areolar  tissue,  to  one  resembling  in  consis- 
tence ligament  or  fibro-cartilage.  Hence,  as  far  as  structure  is  concerned 
we  may  have  fibro-molecular,  fibro-miclcated,  and  fibro-cellular  fibrous 
growths. 

1.  One  of  the  most  common  forms  of  patliological  fibrous  tissue  is 
that  of  arafn.r,  which  is  generally  produced  in  the  same  manner  in  every 
tissue  and  organ.  The  exudation  in  such  cases  is  partly  transformed 
into  filaments,  and  partly  into  pus.  The  former  are  in  connection  with 
the  deep-seated  tissues  and  capillaries,  and  are  covered  and  protected 
bv  the  latter.  On  examining  a  fungous  granulation  on  the  surface  of  a 
wound,  it  may  be  seen  to  contain  round,  oval,  caudate,  and  fusiform  cells, 
in  all  stao-es  of  their  development  towards  fibres.  As  these  increase  in 
amount  and  become  approximated,  the  formation  of  pus  gradually  ceases. 
At  length  the  new  growth  reaches  the  surface  of  the  healthy  tissue,  con- 
tracts, causing  more  or  less  puckering  of  the  surrounding  structures,  and 
becomes  dense  like  ligament.     (See  Fig.  114.) 

2.  Another  form  of  pathological  fibrous  growth  occurs  after  the  sub- 
cutaneous section  of  tendons,  and  in  the  coats  of  some  hollow  viscera. 
In  this  case  the  exudation  thrown  out  fibrillates,  oval  or  fusiform  nuclei 
are  formed,  which  are  scattered  irregularly  through  the  mass,  and  the 
whole  often  assumes  a  remarkable  degree  of  toughness.  We  have  seen 
the  coats  of  the  stomach  above  an  inch  thick  from  this  cause,  entirely 
independent  of  cancerous  formation.     (Fig.  146.) 

3.  A  third  form  of  pathological  fibrous  growth  is  the  result  of  chronic 
exudation  on  serous  membranes.     The  white  patches  so  frequently  seen, 


Fig.  142.  Cell  fibres  and  fibre-cells  from  a  fibro-cellular  growth  in  the  coats  of  the 
stomach. 

Fig.  143.  Fusiform  cells  fi"om  a  sarcomatous  growth  in  the  kidney.  (See  also 
Fig.  190.) 

Fig.  144.  Fibro-nucleated  structure,  from  a  so-caUed  medullary  sarcoma  of  the 
humerus. 

Fig.  145   Fibrous  stroma  of  a  tumour  acted  on  by  acetic  acid.  250  diam. 


FIBROUS  GROWTHS. 


153 


more  especially  on  tlac  pericardium,  pleura,  and  peritoneum,  are  owing 
to  this  cause.  (Fig.  147.)  Occasionally  such  membranes  are  connected 
by  bands  of  firm 
fibrous  tissue,  or 
closely  united  and 
hypertrophied  into 
a  dense,  white  liga- 
mentous substance, 
upwards  of  half  an 
inch  thick,  as  may 
frequently  be  seen 
in  the  pleurie  over 
chronic  tubercular 
lungs. 


Fig.  146. 


4.  A  fourth  form  of  pathological  fibrous  growth  is  seen  in  an  increase 
of  the  areolar  tissue  of  the  skin,  or  other  organs,  and  also  results  from 
exudation.  Thus  we  observe  peculiar  thickening  and  indurations  of  the 
skin,  owing  to  this  cause,  in  the  adult,  and  in  the  hide-bound  skin  of 
certain  foetuses.  Atrophy  of  parts  may  arise  as  a  consequence,  through 
pressure  thereby  produced ;  for  instance,  muscle  may  be  converted  into 
a  ligamentous  substance.  So  called  cirrhosis  of  the  liver,  lung,  and  kid- 
ney, are  owing  to  a  similar  cause. 

5.  A  fifth  form  of  pathological  fibrous  growth  is  that  of  tumour.  Under 
this  head  must  be  classed  a  number  of  growths,  hitherto  denominated 
sarcoma  and  neuroma,  as  well  as  those  usually  called  fibrous.  They  all 
consist  of  a  fibrous  structure,  in  difterent  stages  of  development,  the 
softer  and  more  vascular  forms  being  such,  even  when  their  si;bstance 
has  not  yet  completely  passed  into  perfect  fibres.  For  this  reason  thej" 
have  been  made  to  constitute  a  distinct  group  by  Lebert,  under  the  name 
of  fibvo-plastic  tumours,  and  may  be  fibro-nuclear  or  fibro-cellular  in 
structure.  Such  growths,  however,  may  always  be  seen  passing  into 
true  fibrous  tissue.  In  some,  Avhilst  one  part  of  a  tumour  is  sarcomatous, 
or  fleshy,  another  is  truly  fibrous;  but  the  diff'erence  is  only  one  of 
development,  and  cannot  therefore  constitute  a  good  ground  of  distinc- 
tion. Other  kinds  of  fibrous  tumours  resemble  tough  ligament  and 
fibro-cartilage,  and  present  a  variety  of  intermediate  conditions  of  form 
between  the  areolar  and  elastic  tissues.  Fibrous  tumours,  therefore, 
may  be  divided  into, — 1st,  sarcomatous  ;  2d,  dermoid  ;  and  3d,  neuroma- 
tous fibrous  tumours. 

Sarcomatous  or  soft  fibrous  Tumours. — These  tumours  are  either 
spherical,  or  more  or  less  lobulated  (pancreatic  sarcoma  of  Abernethy). 
The  first  are  of  the  consistence  of  muscular  tissue,  or  very  soft  cartilage, 
and  are  generally  surrounded  by  a  distinct  cyst.  On  section,  they  pre- 
sent a  smooth  or  finely  granular  surface.  Their  colour  varies  from  a 
yellowish-white  to  a  rose-pink  or  deep  red,  and  is  dependent  on  their 
degree  of  vascularity.  Occasionally  a  section  presents  different  colours, 
the  external  portion  being  more  vascular  than  the  internal ;  or  it  is  more 

Fig.  146.  Fibres  from  induration  of  the  stomach,  with  embedded  nuclei. 
Fig.  14T.  Fibrous  tissue,  with  free  nuclei  and  fusiform  cells,  from  a  white  patch 
on  the  peritoneum. 

Fig.  148.  The  same,  after  the  addition  of  acetic  acid.  250  diam. 


154 


PRINCIPLES   OF   MEDICINE. 


or  less  mottled,  the  red  tint  alternating  witli  the  yellow.  At  other  times 
the  section  presents  several  ecchymotic  spots,  varying  in  size,  caused  by 
extravasation  of  blood  from  the  capillaries.  Owing  to  the  vascularity  of 
these  tumours,  there  is  a  disposition  in  them  to  exudation,  and  to  a 
breaking  down  of  their  substance,  with  formation  of  a  purulent  fluid. 

For  the  most  part,  they  increase  in  size  slowly,  and  only  cause  incon- 
venience from  their  bulk,  or  by  pressure  on  neighboui'ing  nerves  and 
tissues.  Owing  to  this  pressure,  they  may  induce  absorption  or  ulcera- 
tion of  the  parts  around  them. 

Not  unfrequently  these  tumours  are  more  soft  and  lobulated,  and  have 
in  consequence  been  frequently  mistaken  for  encephaloma.  The  lobules 
vary  greatly  in  size,  and  present  externally  a  papillary,  or  cauliflower 
form,  sometimes  resembling  the  pancreas,  and  hence  the  name  given  to 
them  by  Abernethy.  Occasionally  the  lobules  are  surrounded  by  a 
more  or  less  dense  layer  of  areolar  tissue.  They  are,  for  the  most  part, 
of  a  greyish,  yellowish,  or  rosy  colour,  their  tint  varying  with  their 
amount  of  vascularity. 

These  tumours  are  found  in  many  places,  as  below  the  skin,  richly 
supplied  with  cellular  and  fibrous  tissue.  They  are  not  unfrequently 
observed  in  the  mamma,  where  their  separation  from  scirrhus  consti- 
tutes one  of  the  nicest  points  of  surgical  diagnosis.  They  may  occur  in 
bone,  and  have  received  the  name  of  osteosarcoma,  although  many 
tumours  that  have  received  this  name  have  been  shown  to  be  cancer- 
ous. They  constitute  small  mushroom-like  growths  on  the  conjunctiva 
(Lehert),  and  may  destroy  the  eye  from  the  pressure  caused  by  their 
enlargement. 

The  minute  structure  of  these  sarcomatous  tumours  is  essentially 


S-f«l]§^  fi 


Tin.  140. 


Fi£j.  150. 


Fitr.  152. 


fibrous,  but  many  of  the  fibres  are  seen  to  be  made  up  of  congeries  of 
fusiform  cells  closely  applied  together  (Figs.  151,  190).  These  cells 
are  of  a  spindle  shape,  varying  in  length  and  breadth,  and  are  for  the 
most  part  distinctly  nucleated.  Many  of  them  may  be  seen  branched 
at  their  extremities,  and  passing  into  fibres,  according  to  the  mode  of 


Fig.  149.  Cells  iu  the  soft  part  of  a  fibrous  tumour  removed  from  the  neck  by  Mr. 
Syme. 

Fig.  150.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  151.  Fibres  in  various  stages  of  development  from  a  harder  nodule  of  the 
same  tumour. 

Fig.  152,  Perfect  fibrous  tissue  from  another  nodule  of  considerable  density.    250  di. 


FIBEOUS  GROWTHS. 


155 


development   of  fibrous   tissue   described  by  ScbAvann.     In  some,  tbe 
nucleus  has  disappeared.     Other  of  the  cells  are  round  or  oval,  or  only 


Fig.  158. 


rvs.,-^ 


^MffSSSfM  ^d/i^io/^^, 


m 


m 


m^ 


Fig.  155.  Fig.  156. 

slightly  elongated.  All  these  stages  of  a  fibro-cellular  growth  may  be 
observed  in  the  same  tumour.  In  the  softer  parts,  isolated  cells  and 
nuclei  abound  (Fig.  149),  whereas,  in  the  harder  and  denser  parts,  the 
development  into  fibrous  tissue  is  perfect  (Figs.  151,  152). 

At  other  times  associated  with  the  fibres  we  find  a  multitude  of  oval 
nuclei,  without  cells  of  any  kind.  These 
1  described  in  1849  as  fibro-nucleated 
growths.  They  may  be  hard  or  soft,  and 
presentthe  structure  represented  Figs.  153 
to  156,  and  Fig.  144. 

Some  tumours  of  this  kind  are  so  soft, 
as  to  be  pulpy  in  their  consistence,  and 
contain  between  the  meshes  of  their  fibro- 
cellular  structure  a  certain  amount  of  se- 
rous liquid.  These  are  soft  pohj'pi.  For 
the  most  part,  they  constitute  promi- 
nences on  the  mucous  membrane,  to  which 
they  are  attached  by  a  neck,  which  may 
be  broad  or  narrow  (Fig.  157).  Exter- 
nally they  are  covered  Avith  mucous  membrane,  more  or  less  hypertro- 
phied  and  thickened  (Fig.  160). 

Dermoid  or  hard  fibrous  tumours.  These  tumours  are  generally  of  a 
white  colour,  more  or  less  tough  and  elastic,  resembling  the  well-known 
structure  of  the  dermis.  This,  indeed,  is  not  so  apparent  in  examining 
the  comparatively  thin  human  dermis ;  but  on  looking  at  that  of  some 
of  the  laro-er  animals,  and  more  especially  of  the  whale,  the  analogy  in 


Fie.  157. 


Fig.  153.  Corpuscles  scraped  fi'om  tbe  surface  of  a  fibro-nucleated  growth  of  the 
thigh,  excised  by  Mr.  Miller. 

Fig.  154.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  155.  Appearance  of  a  thin  section  of  the  tumour. 

Fig.  156.  Another  section  treated  ^vith  acetic  acid.  250  diam. 

Fig.  157.  Soft  polypi  growing  from  the  Schneiderian  mucous  membrane. — {LisUm) 
— Half  natural  size. 


156 


PRINCIPLES   OF   MEDICINE. 


structure  at  once  becomes  evident.     These  tumours  are  of  a  rounded  or 


Fis.  159. 


Fig.  160. 


Fiif.  161. 


jiiji' V/f  ^^^Ai^^v^ 


>K^" 


^N 


Fi-    16-.' 


oval  form,  frequently  embedded  in  a  cyst,  composed  of  the  indurated 

-    structures  in  whicli  they  lie.     They  are 
^^  of    considerable    density,    varying    from 

-'-'^  -~^  that  of  tendon  to  that  of  ligament  or 

'V;i^    fibro-cartilage,    and    on    section    present 
"*^    numerous  white   glistening   fibres,    inti- 
mately interwoven  together,  or  arranged 
.-■^^\    in  bundles  constituting  circles,  or  loops 
intercrossing   Avith   each  other.       Occa- 
sionally they  have  a  calcareous  centre  or 
nucleus.       Their     colour     is    generally 
white,  but  sometimes  they  have  a  vellow- 
ish  tinge.     They  are  for  the  most  part 
not    very    vascular,    although    there    is 
great  difference  in  this  respect,  some  approaching  the  pinkish  colour  of 

sarcomatous  growths,  and  others 
being  of  dead  white  and  of  extreme 
density,  containing  scarcely  any  ves- 
sels. They  vary  greatly  in  size, 
from  that  of  a  pin's  head  to  a  volume 
measuring  several  feet  in  circum- 
ference. 

These  tumours  may  be  situated 
in  various  tissues  and  organs,  as  in 
the  subcutaneous  and  submucous 
cellular  tissue,  in  the  mamma,  and 
uterus,  in  which  last-named  organ 
Fig-  163.  they  are  most  common.     When  de- 

veloped in    the  uterus,  they  often  push  the  mucous  membrane   before 


Fig.  1.58.  Fibre  cells  and  fibres  from  the  pulpy  interior  of  a  poljpus  removed  by 
Mr.  Syme. 

Fig.  159.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  160.  Ciliated  epithelial  and  pus  cells  from  the  exterior  of  the  tumour. 

Fig.  161.  The  same,  after  the  addition  of  the  acetic  acid. 

Fig.  162.  Section  of  a  dermoid  fibrous  tumour,  embedded  in  the  uterine  waUs. 
One-fourth  of  the  entire  growth  is  represented.     Natural  size. 

Fig.  163.  Section  of  a  dermoid  fibrous  tissue  from  the  uterus,  afler  the  addition  of 
acetic  acid,  showing  the  concentric  direction  of  the  fibres.  250  diam. 


FIBROUS   GEOWTHS.  157 

them.  In  this  way  they  grow  outwards,  forming  what  are  called  hard 
Ijoliipi.  At  other  times  they  grow  towards  the  serous  or  internal  cavitv, 
pushing  the  membrane  before  them  in  a  similar  manner,  so  that  it  ulti- 
mately constitutes  a  neck  or  pedicle,  by  which  they  are  attached  to  the 
uterus.  Such  pedunculated  fibrous  tumoui-s  are  sometimes  found  in  the 
peritoneum,  growing  from  the  uterus.  Occasionally  the  pedicle  breaks 
across,  and  the  tumour  becomes  free  in  the  serous  cavitv.  To  the  same 
cause  are  owing  the  small  fibrous,  oval  or  round  bodies,  called  loose 
cartilages,  found  in  the  joints,  more  especially  that  of  the  knee,  some  of 
which  are  truly  osteo-cartilaginous.  Others  are  found  in  the  veins,  and 
denominated  phhbolites. 

The  minute  structure  of  these  dermoid  tumours  is  found  to  consist  of 
fusiform  cells  more  or  less  aggregated  together.  In  the  softer  portions 
of  the  gi-owth  they  can  easily  be  separated  by  needles,  but  in  the  indu- 
rated   portions   they   are    so  ^^ 

dense  that  this  is  impossible.  / '.i^^'<:i''ii  ^J U i  /  /  a  Uiir'* '/r.^/'y<^>  4 
Sometimes  the  filamLs  are  |^^^Ml^^^^%f^^^C 
more  or  less  waved,  as  in  or-  \''S'^^-^^'^Ai.'-*i  -''f'-^'^^'j/'^^^ih^ 

dinary  nbrous  tissue ;  at  others,    '^"jT- 
they  are   curled  and  brittle,  ^-^V, 

as  in  elastic  tissue.     On  raak-    ^/'r,  _  -v-W 

ing  a  thin  section,  they  may    >^/,      .  •  i  .  ;^£%0 

often  be  seen  to  form  a  con-  ..^^il^l^'-f    -  "£r;>  ^  /  ' ''^ '^^.P 

centric  fibrous  structure,  and  ^^^f '^'^  .  J?^//jy^c^4i 

on  the  addition  of  acetic  acid,  0f^'''  ^  ^^  V^  '^'^^  -p^^f  ^ 

the  nuclei,  scattered  through-  ^/  ,  \\^^^''       ^ 

out  the  tissue,  are  made  very  ''  ',  .„.    iv 

apparent    (Fig.    163).      Xo't  Fig.  164 

unfrequently  these  latter  are  collected  together  in  masses  (Fiij.  164).  and 
sometimes  they  are  isolated,  as  in  the 
sarcomatous  tumours ;  but  then  the 
proportion  of  them  to  the  fibrous 
element  is  generally  small.  The  bony 
nuclei  of  such  tumours  are  composed 
of  amorphous  mineral  matter,  not  of 
tnie  bone  (see  Fig.  345),  although 
Lebert  says  that  on  two  occasions  he 
has  seen  true  bone  produced.  ^Vedl 
also  has  figured  true  bone  in  the  inte- 
rior of  these  growths.     (See  Fig.  270.) 

The  two  forms  of  fibrous  growth 
now  spoken  of  may  frequently  be 
found    associated    together     in    one  f:^-.  ic\ 

tumour.  Some  are  composed  of  several  rounded  or  oval  masses 
varying  in  size,  enclosed  and  separated  from  each  other  by  a  cvst, 
or  layer  of  areolar  tissue.      The  external  surface,  under  such  circum- 

Fig.  164.  Section  of  hard  uterine  polvpus,  which  had  been  boiled  in  dilute  acetic 
acid  and  dried ;  a,  groups  of  nuclei,  surrounded  bv  bundles  of  fusitbrm  fibres — ( Wedl). 
250  diam. 

Fig.  165.  Section  of  Neuroma  connected  with  three  nervous  tnmks. — Xatural 
size.— {Smith.) 


153 


PKINCIPLES   OF   MEDICINE. 


stances,  is  more  or  less  nodulated.  It  may  frequently  be  observed 
that  some  of  these  nodules  are  soft  and  pulpy — semi-gelatinous,  with 
a  very  sparing  laver  of  fibrous  tissue  ;  whilst  others  may  be  seen  more 
or  less  touo-h,  gradually  passing  into  a  fibro-caitilaginous  density,  grating 
under  the  knife.  Xay,  even  in  the  same  nodule  I  have  frequently  ob- 
served some  parts  of  it  soft  and  others  hard,  and  have  shown  that  the 
softer  parts  are  mostly  cellular,  and  the  harder  fibrous,  and  that  between 
the  two  there  are  many  degrees  of  variation. 

Neuromatous  Fibrous  Tumours. — This  form  of  fibrous  tumour  is 
developed  in  the  nerves,  sometimes  spontaneously,  at  others  as  the  result 
of  injuries,  and  especially  of  amputation.  In  the  museum  of  the  Rich- 
mond Hospital,  Dublin,  I  examined  a  most  remarkable  series  of  prepara- 
tions, taken  from  two  individuals,  in  whom  almost  every  nerve  of  the 
bodv  presented  knotty  swellings.  In  some  places  these  were  developed 
into  tumours,  which  varied  in  size  from  a  pea  to  that  of  the  human 
head.*  A  subcutaneous  tumour,  described  by  the  late  Mr.  W.  "Wood  of 
Edinburgh,  must  be  referred  to  this  class  of  tumours.+ 

All  these  neuromata,  on  being  minutely  examined,  are  found  to  con- 
sist of  fibrous  texture,  more  or  less  dense,  the  filaments  often  arranged 
in  wavv  bundles  running  parallel  to  each  other,  but  occasionally  assum- 
ino-  a  looped  form,  or  intercrossing  with  each  other,  as  in  Fig.  162.  I 
have  also  found  them  to  contain  groups  of  cells,  so  that,  on  the  addition 
of  acetic  acid,  they  closely  resemble  the  structure  represented  in  Fig.  164. 


Fig.  166.  Fig.  167. 

Not  unfrequently  they  are  fibro-cartilaginous,  sometimes  with  the  cells 
closelv  ao:frregated  together,  at  others  widely  scattered  (Fig.  166).  In 
some  "of  ■the  neuromatous  swellings  described  by  Dr.  Smith  of  Dublin,* 
I  found  the  fibrous  tissue  to  present  wavy  bundles,  among  which  a  few 

*  See  Smith's  Treatise  on  Xeuroma. — Dublin,  1849. 
f  Edin.  iled.  and  Surg.  Journal,  1812. 


Fiff.  166.  Thin  section  of  a  subcutaneous  tubercle,  composed  of  fibro-cartilage. 
Fig.  167.  Fibrous  structure  of  a  neuromatous  swelling,  given  to  me  by  Dr.  Smith, 
&om  one  of  the  cases  he  has  described.  250  diam. 


FATTY   GROWTHS, 


159 


grannie  and   cartilage  cells  were  scattered  and   shrivelled,   apparently 
from  the  action  of  spirit  (Fig.  167). 

Fatty  Growths. — Lipoma. 

The  morbid  increase  of  fat  is  frequently  so  imperceptible,  that  it  is 
impossible  to  separate  the  pathological  from  the  phvsioloo-ical  state. 
Obesity  may  gradually  increase,  either  locally  or  generally,  internally  or 
externally,  so  as  to  cause,  not  only  inconvenience,  but  actual  disease. 
Some  individuals  have  become  celebrated  from  their  excessive  fatness, 
(See  Polysarcia.) 

Fat  sometimes  occurs  in  masses,  being  only  an  exaggeration  of  the 
normal  texture  of  the  part,  as  when  it  collects  about  the  heart,  in  the 
omentum,  or  on  the  serous  membranes,  in  which  case  it  takes  the  exact 
form  of  the  included  viscera.  Fat  may  also  be  aggregated  in  masses  in 
unusual  situations,  and  then  form  the  so-called  fatty  tumour. 


Fis.  163. 


Fatty  tumours  vary  in  size ;  they  may  reach  a  growth  weighing 
upAvards  of  30  lbs.  Sometimes  their  surface  is  lobulated,  at  others 
smooth.     They  are  of  a  yellow  colour,  resembling  adipose  tissue,  and 

Fig.  168.  Lobulated  Lipoma  of  the  nose.  —(Bickersitth.) 


160 


PRINCIPLES   OF  MEDICINE. 


are  occasionallv  divided  into  bands  by  -white  fibrous  tissue.  The  rela- 
tive amount  ol'  these  two  elements  varies  greatly  in  different  specimens, 
some  being  soft,  oily,  containing  few  fibres,  others  being  hard  and  dense, 
the  areolar  tissue  preponderating.  For  the  most  part  they  are  very 
sparingly  supplied  with  blood-vessels ;  the  vessels  abound  most  in  the 
fibrous  varieties.  In  the  latter  case  they  are  liable  to  ulcerate,  and, 
under  such  circumstances,  have  frequently  been  mistaken  for  cancer. 
Some  of  these  growths,  indeed,  may  be  con- 
sidered as  fibrous  or  sarcomatous  tumours, 
combined  with  an  unusual  quantity  of  fat. 
Occasionally  they  are  connected  with  the 
ordinary  adipose  tissue  of  the  body.  We  see 
this  in  fatty  tumours  so  common  in  the  sub- 
cutaneous tissue.  They  are  often  surrounded 
by  a  delicate  cyst  or  envelope  ;  but  in  others 
this  is  not  perceptible.  It  is  when  the  collec- 
tion of  fat  resembles  the  ordinary  adipose  tis- 
sue, that  the  tumour  has  received  the  name 
o^ Lipoma.  "When  it  is  more  lardaceous,  some 
have  applied  to  it  the  term  Steaioma,  in  the 
■ '•  same  manner  as  when  the  substance  is  en- 

cysted. ~\\'hen  firm,  and  largely  mingled  with  fibres,  it  may  be  called 
Fibro-Lipomatous^  as  in  the  lobulated  tumours  that  constitute  so  fright- 
ful a  deformity  of  the  nose  (Fig.  168) . 

The    minute    structure    of   these   tumours    varies   according   to    the 
amount  of  adipose  or  fibrous  tissue  in  their  composition.     The  adipose 


Fis.  170. 


Fiir.  171. 


matter  is  composed  of  vesicles  of  a  round  or  oval  form,  more  or  less  liable 
to  undergo  alterations  in  shape  from  pressure  (Fig.  170).     They  vary 

Fig.  169.  Smooth  Lipoma,  removed  from  under  the  tongue,  one-half  the  natural 
size. — [Liston.) 

Fig.  170.  Two  layers  of  voluminous  fat  cells,  varying  in  size,  from  a  i/powia.  200  rfj. 

Fig.  171.  Fat  ceils  from  the  same  Lipoma,  dried,  showing  crystalline  bundles  of 
Margaric  acid.  250  diam. 


CYSTIC   GEOWTHS. 


161 


from  the  y oVot^^  to  jj^tli  of  an  incli  in  diameter ;  are  composed  of  a 
diaphanous  cell-wall,  which  frequently  includes  a  nucleus.  The  nucleus 
is  crenerally  round  or  oval,  about  the  2 oVoth  or  y gVo^'h  of  an  inch  in 
diameter.  '  Occasionally  it  is  stellate  or  penniform,  of  a  crystalline 
appearance,  from  the  formation  of  crystals  of  margarine  or  margaric  acid 
around  it  (Figs.  171,  172  a).  On  rupture  of  the  cell- wall  the  oil  may 
be  made  to"  flow  out,  and  the  cell-wall 
puckers  or  shrinks  up.  Such  collapsed 
cells  may  frequently  be  seen  among  the 
more  perfect  formations,  mixed  with  glo- 
bules of  oil  and  fat  granules.  The  fibrous 
tissue  presents  the  usual  appearance  of 
areolar  texture  running  between  groups  of 
the  adipose  cells,  being  denser,  and  occu- 
pying greater  space,  according  to  the  pro- 
portion in  which  it  enters  the  tumour. 
Steatomatous  and  melicerous  fatty  matter 
may  consist  of  the  cells  just  described, 
minified  in  various  proportions  with  granu- 
lar matter.  In  some  melicerous  encysted  growths,  we  have  found  the 
whole  to  be  composed  of  granular  matter,  in  which  faint  traces  of  deli- 
cate cell-walls  were  seen  more  or  less  compressed  together.  In  all  such 
productions  the  relative  amount  of  the  vesicular  and  granular  elements 
varies  greatly. 

An  excess  of  fat  may  cause  the  entire  disappearance  of  the  usual 
structure  of  a  part,  and  its  conversion  into  adipose  tissue.  The  muscular 
system  is  very  liable  to  this  fatty  transformation  or  degeneration,  which 
often  occurs  in  the  heart,  and  in  muscles  which  have  not  been  much 
exercised,  owing  to  local  disease  or  paralysis.  In  this  case  adipose  tissue 
o-enerallv  springs  up  in  the  cellular  substance  surrounding  the  muscular 
lisciculi,"  and  by  its  increase  and  pressure  upon  them,  causes  the  trans- 
verse striffi  to  disappear,  and  the  whole  to  assume  a  granular  appearance 
— (See  Fatty  Degeneration,  Fig.  304). 


Fis.  1T2. 


Ci/stic  Groicths. —  Cystoma. 

The  different  crypts  and  follicles  of  the  skin  and  mucous  membrane, 
as  well  as  several  of  the  excretory  ducts  of  internal  organs,  may  become 
obstructed,  and  as  a  consequence  enlarged  and  hypertrophied.  It  is 
true  such  growths  usually  consist  of  one  or  more  elementary  tissues,  and 
do  not  therefore  properly  constitute  a  class  of  themselves.  Their  impor- 
tance in  a  practical  point  of  view,  however,  as  well  perhaps  as  the  diffi- 
cultv  of  knowing  under  what  head  to  describe  such  compound  growths, 
warrants  our  speaking  of  them  separately. 

Encysted  growths  are  composed  of  a  cyst  or  envelope,  enclosing 
various  kinds  of  contents.  They  differ  greatly  in  size,  situation,  and 
structure,  which  renders  their  arrangement  somewhat  difficult.    By  some 


Fig.  172.  Structure' of  a  Fibro-Lipornaious  tumour;  a,  isolated  cells,  showing  stel- 
late crvstals  of  Margaric  acid.  2-40  diam. 

11 


162 


PRINCIPLES   OF   MEDICINE. 


they  have  been  divided  into  simple  and  com])ound,  according  as  the 
tumonr  is  formed  of  one  cyst,  or  is  composed  of  several.  By  others  they 
have  been  arranged,  according  to  the  nature  of  their  contents,  into 
hygromatous,  atheromatous,  melicefoiis,  and  steatomatous  growths.  The 
latter  mode  of  division  is  very  faulty,  as  many  of  these  varieties  are  only 
altered  forms  of  one  substance — ftit;  whilst  some  compound  encysted 
tumours  contain  various  kinds  of  contents  in  separate  cysts.  But  as 
there  can  be  no  doubt  that  the  peculiar  contents  give  to  these  growths 
a  distinctive  character,  we  shall  first  speak  of  them  as  simple  or  com- 
pound, and  then  describe  their  different  kinds  of  contents. 

Simple  cystic  grotvths. — These  growths  are  formed  of  a  cyst  generally 
composed  of  fibrous  tissue,  lined  by  a  smooth  membrane.  Sometimes 
the  membrane  is  structureless,  or  only  composed  of  areolar  tissue.     At 

other  times  it  is  covered 
with  a  distinct  layer  of 
epithelial  cells,  the  nuclei 
of  which  are  very  apparent 
on  the  addition  of  acetic 
acid.  The  former  kind  con- 
stitute the  vesicles  so  fre- 
quently found  in  the  plexus 
ch oroides,  in  the  kidneys, 
ovaries,  etc.,  and  vary  in 
size  from  a  pin's  head  to 
that  of  a  hazel  nut,  or  even 
walnut,  and  usually  have 
aqueous  contents.  The  lat- 
ter kind  constitute  the  cys- 
tic o-rowths  which  arise  in  the  follicles  of  the  skin,  in  the  mamma, 
ovaries,  testicles,  etc. ;  these  frequently  reach  the  size  of  an  orang-e,  and 
are  sometimes  much  larger,  and  vary  greatly  as  to  the  nature  of  their 
contents.  For  the  most  part  they  are  only  sparingly  supplied  with 
blood-vessels,  and  seldom  cause  inconvenience  except  from  the  deformity 
they  occasion  when  situated  externally. 

Compound  cystic  groivths  are  of  two  kinds.  _  1st,  The  external  sac 
may  contain  on  its  internal  surface  second- 
ary or  even  tertiary  cysts,  which  may  be 
sessile  or  pedunculated — or  the  growth 
may  be  divided  into  numerous  compart- 
ments by  divisions  of  the  fibrous  sac. 
These  are  the  true  multilocular  encysted 
Fig.  1T4.  Fig.  175.        tumours.     The  external  cyst  in  every  case 

is  formed  of  fibrous  tissue.  The  intenvil  surface  is  smooth,  sometimes 
with,  at  others  without  an  epithelial  layer.     The  primary,  as  well  as  the 


Fig.  173.  Simple  cyst  of  the  broad  ligament  of  the  uterus,  with  very  vascular 
walls,     a,   New  vessels;  &,   broad  ligament. — {Wedl.)  30  diam. 

Fig.  174.  Diagram  of  compound  cj'stic  growth,  containing  secondary  and  tertiary 
cysts,  developing  themselves  endogenously. 

Fig.  175.  Diagram  of  compound  cystic  growth,  in  which  the  included  cysts  are 
formed  by  irregular  divisions  of  the  fibrous  sac. 


CYSTIC   GROWTHS. 


163 


secondary  cysts,  are  for  the  most  part  richly  supplied  with  blood-vessels, 
and  hence  they  are  peculiarly  prone  to  - 

contain    exudation   which    may    undergo  ^ 

various  kinds  of  development.     They  may 
also  ulcerate.     In  the  ovary  these  growths 

.  a 

frequently  attain  an  enormous  size,  mea- 
suring several  feet  in  circumference  ;  the  \ 
cystic  internal  membranes  often  secreting 
more  or  less  rapidly  even  gallons  of  tluid. 
2d,  Numerous  cysts  may  be  pedunculated 
from  one  stock,  and  more  or  less  crowded  "  „^^ 
together,  with   a  tendency  to  grow  out-  ^"''  W 

wards  instead  of  inwards  ;  as  happens  in  "      ■  ^..b,,^'' 

the    case    of    so-called   uterine   hydatids,  Fig.  1T6. 

which  is  a  cystic  disease  of  the  chorion,  as  described  by  Mittenheimer. 


Fijr.  ITT. 


The  contents  of  cystic  growths  are  very  various,  and  give,  as  we  have 
previously  stated,  a  peculiar  character  to  them. 

1,  The  contents  may  be  a  perfectly  colourless  fluid,  resembling  water, 

*  Mailer's  Archiv.  fiir  Anatomie,  etc.,  1850,  p.  41 T. 


Fig.  176.  Compound  cystic  sarcoma  of  the  mamma.  The  cysts  are  more  nume- 
rous at  a  than  at  h. — {Miller.)  One-fourth  the  natural  size. 

Fig.  177.  Structure  of  a  cystic  chorion  belonging  to  an  ovum,^  at  the  eighth  or 
tenth  week. — (  Wedl.)  a,  An  enlarged  villus,  covered  with  epithelium,  having  a 
globular  and  a  retort-shaped  prolongation  at  its  extremity;  h  and  d,  outlines  of 
other  enlarged  villi,  containing  hyaline  spaces  c  and  e ;  /,  nuclei  and  cells  in  the 
interstitial  substance  ;  g  and  ft,  roots  of  villi  undergoing  fatty  degeneration. 

250  diam. 


164 


PRIXCIPLES  OF   MEDICINE. 


or  the  limpid  serum  so  frequently  secreted  in  the  lateral  ventricles  of  the 
brain.  It  is  structureless,  and  chemically  contains  a  minute  proportion 
of  salts,  and  a  small  amount  of  albumen,  -vshich  coagulates  on  boiling. 
Such  are  frequently  the  contents  of  so  called  serous  cysts,  or  false 
hydatids  of  the  plexus  choroides,  kidneys,  ovaries,  etc.  A  Hydrocele, 
and  other  dropsies  of  shut  serous  sacs,  may  be  looked  on  pathologically, 
as  constituting  a  form  of  hygromatous  encysted  growth. 

2.  The  contained  fluid  may  have  an  amber  or  golden  yellow  colour, 
and  resemble  the  serum  formed  after  the  coagulation  of  the  blood.  It 
is  still  structureless,  but  contains  a  large  amount  of  albumen,  as  is  proved 
by  the  action  of  heat  and  nitric  acid, 

3.  The  contents  are  more  or  less  gelatinous,  sometimes  slightly  so, 
like  weak  gelatine,  at  others  they  are  firm,  and  capable  of  being  cut  with 

a  knife  like  tolerably  strong 
glue  or  firm  calves-foot  jelly. 
The  colour  of  the  gelatinous 
matter  may  vary  fi'om  a 
slight  yellowish  tinge,  to  a 
deep  amber,  or  brownish-yel- 
low colour.  Sometimes  this 
matter  is  structureless,  at 
others  it  may  be  seen  to  con- 
tain very  delicate  filaments, 
combined  with  pale  oval 
bodies,  the  outlines  of  which 
become  stronger  on  the  addi- 
tion of  acetic  acid  (Fig.  179).  Tliis  re-agent  frequently  causes  the  gelati- 
nous mass  to  coagulate  into  a  fimi  white  fibrous  structure,  capable  of  being 

separated  by  neeclles,  and  pre- 
senting the  appearance  of  fila- 
mentous tissue.  This  kind  of 
contents  is  common  in  the  cysts 
of  the  thyroid  gland  and  ovary, 
and  I  have  seen  it  in  the  kidney 
and  other  organs.  On  one  occa- 
sion the  gelatinous  matter  in 
the  kidney  contained  numerous 
granules ;  and  more  than  once  I 
have  found  in  the  centre  of  the 
clear  amber  masses  a  creamy 
white  substance,  either  wholly  granular  (Fig.  298),  or  in  the  process  of 
formation  into  pus  corpuscles. 

4.  The  cyst  may  be  distended  with  epithelial  cells,  which  have  evi- 
dently been  thrown  ofi"  from  its  internal  surface,  and  been  compressed 


Fig.  173. 


Tig.  179. 


Fie.  ISO. 


Fig.  178.  Colloid  cystic  growths  in  three  lobules  of  the  thyroid  gland.- — ( Wedl.)  15  di. 

Fig.  179.  Delicate  oval  corpuscles  in  amber-coloured,  transparent  colloid  matter 
01  the  ovary. 

Fig.  180.  Eound  and  oval  corpuscles  with  filaments  in  light  yellow,  semi-transparent 
gelatinous  coUoid  matter  in  the  ovary.  250  diam. 


CYSTIC   GROWTHS. 


165 


too-ctlicr,  and  partially  broken  down.  Hence  on  examination,  clusters  of 
such  scales  may  be  found  mixed 
with  numerous  debris,  and  fat 
Sjranules  and  globules,  sometimes 
with  crystals  of  cholesterine. 
(Fiij.  185.)  The  contents  of  the 
cysts  are  usually  of  a  white  or 
slightly  yellow  colour,  some- 
times fluid,  at  others  semi-solid. 
The  molluscum  contagiosum  of 
dermatologists  is  thus  constitut-  ^'S-  l^i. 

ed.  A  small  pedunculated  simple  cyst,  dependent  from  the  peritoneal 
surface  of  the  ovary,  was  found  by  Wedl  to  contain  the  structures  repre- 
sented Fior.  184,. 


Fig.  1S2. 


Fig.  184. 

5.  The  contents  may  consist  principally  of  fat,  either  amorphous, 
crystallized,  or  organized,  that  is  cellular.  If  amorphous,  they  resemble 
honey,  constituting  the  melicerous  growths  of  morbid  anatomists.  In 
many  cases,  however,  where  the  yellow  colour  is  uniform,  and  the  con- 
tents, closely  resembling  honey  to  the  naked  eye,  break  down  under  the 
finger,  faint  cell-walls,  more  or  less  compressed  together,  may  be  observed 
by  the  microscope  in  them.  At  other  times  the  fatty  contents  are  of  a 
whitish  colour,  forming  masses  of  a  pearly  aspect  and  smooth  surface, 
and  are  mingled  with  a  roughened  yellowish,  and  more  granular  fatty 
matter.  This  is  the  cholesteatoma  of  Miiller.  This  white  matter  con- 
sists of  numerous  crystals  of  cholesterine  placed  in  a  close  juxta-position, 
— the  granular  fatty  matter  of  oil  globules  and  granules  mixed  with 
broken  up  crystals,   epithelial  scales,  and   sometimes  the  products    of 


Fig.  181.  Oval  epithelial  cells  from  the  lining  membrane  of  an  ovarian  cyst. 

Fig.  182.  Polygonal  epithelial  cells  from  the  same  lining  membrane. 

Fig.  183.  Section  of  the  wall  of  the  same  cyst,  showing  the  epithelial  cells  in  situ. 

Fig.  184.  Cells  from  the  interior  of  a  simple  cyst,  a,  b,  c,  Cells  developing  endo- 
genously,  independent  of  the  nucleus,  which  is  embedded  in  the  wall  of  the  parent 
cell :  d,  e,  the  same,  undergoing  the  fatty  degeneration ;  /,  g,  cylindrical  epithelium, 
seen  sideways  and  from  above ;  h,  polygonal  epithelium  cells ;  i,  fibre  cells. — (  Wedl.) 

250  diam. 


166 


PRIXCIPLES   OF  MEDICINE. 


fibrinous  exudation  (Fig.  185,  187).     Such  is  the  general  structure  of  the 
atheromatous  encvsted  frrowths  of  various  authors. 


Fig.  185.  Fig.  1S6. 

Again,  the  fatty  matter  may  be  more  or  less  lardaceous  in  character, 
and  consists  of  beautiful  round  or  oval  cells,  some  of  which  are  distinctly 


"r, 


Fiff.  1S7. 


l^ 


Fifr.  ISS. 


nucleated.     Mixed  with  these  may  be  a  granular  matter,  combined  with 


Fig.  185.  Structure  of  cholesteatoma,  consisting  of  disintegrated  fat  vesicles  and 
epithelial  scales,  with  numerous  crystals  of  cholesteruie. — [Beak.)  215  diam. 

Fig.  186.  Encysted  tumour,  with  fatty  steatomatous  contents.  Natural  size. — 
(Listen.) 

Fig.  187.  Contents  of  a  large  atheromatous  cyst,  opened  by  Mr.  Syme,  consisting 
of  numerous  crystals  of  cholesterine,  oily  granules,  granule  and  pus  cells,  with  en- 
closed cysts  containing  oil  granules. — {ATurchison.)  200  diam. 

Fig.  188.  Adipose  cells,  embedded  in  fatty  granular  matter,  from  a  steatomatous 
encysted  tumour  of  the  ovary.  250  diam. 


CYSTIC   GROWTHS.  167 

epithelial  cells  or  their  debris  (Fig.  188).  At  other  times  no  distinct 
cells  can  be  observed,  only  a  granular  or  amorphous  mass,  the  greater 
part  of  which  is  soluble  in  ether.  This  constitutes  the  steatomatous 
encysted  growth  (Fig.  186). 

6.  Many  encysted  growths  contain  hair  and  teeth.  The  hair  is  occa- 
sionally inserted  into  the  walls  of  the  cyst,  at  other  times  lies  loose  in  it, 
mixed  with  the  fatty  or  other  contents.  The  hair  has  exactly  the  same 
structure  as  the  hairs  in  other  parts  of  the  body,  having  distinct  bulbous 
roots.  When  attached  they  are  surrounded  by  a  follicle  in  the  lining 
membrane  ;  when  loose  they  have  been  evidently  grown  in  follicles,  and 
been  afterwards  separated.  Their  apices  are  frequently  split  up  into  several 
fibres  in  the  longitudinal  direction.  The  teeth  belong  sometimes  to  the 
first,  and  sometimes  to  the  second  dentition.  They  present  on  section 
the  usual  structure  of  cavity,  with  ivory,  enamel,  and  bone.  Sometimes 
they  are  found  embedded  in  a  follicle  of  the  lining  membrane,  at  others, 
like  the  hairs,  they  are  quite  unattached. 

7.  Occasionally  the  cysts  contain  lymph,  softened  fibrin,  and  purulent 
matter,  presenting  the  structure  of  molecules  (Fig.  189),  or  of  pus  and 
granule  cells — this  is  the  result 
of  exudation  into  their  cavities. 
Occasionally  there  is  a  sei'ous 
fluid  more  or  less  mixed  up  with 
extravasated  blood,  giving  to  the 
contained  liquid  various  colours 
and  appearances,  according  to  the 
age  of  the  extravasation.  Thus 
it  may  be  red,  dark  brown  (re- 
sembling cotfee),  of  a  dark-green-  "' 

ish  tinge,  etc.  etc.  Sometimes  it  is  of  a  dark-bluish  or  blackish  tint  from 
excess  of  pigmentary  deposit. 

8.  Sometimes  the  contents  of  a  cystic  growth  are  formed  of  a  solid 
exudation,  which   has  undergone  the  sarcomatous 
transformation  as  previously  described,  and  wholly  liilA^4'-SM  4 
consists  of  fusiform  cells  (Fig.  190).     The  exuda-       Jll(s?rlp*lff|f'-] 
tion  poured  into  such  cysts  may  pass  into  the  can-     ^'/Ji^-H^V 
cerous  formation,  and  then  the  characters  we  have     *°-'-i"'!i-°'n' :^ 
described  will  be  associated  with  those  which  dis- 
tinguish cancer. 

9.  Some  cysts  contain  the  peculiar  secretion  of  >,  ,  .  -aj^'^ 
the  organ  in  which  they  are  found.  Thus  cysts  in  "  "  ""  ° 
the  liver  may  be  full  of  bile,  and  those  in  the  kid-  *'^"  ^^^' 
ney  of  urine. 

10.  Lastly,  cysts  may  contain  a  greater  or  smaller  amount  of  mineral 
matter. 

The  mode  in  which  encysted  growths  are  developed  is — 1st,  By  the 
hypertrophy  of  pre-existing  tissues,  whereby,  from  the  accumulation  of 

Fig.  189.  Cysts  in  cystic-sarcoma  of  the  mamma,  filled  with  molecular  matter. 
Fig.  190.  Fibrous  tissue  composed  of  fusiform  corpuscles,  from   a  sarcoiuatous 
encjsted  growth  in  the  kidney.  250  diaia. 


168 


PRINCIPLES   OF   MEDICINE. 


materials  Avitliin,  canals  are  distended,  follicles  or  vesicles  enlarged,  and 
their  -walls  thickened.  Thus  the  simple  cysts  in  the  plexus  choroides 
are  owing  to  effusion  of  serum  into  the  areolar  spaces  in  the  villi  of  the 
membrane,  and  their  subsequent  distension.  Those  in  the  kidney  may 
be  owing  to  the  dilatation  of  uiiniferous  tubes  above  an  accidental 
obstruction  in  the  same  manner  that  the  -whole  kidney  may  become 
encysted  from  obstruction  of  the  ureter.  The  Malpighian  capsules  also, 
or  the  shut  sacs  of  the  thyroid,  may  be  distended  with  fluid,  which  thus 
forms  cysts.  In  like  manner  the  crypts  of  the  skin,  the  blind  sacs  of 
conglobate  glands,  or  of  the  follicles  of  mucous  membranes,  become 
obstructed  at  their  orifice ;  and  their  contents  gradually  accumulating, 
distend  the  walls,  which  become  enlarged  and  thickened.  Simple  cysts 
in  the  ovary  become  dilated  by  enlargement  of  isolated  Graafian  vesicles, 
either  deep  in  the  stroma  of  the  organ,  or  on  the  surface,  when  they 
grow  outwards,  and  become  pedunculated. 

This  mode  of  cystic  formation,  ti'om  distension  by  material  that 
cannot  readily  find  an  escape,  is  remarkably  well  observed  in  bones, 

in  which  cysts  are  some- 
times produced  in  conse- 
quence of  accumulated  pus. 
In  the  Edinburgh  University 
Museum  is  a  remarkable  pre- 
j)aration,  in  which  a  large 
osseous  cyst  has  been  deve- 
loped in  this  manner,  at  the 
lower  end  of  the  Femur  (Fig. 
191) ;  and  in  the  Edinburgh 
College  of  Surgeons'  Mu- 
seum, is  another,  which  has 
formed  in  a  similar  manner 
in  the  head  of  the  tibia 
(Fig.  192).  In  the  first  spe- 
cimen the  osseous  cystic 
Avails  are  thin,  in  the  second 
they  are  greatly  thickened. 
In  this  respect  they  resemble 
the  cranial  bones,  which  in 
some  cases  are  expanded 
and  rendered  thin,  and. 
under  other  circumstances 
become  preternaturally  thick  through  disease. 

2d,  The  origin  of  compound  encysted  tumours  is  not  so  well  de- 
termined. It  is  very  probable,  how-ever,  that  in  most  cases  they  consist 
of  clusters  of  simple  cysts,  which  become  compressed  together,  assume 
an  increased  power  of  groAvth,  and  are  at  length  surrounded  by  a  cap- 
sule. They  are  most  common  in  the  ovary ;  and  here  we  can  readily 
understand   how  successive  growths  of  Graafian  vesicles  may  give  rise 


Fis.  191 


192. 


Fig.  191.  Cystic-osteoma  of  the  femur.      One-eighth  (he  natural  size. — {Miller.) 
Fig.  192.  Cystic-osteoma  of  tlie  tibia.     One-eighth  the  natural  size. — {Miller,  copied 
from  the  preparations  above  referred  to.) 


CYSTIC   GROWTHS. 


169 


either  to  tlie  appearance  of  secondary  or  tertiary  cysts,  or  to  the  mul- 
tilocnlar  form  we  have  described.  Once  produced,  the  compound  cyst 
enlarges,  the  individual  ones  grov?  sometimes  inwards  and  sometimes 
outwards,  according  as  there  is  more  room  for  expansion  in  the  one 
direction  or  the  other.  In  the  former  case  they  open  into  each  other 
by  ulceration.  Hence,  in  very  old  compound  cystic  growths,  we  find 
one  large  cavity  with  the  traces  on  its  internal  wall  of  previously  existing 
cysts,  or  bands  and  divisions  with  pouches  between  them.  In  the  latter 
case  they  grow  outwards,  forming  clusters  of  cysts  more  or  less  pe- 
dunculated, as  in  the  so-called  hydatid  moles  of  the  chorion  (Fig.  177,  a). 
These  endogenous  and  exogenous  modes  of  growth  are  sometimes  found 
in  the  same  specimen. 

3d,  Another  mode  in  which  compound  cysts  are  formed  is  by  the 
gradual  enlargement  of  the  areolae  in  newly-formed  fibrous  tissue.  On 
examining  thin  sections  of  sarcomatous  growths,  we  observe  the  fila- 


Fig.  193. 


Fitr.  194. 


mentous  tissue  arranged  in  a  circular  form,  enclosing  spaces  varying  m 
size.  These  spaces  are  often  lined  by  a  distinct  epithelial  membrane, 
and"  sometimes  contain  serum,  blood,  or  exudation,  either  in  a  granular 
or  fibrous  state.  Such  growths  have  long  been  known  under  the  name 
of  cystic  sarcoma  (Figs.  193,  194,  and  also  Figs.  lV6,  189). 

4th,  The  glandular  or  epithelial  cells  of  an  organ  assume  an  increased 
power  of  development,  and  become  scattered  through  its  tissue  in  great 
numbers.  In  the  kidney  especially,  a  cystic  disease  is  not  unfrequently 
met  with,  in  which  the  'cysts  vary  from  the  size  of  a  pea  down  to  the 
__i__th  of  an  inch  in  diam'eter,  as  may  be  accurately  traced  with  the  aid 
of  the  microscope. 

The  diao-nosis  and  treatment  of  encysted  growths  belongs  to  the  spe- 
cial pathoTogy  of  each  organ  affected  by  them.  It  need  only  be  men- 
tioned here  that  a  knowledge  of  the  structure  of  these  tumours  is  not 
unimportant,  as  an  examination  of  the  fluids  discharged  from  them  fre- 
quently enables  us  to  speak  with  certainty  regarding  their  nature. 


Fio-.  193.  Cysts  in  cystic-sarcoma  of  the  mamma,  crowded  with  cells ;  a,  the  cells 
after  the  addition  of  acetic  acid.  . 

Y\^.  194.  Fibrous  stroma  from  another  part  of  the  same  tumour,  with  commenc- 
ing enlargement  of  the  areolar  spaces,  after  the  addition  of  acetic  acid.    250  diam. 


170 


PRINCIPLES   OF   MEDICINE. 


Glandular  Groivths. — Adenoma. 

Glandular  growths  are  essentially  hypertrophies  of  gland  texture,  in 
the  same  manner  that  fibrous  or  fatty  growths  are  an  increase  of  fibrous 
or  fatty  tissues.  But  the  structure  of  a  gland  is  compound,  and  em- 
braces two  kinds  of  growth.  Strictly  speaking,  the  growths  are  fibro- 
epithelial,  but  of  a  kind  so  peculiar  as  to  warrant  Lebert  and  Birkett  in 
constituting  them  into  separate  groups. 

Glandular  growths  may  be  regular  or  irregular,  that  is,  they  may 
involve  the  entire  gland  or  only  a  portion  of  it,  and  in  the  latter  case 
they  may  assume  the  form  of  tumour.  They  may  also  be  perfect  or 
imperfect,  in  the  first  case  closely  resembling  the  gland  structure,  in  the 
second  difi"ering  from  it  in  various  degrees,  and  passing  into  fibrous, 
cystic,  fatty,  and  other  forms  of  growth.     It  is  not  our  intention  to  enter 


.'S?^^^'^/? 


Fig.  195. 

into  minute  descriptions  of  the  various  appearances  and  modifications  of 
structure  they  present  in  the  several  glands.  Under  the  names  of  chro- 
nic mammary  tumour,  bronchocele,  enlarged  prostate,  and  hypertro- 
phied,  indurated,  or  swollen  glands,  their  existence  was  recognised  be- 
fore their  structure  was  known.  While  now  it  has  become  apparent 
that  growths,  which  are  truly  glandular  in  their  nature,  have  frequently 
been  mistaken  for  fibrous  and  even  for  cancerous  formations. 

These  growths  are  sometimes  lobulated,  with  the  lobes  more  or  less 
compressed,  and  the  interlobular  fibrous  tissue  varying  in  density  and 
amount.  They  may  reach  a  considerable  size.  One,  removed  from  the 
female  breast  by  Mr.  Syme,  which  I  carefully  examined,  was  larger  than 


Fig.  195.  Structure  of  a  cjstic  glandular  tumour  of  the  neck,  in  the  neighbour- 
hood of  the  thyroid  gland,  a,  Appearance  of  a  portion  slightly  separated  and  viewed 
by  a  simi^le  lens,  presenting  a  grape-like  bunch  of  lobules ;  h,  c,  d,  ultimate  lobules, 
composed  of  single  or  branched  CiBcal  tubes,  distended  with  epithelial  cells ;  e,  dis- 
tended condition  of  these  on  tlie  addition  of  water ;  /  alteration  of  their  shape  on 
pressure;  g,  fusiform  cells  found  in  small  numbers. — {Redfern.)  250  diam. 


GLANDULAR  GROWTHS. 


171 


the  human  adult  head,  aud  weighed  upwards  of  eight  pounds.  To  the 
feel  they  vary  in  density,  are  lobular  or  smooth  externally,  and  in  the 
latter  case  are  not  unfrequently  surrounded  by  a  fibrous  capsule.  On 
section  they  are  sometimes  smooth  and  glistening,  at  others  somewhat 
granular  and  dull.  The  cut  surface  varies  in  colour,  sometimes  being 
almost  white,  at  others  of  a  pale  yellow,  pink,  or  fawn  colour,  apparently 
from  the  greater  or  less  amount  of  vascularity  of  the  particular  speci- 
men. Their  mode  of  growth  is  by  no  means  uniform.  Sometimes  they 
remain  indolent  and  stationary,  then  again  they  increase  steadily  in_  size, 
slowly  at  one  time  and  rapidly  at  another.  Occasionally,  after  giving 
rise  to  much  anxiety,  they  gradually  disappear,  but  not  unfrequently 
they  present  all  the  external  characters  and  symptoms  of  fibrous  or  sar- 
comatous tumours,  and  now  and  then  those  of  true  cancer. 

In  structure,  glandular  tumours  consist  of  gland  elements— that  is  to 


n\  lk'i>'^  J 


'€^m^f^'W0i  mm 


Fig  19T 


Fu  19s 


say,  of  a  basement  membrane,  furnished  with  blood-vessels  on  one  side, 
and  nucleated  cells  or  nuclei  on  the  other.  Their  firmness,  softness,  and 
friability,  depend  upon  the  amount  of  fibrous  tissue  in  them,  and  upon 
the  number  of  cells.  The  follicles  are  frequently  much  distended,  pre- 
senting blind  sacs  apparently  without  ducts,  and  are  crowded  with  epi- 
thelial cells,  more  or  less  compressed  together.  If  ducts  do  communi- 
cate with  them,  these  are  similarly  distended,  as  seen  in  Fig.  198. 

The  thyroid  gland  is  especially  liable  to  a  new  formation  of  tissue, 
first  described  by  Rokitansky,  in  which  embedded  in  a  lax  fibrous  stroma 
are  rounded  vesicles,  surrounded  by  a  layer  of  delicate  pavement  epithe- 


Figs.  196,  197,  and  198.  Structure  of  a  glandular  tumour,  surrounded  by  a  fibrous 
cyst,  removed  from  the  female  mamma.  Fig.  196.  Thin  section  transverse  to  the 
glandular  lobules,  after  the  addition  of  acetic  acid,  shewing  the  condensed  epithelial 
lining  membrane  and  enclosed  epithelium  cells.  Pig.  197.  a,  Mass  of  epithelium 
separated  from  the  cut  lobule ;  b,  cellular  contents ;  c,  the  same,  after  the  addition 
of  acetic  acid.  Fig.  198.  Longitudinal  section  of  one  of  the  ducts  leading  from  the 
lobules,  after  the  addition  of  acetic  acid.  250  diain. 


172 


PRINCIPLES  OF   ilEDICIXE. 


lium,  and  containing  colloid  substance,  which  escapes  when  one  of  these 

is  raptured,  Fig.  199,  «,  B* 
"Whether  the  remarkable 
structure  denominated  by 
M.  Robin,  "  Tunieur  Hete- 
radenique,"f  in  any  way  re- 
sembles this,  it  is  difficult  for 
me  to  say,  never  liaving  liad 
an  opportunity  of  examining 
a  specimen. 

Lymphatic  glands  are  very 
liable  to  enlarge  through  lo- 
cal irritation,  arising  from  a 
neighbouring  ulcer  or  injury ; 

O^-^  ~==^    I       and  the  mesenteric  glands  are 

(2)       (       N^  '  .    '    '       especially  so,  in  consequence 

'  ^  ^'^  of  the  various  ulcers  which 

form  in  the  intestines.  In 
typhoid  fever  they  are  fre- 
quently found  swollen  as 
large  as  hens'  eggs,  present- 
ing a  reddish  or  purple  hue 
externally,  soft  and  spongy 
to  the  feel,  on  section  exhi- 
biting a  granular  texture  and 
greyish  hue,  and  on  pressure  yielding  a  dirty  white  juice.     This  juice 


T\s.  199. 


Fig.  200.  Fig.  201.  Fig.  202. 

abounds  in  the  cell  elements  of  the  gland,  which  exhibit  an  increased 

*  Zur  Anatomie  des  Kropfes,  "Wien,  1849. 

f  Lebert's  Anatomie  Pathologique  Generale  et  Speciale,  Liv.  10,  11. 


Fig.  199.  New  formed  tissue  in  a  follicle  of  the  thyroid  gland.  A,  Areolar  fibrous 
tissue  surrounding  the  epithelial-like  lining  of  the  areolas.  Many  of  these  have  been 
removed  to  show  the  glandular  formations  within.  These  vary  in  shape,  some,  &,  d, 
being  constricted,  others  round  or  oval — a,  c.  B,  Colloid  masses  of  various  shapes 
from  the  interior  of  a.  g,  Epithelium,  with  commencing  fatty  degeneration,  seen 
also  at  d,  e,  and  /.  h,  Blood-vessels  containing  colourless  corpuscles  of  the  gland. — 
(Wedl.) 

Fig.  200.  Cells  in  fluid,  squeezed  from  a  mesenteric  gland,  in  a  case  of  typhoid 
fever. 

Fig.  201.  The  same  in  another  case. 

Fig.  202.  The  same  cells,  after  the  addition  of  acetic  acid.  250  diam. 


EPITHELIAL   GROWTHS.  173 

power  of  development.  The  cells  enlarge,  their  nuclei  divide  into  two, 
these  increase  by  division  into  four,  or  a  multiple  of  two,  and  often  form 
a  cluster  in  the  centre  of  the  cell,  as  seen  in  the  accompanying  figures 
(Figs.  200,  201). 

the  causes  w^hich  excite  glandular  growths  are  not  always  apparent. 
They  may  be  constitutional  and  local,  and  in  the  latter  case  the  irrita- 
tion exciting  them  may  be  direct,  as  from  a  blow  ;  indirect,  as  from  a 
neio-hbouring  sore  ;  or  retlex,  as  when  uterine  disease  aftects  the  mam- 
raaf  Sometimes  when  the  apparent  cause  is  removed,  the  glandular 
growth  disappears,  but  at  others  it  continues  to  grow  independently  of 
any  such  cause.  The  laws,  which  regulate  the  occasional  persistence  or 
disappearance  of  these  growths,  have  not  yet  been  determined,  but  one 
essential  and  hitherto  unrecognised  condition,  with  regard  to  their  inde- 
pendent growth,  admits  of  being  explained  in  the  following  manner  : 

At  first  the  irritation,  however  communicated  to  the  gland,  whether 
direct  or  reflex,  operates  by  stimulating  it  to  increased  cell-growth,  and 
by  augmenting  the  flow  of  blood.  Hence  ensue  turgescence  and  en- 
largement, with  the  formation  of  cells,  often  in  such  numbers  that  they 
cannot  readily  escape.  This  is  especially  the  case  in  the  female  mamma 
of  young  women  not  pregnant,  in  whom,  while  this  morbid  action  is 
progressing,  the  proper  function  of  the  organ  is  in  abeyance.  Hence  the 
follicles  enlarge  more  or  less  rapidly,  and  according  to  the  amount  of 
irritation  and'increased  nutrition  which  results,  is  the  consequent  amount 
of  growth.  It  frequently  happens,  however,  that  if  the  increased  amount 
of  cell  elements  can  find  a  ready  exit,  they  retain  their  normal  type  for 
a  certain  time,  and  on  the  cessation  of  the  cause,  they  cease  to  be  formed 
or  accumulated,  and  the  growth  disappears.  But  when  they  assume  a 
power  of  independent  development,  this  is  not  so  readily  accomplished. 
In  this  case  they  continue,  and,  by  the  permanent  stimulation  to  growth, 
form  persistent  tumours. 

Again,  the  enlargement  of  glands  in  the  neighbourhood  of  cancerous 
and  scrofulous  ulcers  or  growths  is  not  necessarily  caused  by  the  pre- 
sence of  cancer,  or  tubercle  in  them.  I  have  frequently  examined  en- 
larged axillary  glands,  which  have  been  removed  with  cancerous  breasts, 
and  found  nothing  but  simple  hypertrophy  of  those  glands.  In  the 
case  of  an  extensive  epithelioma  of  the  thigh,  for  which  amputation 
was  performed  by  the  late  Mr.  R.  Mackenzie,  the  inguinal  glands  on  the 
aftected  side  were  greatly  enlarged.  After  the  death  of  the  individual, 
1  found  no  epithelioma  in  those  glands,  but  again  only  simple  hyper- 
trophy. But  if  this  condition  be  allowed  to  remain  for  any  length  of 
time,  "epithelioma  as  well  as  cancer  does  form  in  them,  or  simple  and 
tubercular  exudations  are  thrown  out,  which  assume  the  character  of 
pus  or  tubercle.  It  follows  that  enlarged  glands  are  not  a  necessary 
proof  of  the  extension  of  certain  growths  secondarily,  and  that,  as  we 
shall  subsequently  see,  their  commencement,  instead  of  discouraging, 
ought  perhaps  in  certain  circumstances  to  lead  the  surgeon  to  an  early 
excision  of  the  tumour. 

Epithelial  Growths. — Epithelioma. 
The  epidermic  and  epithelial  cells  are  continually  thrown  oft'  from  the 


174  PRINCIPLES   OF   MEDICINE. 

skin  and  mucous  membranes,  and  new  ones  are  as  constant!}^  formed. 
Numerous  circumstances  may  arise,  which  induce  their  production  in 
greater  numbers,  or  their  accumulation  in  particular  parts.  In  this  case 
they  may  soften  and  give  a  morbid  character  to  fluids,  as  that  of  the 
urine,  or  they  may  become  indurated,  causing  thickenings  or  swellings 
on  the  mucous  surfaces,  callosities,  or  tumours  of  the  skin.  Structures 
composed  of  epidermic  growths,  as  hair  or  horn,  may  become  excessive, 
or  arise  in  parts  which  are  unusual.  Lebert  was  the  first  to  point  out 
that  many  of  the  tumours  hitherto  called  cystic,  fibrous,  and  even  can-, 
cerous,  belong  to  this  class  of  growths.  In  all  cases,  they  consist  of  an 
increased  number  of  epidermic  or  epithelial  cells,  more  or  less  com- 
pressed together,  frequently  united  by  filaments  of  fibrous  tissue,  and 
supplied  by  blood-vessels.  The  term  epithcUoma,  first  introduced  by 
Hannover,  may  be  appropriately  applied  to  the  entire  group. 

The  following  are  the  principal  forms  assumed  by  this  kind  of 
growth  : — 

1.  Corns  and  CaUosiiies  consist  of  a  local  hypertrophy  of  the  epider- 
mis, and  are  composed  of  numerous  epidermic  scales  condensed  into  an 
indurated  mass.  The  corn  is  a  distinct  rounded  or  acuminated  tumour, 
varying  in  size  from  a  barley-corn  to  that  of  a  pea,  more  commonly 
surrounded  by  indurated  epidermis.  On  examining  a  vertical  section 
under  high  magnifying  powers,  it  appears  irregularly  fibrous,  but  on 
making  a  horizontal  section  these  are  shown  to  be  the  edges  of  epider- 
mic scales,  each  of  which  has  its  distinct  nucleus.  Occasionally  these 
cells  soften  and  separate  from  each  other,  constituting  the  soft  corn. 
Callosities  of  the  skin  exactly  resemble  corns  in  structure,  but  are  dif- 
fused over  a  greater  surface. 

Both  corns  and  callosities  are  occasioned  by  interrupted  pressure  upon 
any  part  of  the  skin.  To  a  certain  extent  they  protect  the  delicate 
nervous  filaments  below.  At  other  times,  from  their  bulk  or  hardness, 
they  cause  increased  pain  whenever  the  pressure  is  modified  or  increased. 
Corns  are  common  on  the  feet  from  undue  pressure  of  the  shoe  ;  callosi- 
ties occur  on  the  knees  of  housemaids,  on  the  hands  of  handicrafts- 
men, sempstresses,  etc.,  or  in  any  other  portion  of  the  surface  exposed 
to  pressure.  The  cure  consists  in  removing  the  cause.  We  have  fre- 
quently observed,  that  during  an  attack  of  fever  and  the  subsequent  con- 
.valescence,  the  corns  and  callosities  on  the  feet  of  patients  have  dis- 
appeared, having  "  grown  out,"  as  it  is  called.  Changing  the  shoe  or 
bootmaker,  or  obtaining  another  last,  has  been  known  to  remove  them. 

2.  The  scaly  skin  diseases  must  be  classified  among  epidermic  growths. 
Accumulations  of  epidermic  scales,  upon  a  reddened  and  indurated  sur- 
face, constitute  their  characteristic  features.  In  p>S'^'>'^'^^^^  they  are 
gathered  together  in  considerable  masses.  In  pityriasis  the  scales  are 
smaller,  are  more  easily  separated  from  the  surface,  and  frequently  asso- 
ciated with  minute  cryptogamic  vegetations.  The  flattened  and  im- 
bricated form  of  ichthyosis  is  also  composed  of  similar  accumulations  of 
epidermic  scales,  but  without  the  reddened  surface.     (Fig.  85.) 

3.  War  tsand  Condylomata  are  also,  for  the  most  part,  composed  of 
epidermic  cells  condensed  together.  The  wart  consists  of  projections  of 
a  papillary  form,  varying  in  size,  and  occurs  under  circumstances  where 
pressure  does  not  take  place.     These  growths  appear  to  be  constitutional, 


EPITHELIAL   GROWTHS.  175 

or  associated  with  peculiar  states  of  tlie  body.     Thus  condylomata   and 


Fi^.  203. 


Fig.  204. 


warts  are  frequently  found  round  the  margins  of  the  anus,  vulva,  and  penis, 
in  syphilitic  individuals.  Warts,  assuming  the  form  of  cauliflower  ex- 
crescence, often  arrive  at  a  large  size  in  such  situations,  weighing  even 
several  pounds.  They  frequently  form  on  the  hands  of  young  persons, 
and  are  sometimes  found  in  other  parts  of  the  body,  coming  and  going 
without  any  obvious  cause. 

Condijlomata,  when  closely  examined,  seem  to  be  made  up  of  a  con- 
geries of  papillae  {^papilloma),  sometimes  flattened  at  the  top,  so  that 
they  cannot  be  separated  ;  at  others,  presenting  fissures  or  sulci  which 
lead  down  to  a  common  stalk.  Sometimes  the  papillfe  are  small  and 
rounded ;  at  others,  elongated  and  en- 
larged at  their  extremities.  The  tumours 
thus  formed  may  be  only  the  size  of  a 
pin's  head,  or  may  be  so  large  as  to  weigh 
several  pounds.  In  the  latter  case  the 
central  portions  seem  to  consist  of  a  fi- 
brous structure,  probably  an  hypertrophy 
of  the  dermis,  which  is  supplied  with 
blood-vessels  (Fig.  206).  Their  surface 
sometimes  is  smooth,  resembling  thick- 
ened epidermis  ;  at  others  it  is  lobulated, 
composed  of  rounded  groups  of  papillfe, 
resembling  externally  a  cauliflower. 
These  tumours,  when  small,  are  almost 
wholly  composed  of  epithelial  scales, 
which  assume  a  square  or  elongated  form, 
their  nuclei  being  for  the  most  part  very 
distinct.  In  the  larger  growths  the  sur- 
face is  similarly  composed,  but  internal- 
ly we  find  more  or  less  areolar  tissue,  supplied  with  blood-vessels. 


Fig.  203.  Warts  on  the  penis.      One-fourth  the  natural  size. — {Adon.) 

Fig.  204.  Summit  of  a  papilla  from  a  wart. 

Fig.  205.  Perpendicular  section  of  a  papilla  from  an  acuminate  condyloma,  after 
the  addition  of  acetic  acid,  a,  Vascular  loop — internal  to  which  is  fibrous  tissue  form- 
ing the  axis  of  the  papilla — outside  are  nuclei,  h,  b,  Basement  membrane,  c,  c, 
Epidermic  cells.— ( Wedl.)  250  diam. 


176 


PRINCIPLES   OF   MEDICIXE. 


snipping  oif  a  small  isolated  papilla  from  such  a  tumour,  and  examining 
it  entire,  it  presents  a  conical  or  round  projection,  covered  with  epider- 
mic scales,  as  in  Fig.  204.  When  a 
vertical  section  of  it  is  made,  we  ob- 
serve a  vascular  loop,  surrounded  by 
basement  membrane,  external  to  which 
are  layers  of  epithelial  cells  varying 
in  thickness  (Fig.  205).  The  Ver- 
ruca Achrocordon  is  a  peculiar  epi- 
dermic tumour,  furnished  with  a  cen- 
tral canal,  through  which  blood-vessels 
ramity  abundantly  to  all  parts  of  the 
"'°''""'  tumour.     The  central  parts  of  such 

tumours  are  composed  of  fibrous  structure  (Fig.  206) ;  externally  they 
consist  of  epidermic  scales,  arranged  concentrically  round  the  central 
vascular  part,  which,  if  cut  into,  gives  rise  to  great  haemorrhage.  (  Vor/el.) 
All  these  tumours  may  soften  and  ulcerate  on  the  surface,  and,  under 
such  circumstances,  give  rise  to  purulent  and  ichorous  discharges. 

4.  Another  form  of  epithelioma  is  one  which  frequently  commences 
as  an  ulcer,  although  sometimes  it  is  preceded  by  slight  induration  of 

or  a  small  wart  on  the  part 
affected.  It  is  common  in 
the  under  lip,  in  the  tongne, 
and  in  the  cervix  uteri.  In 
the  lip  there  may  often  be 
observed  a  furrow  or  groove 
in  the  indurated  spot  or  wart, 
in  which  the  ulceration  com- 
mences. This  slowly  extends, 
with  indurated,  thickened, 
and  raised  margins,  is  cir- 
cular and  cup-shaped,  its  sur- 
face sometimes  covered  with 
a  white  cheesy  matter,  at 
others  with  a  thick  crust  or 
scab  (Fig.  207).  It  slowly 
extends,  until  it  involves  a 
greater  or  less  portion  of  the 
lip  and  neighbouring  parts, 
pouring  forth  a  foul  ichorous 
discharge.  In  the  tongue, 
the  disease  follows  a  similar 
Fig.  2:7.  course ;  the  base  of  the  sore, 

however,  is  generally  more  fungoid  or  papillated  on  the  surface,  and  ex- 
ceedingly dense,  owing  to  the  close  impaction  and  compression  together  of 
laminae  of  epithelium.    These  on  section  jiresent  a  mass  having  a  white  sur- 


Fig.  206.  Transverse  section  of  the  base  of  a  condyloma.     The  dark  shading  in 
the  centre  and  radiating  hnes,  represent  dense  fibrous  vascular  tissue. — ( Wedl.) 
Fig.  207.  Ulcerated  epithelioma  of  the  lip. — {Liston.) 


EPITHELIAL   GROWTHS. 


177 


face,  with  a  terniency  to  split  up  and  separate,  are  dense  to  tlie  feel,  and 
do  not  yield  on  pressure  a 
milky  juice  (Fig.  208).  On 
the  cervix  uteri  similar  ul- 
cers are  very  common,  with 
hard  irregular  edges,  yield- 
ing a  copious  ichorous  dis- 
charge, and  causing  more  or 
less  thickening  of  the  neigh- 
bouring textures.  The  so- 
called  cauliflower  excres-  ^'='-  ^OS- 
cence  is  a  form  of  epithelioma;  so  also  are  the  cancer  of  the  scrotum  of  the 
chimney  sweeper,  certain  forms  of  rodent  ulcer,  and  of  noli  me  tangere. 
An  epithelioma  of  the  hand  is  well  figured  by  Mr.  Paget,*  and  so  also 
is  a  remarkable  one  in  the  interior  of  the  stomach  by  Professor  A. 
Retzius.f 

In  all  these  cases,  the  ulcers,  when  examined  microscopically,  present 


^1  f  f^i  J^^^-C:  y 


r  ■.  r 


]f:, 


\: 


S\ 


Ti%.  209. 


/ 


on  the  surface  masses  of  epithelial  cells  in  all  stages  of  their  develop- 
ment. Some  spherical  and  nucleated  are  about  the  xoVot^^  ^^^  ''^^^  "^^^^ 
in  diameter,  others  are  much  larger;  both  often  resembling  cancer-cells 
when  isolated  or  viewed  alone,  but  associated  with  flattened  scales, 
varvino-  in  shape  and  size,  sometimes  occurring  in  groups  adherent  at 
their  edges,  at  others  mingled  together  in  a  confused  mass.  Many  of 
the  cells  and  scales  often  reach  an  enormous  size  (Fig.  210),  and  as  they 
become  old,  split  up  into  fibres.  These  elements  are  commonly  mingled 
with  numerous  molecules  and  granules,  naked  nuclei,  fusiform,  granular, 
and  pus  cells.     Below  the  surface  the  epithelial  cells  may  be  seen  more 


*  Surgical  Pathology,  vol.  ii.  p.  417. 

f  Museum  Auatoniicum  Holmiense.     Sect.  Path.  Tab.  7. 


1855. 


Fig.  208.  Seetiou  of  an  ulcerated  epithelioma  of  the  tongue.     Natural  size. 

Fig.  209.  Epithehal  cells  compressed  together,  immediately  below  the  surface  of 
the  ulcer,  Fig.  208. 

Fig  210.  Epithelial  cells,  one  of  them  very  large,  in  white  curdy  matter  squeezed 
from  the  duct,  seeu  Fig.  208. 

Fig.  211.  The  same,  seen  in  mass.  250  diain. 

12 


178  PEINCIPLES   OF   MEDICINE. 

or  less  compressed  and  condensed  together,  and  ^vlien  the  ej^ithelioma  is 


Fig.  212. 


Fig.  213. 


chronic,  and  the  structure  dense,  these  present  concentric  laminae  sur- 
rounding a  hollow  space  or  loculus,  evidently  owing  to  the  compression 

Fig.  214. 


Fig.  215.  Fig.  216. 

together  of  numerous  epithelial  scales.     This  peculiar  appearance,  some- 
times called  "  cell  nests,"  is  characteristic  of  this  form  of  epithelioma 

Fig.  212.  Concentric  laminse  of  condensed  epithelial  scales,  from  the  lower  portion 
of  the  white  matter  seen  Fig.  208,  with  epithelial  cells,  and  fragments  of  muscular 
fasciculi. 

Fig.  213.  Muscular  tissue  immediately  below  the  white  mass  Fig.  208. 

Fig.  214.  Epidermic  scales,  in  mass  and  isolated,  from  the  surface  of  an  epithelioma 
of  the  scrotum,  in  a  chimney-sweep. 

Fig.  215.  Group  of  deep-seated  cells,  in  the  same  case. 

Fig.  216.  The  same,  after  the  addition  of  acetic  acid.  250  diam. 


EPITHELIAL   GROWTHS. 


179 


(Fig.  212).  On  breaking  lliem  up,  they  exhibit  a  variety  of  forms,  in 
which  their  epithelial  character  is  visible  on  the  one  hand,  and  the 
fragments  of  concentric  circles  are  seen  on  the  other. 

The  lymphatic  glands  in  the  neighbourhood  of  such  ulcers  liave  a 
great  tendency  to  be  secondarily  atfected,  in  which  case  they  enlarge, 
soften,  and  easily  break  down  under  the  finger.  Not  unfrequently  they 
contain  a  yellow  cheesy-looking  substance,  which,  under  such  circum- 
stances, represents  fatty  degeneration,  analogous  to  the  reticukim  of 
cancerous  formations.  On  crushing  a  portion  of  the  altered  glandular 
substance  between  glasses,  it  presents  the  appearances  represented  Fig. 
217.     If  the  concentric  masses  are  broken  down,  the  individual  epithelial 


;r 


Fi?  217 


cells  are  here  also  seen  to  be  of  various  fantastic  shapes,  in  which 
fragmentary  portions  of  circles  are  detectable  (Fig.  217).  In  the 
yellowish  portions  the  nuclei  are  composed  of  fatty  granules,  and  the 
cells  themselves  are  molecular,  and  mingled  with  numerous  oily  particles 
(Fig.  218,  also  Fig.  92). 

A  modification  of  this  form  of  epithelioma  occurs  on  raucous  surfaces, 
especially  in  the  urinary  bladder,  and  has  been  variously  called  villous 
cancer,    dendritic    veoetation         ..«-<;::5^..,^ 


o 


m^ 


(Zottenkrebs  of  Rokitansky). 
It  forms  a  fungous  projection, 
having  a  fibrous  basis  which 
is  elongated,  into  branched 
stems,  supporting  villi,  more 
or  less  aggregated  together, 
and  covered  with  a  layer  of 
epithelial  cells.  It  is  soft,  and 
readily  breaks  down  under  the 
finger,  the  pulpy  matter  exhi- 
biting under  the  microscope  numerous  irregularly-shaped  cells,  partly 


Fig.  217.  Fragments  of  the  concentric  masses  figured,  Fig.  212,  from  a  lymphatic 
gland. 

Fig.  218.  Epithelial  cells,  in  yellow  cheesy  matter,  of  the  same  gland. 

Fig.  219.  Cells  in  pultaceous  white  matter,  from  a  fungoid  epithelioma  of  the 
urinary  bladder. 

Fig.  220.  The  same,  after  the  addition  of  acetic  acid.  250  diam. 


180 


PEINCIPLES   OF   MEDICINE. 


fibrous,  aixl  partly  epithelial,  in   various  stao-es  of  development  (Fig. 
219). 

5.  Hairy  formations. — Great  varieties  exist  in  different  individuals 
regarding  the  amount  of  hair  on  their  body.  Some  men  have  been 
known  to  be  as  hairy  as  certain  of  the  lower  animals.  Patches  or 
groups  of  hair,  seated  on  a  somewhat  indurated  base,  may  frequently  be 
seen  scattered  over  the  surface  in  parts  usually  smooth  ;  these  constitute 
a  form  of  so-called  mole  on  the  skin.  Hair  has  been  found  on  the 
surface  of  the  mucous  membrane,  and  even  in  the  lungs ;  and  is  common 
in  encysted  tumours,  especially  of  the  ovary  and  testis.  In  several  such 
cases  I  have  found  the  root  of  the  hair  implanted  in  a  follicle,  at  other 
times  loose,  with  the  roots  of  a  bulbous  form  exactly  resembling  those  on 
other  parts  of  the  body.  The  point  of  the  hair  is  generally  somewhat 
truncated,  presenting  at  its  extremity  two  or  more  fibres,  produced  by 

the  longitudinal  splitting 
up  of  the  hair.  In  length 
they  vary  from  one  quar- 
ter of  an  inch  to  several 
inches. 

6.  Horny  i^roductions. — 
Under  this  head  may 
be  classed  the  pi-ominent 
growths  in  some  forms  of 
ichthyosis  ;  tumours  re- 
sembling warts,  but  so  in- 
durated as  to  resemble 
horn,  and  true  horny  ex- 
crescences growing  from 
the  surface. 

In  some  forms  of  ich- 
thyosis^ the  growths  stand 
out  as  distinct  spines, 
broad  on  the  surface,  nar- 
row at  their  insertions, 
like  columns  of  many  sides 
accurately  fitting  to  their 
neighbours.  Horny  tu- 
mours occasionally  occur, 
varying  in  size  from  a 
bean,  or  extending  over 
a  space  the  size  of  half- 
a-crown.  Many  cases  are 
on  record  of  tiue  horn 
having  gTowu  from  the 
surface,  especially  from  the  head,  originating  in  some  sebaceous  follicle. 

Fig.  221.  From  an  old  preparation  in  the  Edinburgh  University  Museum.  The 
medal  attached  to  it  bears  the  following  quaint  inscription—"  Tliis  horn  was  cut  by 
Arthur  Semple,  ehirurgeon,  out  of  the  head  of  Elizabeth  Low,  being  three  inches 
above  the  right  ear,  before  these  witnesses,  Andrew  Temple,  Thomas  Burne,  George 
Smith,  John  Smytone,  and  James  Tweedie,  the  14th  of  May  1671.— It  was  growing 
seven  years ;  her  age  50  years.     Natural  size. 


T\s.  221. 


VASCULAR   GROWTHS. 


181 


Tliev  have  grown  several  inches  long,  as  seen  in  Fig.  221.  On  making 
a  section  of  these  productions,  they  are  found  to  be  identical  with  the 
structure  of  true  horn  in  the  lower  animals,  or  with  that  of  the  nails  on 
the  hands  and  toes.  They  consist  of  condensed  epidermic  scales,  which, 
on  the  addition  of  acetic  acid,  assume  all  the  characters  of  such 
structures. 


Vase ular  Groivths. — Angionoma. 

Vascular  growths  arc  formed  by  an  increase  in  the  dimensions  or 
number  of  the  arterial,  capillary,  or  venous  vessels.  Several  growths 
already  described,  as  well  as  such  as  are  of  a  cancerous  nature,  are  very 
vascular ;  indeed,  so  much  so,  that  in  some  cases  the  slightest  touch 
causes  alarming  ha?morrhage,  as  in  the  case  of  so-called  uterine  polypi, 
and  fungus  hajinatodes.  No  doubt  there  is  considerable  increase  of  vas- 
cular growth  in  such  tumours,  but  their  basis  is  formed  of  other  mate- 
rial,— they  are  not  wholly  vascular.  This  term  is  more  properly  applied 
to  those  diseases  which  have  hitherto  been  ^.^ — ^ 

denominated  aneurism,  erectile  tumours,  and 
varix. 

1.  Aneurism  is  an  arterial  swelling,  which 
may  vary  in  size  from  the  slightest  possible 
dilatation  of  the  calibre  of  the  vessel,  either 
wholly  or  partially,  to  the  formation  of  enor- 
mous tumours,  larger  than  the  human  head. 


Fig.  222. 

In  sucli  cases,  we  find  the  growth  to  consist 
externally  of  the  dihxted  and  hypertrophied 
structures  of  the  vessel  itself,  or  of  the  tissues 
in  its  immediate  neighbourhood,  and  of  lay- 
ers of  blood,  more  or  less  coagulated  within  it. 
The  varieties  of  Aneurism  are  numerous, 
but  the  principal  are — 1.  Aneurism  hy  dila- 
tation, in  which  the  whole  circumference  of  the  vessel  is  dilated.     2. 


Fig.  222.  True  saccular  aneurism  of  the  aorta,  nearly  filled  with  coagulated  clot. — 
One-third  the  real  size. — {After  Hodgson,  slightly  modified.) 

Fig.  223.  Remarkable  spontaneous  varicose  aneurism,  formed  by  communication 
between  the  vena  cava  and  the  aorta  at  its  bifurcation.  A,  Aorta;  B,  Vena  cava  ; 
C,  Aneurism ;  D,  Situation  of  a  round  aperture  somewhat  larger  than  a  sixpence, 
through  which  the  communication  between  vein  and  artery  was  kept  up. — (Syme.) 


182 


PRINCIPLES   OF   MEDICINE. 


Saccular^  also  called  true  Ane^irism,  in  which  one  portion  or  side  of  the 
vessel  is  dilated  into  a  sac.  3.  J^alse  Aneurism,  in  which  the  coats  of  a 
vessel  have  been  ruptured.  It  has  been  called  ^;r/w^<^^'e  when  all  the 
coats  are  divided,  as  by  a  wound,  and  consecutive,  when  it  is  consequent 
on  ulceration  or  rupture  of  the  internal  and  middle  coats.  4.  Mixed 
Aneurism,  in  which,  after  dilatation,  general  or  partial,  of  all  the  coats 
of  a  vessel,  the  internal  and  middle  ones  burst,  and  a  false  aneurism  is 
superadded.  5.  Dissecting  Aneurism,  in  which  there  is  laceration  of 
the  internal  and  middle  coats,  so  that  the  blood  becomes  infiltrated 
between  the  coats  of  the  vessel,  separates  them  for  a  greater  or  less  dis- 
tance, and  bursts  externally  at  some  distance  from  the  internal  lesion. 
6.  Hernial  Aneurism,  in  which  the  external  and  middle  coats  are  lace- 
rated, and  the  internal  protrudes  through  tliem,  forming  a  hernial  aneu- 
rismal   sac.     7.  Aneurism  hij  anastomosis,  in  which  an   artery,  by  an 


Fig.  224. 

unnatural  communication  with  a  vein,  causes  a  pulsating  tumour  in  the 

latter. 

The  tendency  of  these  growths  is  to  burst 
externally  or  internally  into  spaces  Avhere  least 
resistance  is  offered,  but  occasionally  the  clot  of 
blood  in  the  interior  coagulates  to  such  an  ex- 
tent as  to  close  up  the  cavity,  prevent  influx  of 
fluid,  and  cause  spontaneous  cure — a  result 
which  is  observable  in  the  figure  of  a  very 
rare  specimen  of  aneurism  of  the  left  coronary 
artery  described  by  Dr.  Peacock.*  The  special 
Fig.  225.  pathology  of  these  growths,  however,  is  far  too 

extensive  a  subject  to  be  entered  upon  in  this  place. 

*  Monthly  Journal  of  Medical  Science,  March,  1849. 


Fig.  224.  Aneurism  of  the  coronary  artery,  completely  filled  with  coagulated  clot. 
Natural  size. — {Peacock.) 
Fig.  225.  Section  of  erectile  tumour. — {Miller,  after?) 


VASCULAR  GROWTHS. 


183 


2.  Erectile  growths  are  generally  soft ;  for  the  most  part  situated  in 
tbe  subcutaneous  tissue,  tlae  skin  covering  them  being  of  unusual  deli- 
cacy. When  compressed,  they  may  be  gradually  emptied  of  blood, 
which  returns  like  water  into  a  sponge  on  removing  the  pressure.  For 
the  most  part  they  are  congenital.  When  the  arteries  are  numerous  in 
them,  they  have  a  brownish  or  reddish  colour,  and  pulsate  during  life. 
When  the  veins  abound,  they  are  of  a  blue  or  purple  colour.  Their 
texture  consists  of  numerous  capillaries,  more  or  less  distended,  mixed 
with  arteries  and  veins,  the  interstices  of  which  are  filled  up  by  areolar 
tissue.  A  section  presents  a  spongy  texture,  composed  of  fibrous  bands 
closely  resembling  the  appearance  of  the  corpus  cavernosum  penis,  with 
areoke  or  spaces  into  which  the  blood  enters  (Fig.  225).  The  section 
of  a  fresh  tumour  is  not  unlike  that  of  a  sponge  soaked  in  blood.  In 
structure  it  is  composed  of  vessels  of  all  sizes,  abounding  in  capillaries, 
which  are  more  or  less  sacculated  or  aneurismal,  and  anastomose  freely 
with  each  other.     In  one  case  of  erectile  growth  in  the  liver,  I  found 


Fi?.  226. 


the  intervascular  structure  to  consist  of  caudate  and  branched  cells,' and 


Fi2.  227. 


in  another  in  the  brain,  I  found  it  loaded  with  earthy  salts. 

Fig.  226.  Varicose  cutaneous  vessels  of  tlie  anus  in  the  subcutaneous  cellular 
tissue. 

Fig.  227.  Dilated  papillae  of  the  skin,  cut  horizontally,  the  liglit-coloured  papillary 
structure  containing  dilated  vessels — (  Wtdl.)  60  diani. 


184 


PEINCIPLES   OF   MEDICIXE. 


Varix  is  a  permanently  enlarged  and  tortuous  vessel.  Swellings  from 
this  canse  are  for  the  most  pai't  venous,  and  may  exist  in  various  parts 
of  the  body,  but  are  frequent  in  the  saphena  veins  of  the  inferior  extre- 
mities, the  spermatic  veins  (varicocele),  and  htemorrhoidal  veins  {haemor- 
rhoids). In  all  these  cases  the  veins  gradually  enlarge,  and  then  be- 
come distended,  tortuous,  and  coiled  up.     Several  of  these,  accumulated 


Fig.  22S. 

together,  may  produce  knotty  swellings  in  the  legs,  cause  the  testicle  to 
assume  an  unusual  size,  or  produce  tumours  which,  during  defsecation, 
are  protruded  beyond  the  margin  of  the  anus.  Such  growths  may  ulcer- 
ate, and  cause  death  by  haemorrhage,  or  they  may  be  spontaneously 
obliterated  by  the  formation  of  clots  within  them.  An  artery  rarely 
becomes  varicose. 

The  enlargement  of  vascular  growths,  for  the  most  part  arises  through 
dilatation  of  the  vessels ;  no  new  materials  are  produced  in  them,  with 
the  occasional  exception  of  such  as  arise  in  the  clot  of  blood  within 
them,  viz.  fibrous  or  albuminous  laminae,  or  calcareous  masses.  Through 
the  presence  of  these,  the  vessel  becomes  obliterated,  and  gradually 
assumes  the  density  and  appearance  of  ligament. 

Fig.  229. 


m 

Fig.  280.  Fig.  231.  Fi?.  232.  Fig.  2-33. 

New  vessels  constitute  one  of  the  most  common  pathological  forma- 

Fig.  228.  Varicose  vessels  in  the  caput  trigonum  vesicae. — (Wedl.) 
Fig.  229.  Inner  layer  of  umbilical  artery  of  cal<^  eight  inches  long. — [Drummond.) 
Fig.  230.  Succeeding  layer  in  the  same  vessel,  composed  of  spindle-shaped  cor- 
puscles.— {Drummond.) 

Figs.  231  and  232.  Layers  more  external  in  the  same  vessel,  in  different  stages  of 
development  into  fibres. — {Drummond.) 

Fig.  233.  Common  carotid  artery  of  an  embryo  calf  two  inches  in  length,  showing 
diSerent  directions  of  the  fibre  cells. — {Drummond.)  200  diam. 


VASCULAR  GROWTHS. 


185 


tions.  In  the  embryo  the  capillaries  originate  in  independent  cells,  Avhicli 
throw  out  arms  or  prolongations  that  unite  with  one  another  (Figs.  234 
and  235).  The  larger  vessels  originate  in  globular  cells  which  become 
fusiform,  and  arrange  themselves,  some  longitudinally  and  others  trans- 
versely, to  constitute  the  different  coats  of  the  vascular  wall  (Figs.  229 
to  233).  In  the  adult  the  ob- 
servations which  have  been 
made  in  connection  with  this 
subject,  have  led  to  three  theo- 
ries. 1st,  That  new  vessels  are 
of  independent  origin,  and  that 
they,  as  well  as  the  blood  they 
contain,  spring  up  in  a  blastema 
according  to  the  general  laws  of 
cell  formation.  2d,  That  the 
globules  of  the  blood,  escaping 
from  the  vessels,  channel  a  way 
through  the  surrounding  exuda- 
tion, and  thus  form  new  vessels. 
3d,  That  the  walls  of  the  old 


Fig.  234 


vessels  themselves  at  particular  places  present  bulgings  and  irregularities, 
which  become  pushed  out  more  and  more  by  the  vis  a  tergo,  and  so 
form  new  channels.  An  inquiry  into  this  subject  is  surrounded  with 
difficulties,  but  all  the  results  of  modern  research  tend  to  the  conclusion, 
that  in  exudations  new  vessels  for  the  most  part  have  an  mdependent 


Fis.  236. 


Fis.  28T. 


orio-in,  being  formed  as  in  the  embryo  ;  although  old  vessels  may  occa- 
sionally send  out  off-shoots  or  prolongations.  Thus  in  lymph  we  some- 
times observe  cells,  in  all  stages  of  development  of  the  spindle-shaped 
and  branched  forms,  which,  "according  to  the  observations  of  Drum- 
mond,*   and  more  recently  of  Billroth,!  by  their  fusion,  or  by  their 

*  Monthly  Journal  of  Medical  Science,  November,  1854. 

f  Billroth  Ueber  die  Entwicklung  der  Blutgefasse,  Berlin,  1856. 


Ficr  234   Stellate  cells  in  the  tail  of  the  tadpole,  developing  into  capillary  vessels. 

Fi^.  235.  Capillary  vessels  in  different  stages  of  formation  from  stellate  cells,  m 
the  eye  of  the  foetal  ca\i—{Drummond.) 

Fio-  236.  Branched  cells  in  lymph  exuded  on  the  peritoneum. 

Fio-  237.  Vessels  in  an  early  stage  of  formation,  from  a  colloid  tumour  ot  tue 
,     1  °'  250  awm. 

back. 


186 


PEINCIPLES   OF   MEDICINE. 


arrangement  side  by  side,  form  capillaries  of  various  magnitudes.    These 
capillaries  afterwards  unite  themselves  with  the  pre-existing  vessels. 

Cartilaginous  Growths. — Enchondroma. 

Cartilaginous  growths  were  first  described  by  Miiller,  under  the  name 
of  Encliondroma  (Osteochondrophites  of  Cruveil- 
hier).  In  the  soft  parts,  they  are  surrounded  by 
an  envelope  of  cellular  tissue,  and  in  the  bones 
by  a  bony  capsule.  In  the  first  case  they  occur, 
although  very  rarely,  in  the  glands,  as  in  the 
parotid  or  mamma.  In  the  second  case  they  are 
most  common  in  the  bones  of  the  extremities. 
The  tumours  may  be  round  and  smooth,  or  rough 
and  nodulated  from  several  of  them  being  accu- 
mulated together.  Though  hard  to  the  feel,  they 
often  present  a  peculiar  elasticity.  They  crunch 
when  cut  with  the  knife,  usually  present  a  smooth, 
glistening  surface,  and  are  not  unfrequently  more 
or  less  soft,  pulpy,  gelatinous,  and  even  diflluent 
in  some  parts  of  their  substance.  They  are  rarely 
met  with. 

In  structure,  enchondroma  presents  all  the  characters  of  caitilage — 

f  1/  \ ^  /  ^  r  c^\ 

U — V  I  ^  \\f  ^  ffi 


11.7  \1^'  .\/W 

Fig.  240.  Fig.  241. 

that  is,  nucleated  cells  varying  in  size,  isolated  or  in  groups,  situated  in 
a  hyaline  substance.  A  network  of  filamentous  tissue  runs  through  the 
substance  of  the  tumour,  forming  areolae,  in  which  blood-vessels  ramifv. 
Within  the  areolae  so  formed,  the  cartilage  is  found.  These  two  ele- 
ments vary  as  regards  amount  in  diff'erent  tumours.  Sometimes  the 
cartilage  is  in  excess,  resembling  that  in  young  animals,  or  that  in  the 


Fig.  2.33. 


Fig.  2.38.  Enchondroma  of  the  hand  and  fingers.  The  tumour,  of  which  a  section 
has  been  made,  is  enclosed  in  a  bony  capsule.      One-fifth  natural  size. — {Milter.) 

Fig  239.  Structure  of  a  firm  nodule  in  an  enchondroma  of  the  humerus.  The 
right  of  the  figure  represents,  above,  mineral  deposit  in  and  around  the  cells,  and 
below,  some  isolated  cartilage  corpuscles. 

Fig.  240.  The  same,  after  the  addition  of  acetic  acid,  rendering  the  whole,  and 
especially  the  nucleus,  more  transparent. 

Fig.  241.  The  cartilage  cells  and  fibrous  ti.ssue  separated  and  broken  up,  with 
numerous  molecules  in  a  nodule  of  the  same  tumour  which  was  soft  and  in  some 
places  diffluent.  250  diam. 


CARTILAGINOUS  GROWTHS. 


187 


foetus.     At  others  the  fibrous  element  abounds,  the  whole  being-  similar 

Fis.  24-2. 


Fig.  iU. 


Fig.  243. 


Fig.  246. 


in  structure  to  fibro-cartilage.     Between  these  two   extremes  there  is 
every  gradation.     Occasionally  it  presents  all  the  characters  of  articular 

5  c 

a 


Fig.  246. 

cartilage.  I  have  seen  all  these  kinds  in  one  tumour.  The  cells  present 
an  extraordinary  variety  in  their  size  and  form,  being  sometimes  large 
and  embryonic  (Fig.  239),  at  others  small  (Fig.  242).  They  may  con- 
Fig.  242.  Small  cartilage  with  round  granule  cells,  in  the  pulp  scraped  from  the 
section  of  an  enchondroma,  which  in  colour,  density,  and  apijearance,  closely  resem- 
bled a  potato,  or  so-called  Solanoma. 

Fig.  24.3.  The  same  cartilage  cells,  after  the  addition  of  acetic  acid. 
Fig.  244.  Thin  section  of  a  firm  portion  of  the  same  tumour. 
Fig.  245.  Fine  filaments  which  interlaced  the  cells,  these  having  been  washed  out. 
Fig.  246.  Great  variety  of  cell  forms  containing  one  or  more  nuclei,  observed  in 
an  enchondroma  of  the  femur  ;  at  «,  nucleated  cells  are  enclosed  in  areolar  tissue ; 
at  b.  the  cells  nucleated  and  non-nucleated  possess  branched  processes ;  and  at  c,  are 
remarkable  bodies  of  different  sizes,  with  fine  radiating  lines. — ( Weill.)    250  diam. 


188  PEINCIPLES   OF   MEDICINE. 

tain  from  one  to  twenty  nuclei  (Fio-.  246).  In  shape  they  may  be  round, 
oval,  irregular,  or  branched.  They  may  also  be  associated  with  nume- 
rous granule  cells,  as  in  Fig.  242,  from  a  specimen  of  enchondroma, 
removed  from  the  integuments  of  the  neck  by  Mr.  Miller,  which  on  sec- 
tion presented  the  smooth  and  moist  surface  of  a  cut  potato. — (Sola- 
noma.)     (Figs.  242  to  245.) 

Not  unfrequently  a  bony  nucleus  may  be  observed  in  a  nodule  of 
enchondroma,  and  sometimes  all  stages  of  transformation  into  perfect 
bone,  may  be  observed  in  them.  Some  of  the  exostoses,  to  be  spoken 
of  inunediately,  are  owing  originally  to  an  excess  of  cartilaginous  growth. 

Enchondroraatous  tumours  are  continually  mistaken  for  cancerous 
growths,  a  fact  pointed  out  by  Miiller.  They  are  usually  denominated 
osteosarcoma.  Not  unfrequently  they  soften,  and  under  such  circum- 
stances, present  all  the  external  characters  of  what  is  called  soft  cancer. 


7. 


Fig-  24T.  Fig.  248.  Fig.  249. 

This  softened  portion,  even  when  examined  microscopically,  may  lead  to 
error,  as  the  cartilage  cells  which  then  float  loose,  mixed  with  granules 
and  the  debris  of  the  tumour,  very  much  resemble  those  in  cancerous 
growths.  They  may  be  distinguished,  however,  by  the  action  of  acetic 
acid,  which  aff"ects  the  whole  corpuscle  alike,  instead  of  producing,  as  in 
the  case  of  cancer,  a  marked  difference  between  the  external  cell-wall 
and  the  nucleus  (Figs.  240,  249). 

Another  form  of  cartilaginous  growth  is  observed  in  the  so-called 
pulpy  degenerations  and  ulcerations  seen  in  articular  cartilage.  Goodsir 
was  the  first  to  point  out  that  such  ulcerations  were  in  part  owing  to  an 
increased  growth  of  the  cells  ;  and  Redfern,  whilst  he  has  confirmed 
this  statement,  has  described  and  figured  all  the  various  changes  observ- 
able in  those  cells,  and  in  the  inter-hyaline  substance  in  the  difterent 
diseases  of  cartilage  in  man,  and  many  of  the  lower  animals.  In  conse- 
quence of  his  researches  it  is  now  ascertained  that  the  cartilage  cells 
enlarge,  and,  as  Goodsir  pointed  out,  there  are  gradually  formed  within 

Fig.  247.  Thin  section  of  an  enchondroma,  with  a  bony  capsule,  growing  from  the 
ischium  and  pubis. 

Fig.  248.  Separated  cartilage  cells  from  a  softened  portion  of  the  same  tumour. 
Fig.  249.  The  same,  rendered  more  opaque,  after  the  addition  of  acetic  acid.  250  di. 


CARTILAGINOUS   GROWTHS.  189 

them  a  mass  of  secondary  ones.     These  burst  into  the  surrounding  hya- 


•\>r. 


"t 


^.    ^J 


^1*^^*)^  v\^'9^^;4^^^! 


•'1  ,  \         "JV     -^ 


0, 


0  ^7^^-^ 


■  (■' 


Fiji.  250. 


line  substance,  give  it  unusual  softness,  and  cause  it  to  swell.     At  the 


■*^ 


i$M 


Fi-  252. 


same  time  the  hyaline  substance  fibrillates,  and  splits  up,  a  change  best 
observed  on  the  villous  and  rough  abraded  surface  so  commonly  seen  in 
diseased  joints.    Mechanical  injury  inflicted  on  these  structures  produces 


Fig.  250.  Diseased  liuman  articular  cartilage,  from  a  scrofulous  joint,  showing  tlie 
enlargement  of  the  coriDuscles,  the  increase  of  nuclei  within  them,  and  tlieir  escape 
into  the  intercorpuscular  softened  substance. — {Kedfern.) 

Fig.  251.  Similar  alteration  in  costal  cartilage  of  the  dog,  caused  by  the  passage 
of  a  seton  thirty-four  days  before  death. — {Redftrn.) 

Figs.  252  and  253.  Different  appearances  of  enlarged  cells  in  diseased  human 
articular  cartilage. — {Eedfern. ) 


190 


PRINCIPLES   OF   MEDICINE. 


the  same  results,  showing  that  both  it  and  disease  operate  by  stimulating 
cell  nutrition  and  growth  (Figs.  250  to  257,  and  275). 


Fis.  254. 


=akoi_: 


Fisr.  255. 


Fig.  25". 


Osseous  Groivths. —  Osteoma. 


"We  have  seen  that  in  many  cartilaginous  growths  deposit  of  bone  may 
take  place  to  a  greater  or  less  extent.     In  such  cases  the  new  cartilaginous 


Fig.  254.  Tertical  section  of  cartilage  from  the  surface  of  the  patella,  showing  the 
fibrous  splitting  up  of  the  hyaline  substance. — {Bedfern.) 

Fig.  255.  Another  vertical  section  through  the  same  diseased  articular  cartilage; 
a,  free  surface. — [Redftrn.) 

Figs.  256  and  257.  Two  fibrous  projections,  from  the  flocculent  suiface  of  a  dis- 
eased human  semilunar  cartilage. — {Bedfern.)  250  diam. 


OSSEOUS   GROWTHS. 


191 


0^ 


Fis.  258. 


\ 


\ 


Fist.  259. 


Y\<i  260. 


Fie.  261. 


tissue  undergoes  the  true  bony  transformation,  in  the  same  manner  that 

Fig.  258.  Xodulated  exostosis  attached  by  an  osseous  pedicle  to  the  inferior  and 
inner  portion  of  the  femur  of  a  woman,  ajt.  23.  It  had  been  growing  from  her  ear- 
liest youth,  was  accidentally  broken  off  by  a  blow,  and  shortly  after  excised  by  Mr. 
Syme.     Koiural  size. 

Fig.  259.  Lateral  view  of  an  exostosis,  removed  from  the  posterior  and  inner  sur- 
face of  the  humerus,  two  inches  from  its  head,  by  Mr.  Syme.  At  o,  a  piece  of  the 
tumour  has  been  broken  off,  showing  the  cancellated  structure  of  the  interior. — [Lis- 
ter.)    Real  size. 

Fig.  260.  Part  of  a  section  through  one  of  the  prominences  of  the  tumour,  a, 
Superficial  cartilage;  c,  a  portion  of  deep-seated  cartilage,  surrounded  by  dense 
bone ;  6,  and  d,  e,  calcified  cartilage  not  so  dense  as  the  more  superficial  portions. — 
(Lister.)     Seal  size. 

Fig.  261.  Section  of  a  portion  of  the  tumour  at  the  line  of  junction  of  the  calcified 
cartilage,  and  the  cancellous  structure  of  the  interior,  the  earthy  matter  having  been 
removed  by  dilute  hydrochloric  acid.  «,  Cartilage,  with  its  cells  changed  by  the 
process  of  calcification  ;  b,  c,  is  true  bone,  containing  laminae,  lining  the  excavations 
in  the  calcified  cartilage  ;  d,  part  of  a  spiculum  of  the  cancellous  structure ;  e  and/ 
spaces  formerly  occupied  by  medullary  substance — (Lister.)  200  diam. 


192  PRINCIPLES   OF   MEDICINE. 

normal  cartilage  becomes  ossified  in  passing  from  the  fatal  state  through 
the  periods  of  youth,  manhood,  and  old  age.  This  we  must  separate 
from  the  numerous  forms  of  calcareous  concretions  so  frequently  met 
with.  True  bone  may  be  at  once  recognised  by  its  osseous  lacunie  and 
canaliculi.  Earthy  concretions  only  consist  of  an  amorphous  mass  of 
mineral  material.     (Compare  Figs.  265  and  345.) 

Osseous  growths  may  affect  the  external  surface,  the  substance,  or  the 
internal  surface  of  bone.  In  the  first  case  they  are  denominated  exosto- 
ses. They  form  prominences  on  the  surface  of  the  bone  varying  in  size 
from  a  small  point  to  that  of  a  cocoa-nut.  Tliere  is  no  part  of  the  osse- 
ous frame  free  from  them,  but  they  are  very  common  in  the  bones  of  the 
extremities.  They  may  arise  as  the  result  of  direct  local  injury,  as  from 
a  blow  or  fall,  or  they  may  be  connected  witli  peculiar  constitutional 
diseases.  In  syphilitic  constitutions,  exostoses  more  especially  arise 
on  the  shafts  of  the  long  bones  ;  in  rheumatic  persons,  they  surround 
the  joints. 

Many  of  these  growths  on  the  surface  of  bones  have  not  been  shewn 
to  originate  in  cartilage  as  the  bones  themselves  do.  But  in  others  there 
can  be  no  doubt  that  such  is  their  mode  of  growth,  viz.  matter  is 
thrown  out  from  the  blood,  which  is  converted  first  into  cartilage  and 
then  into  bone  (Fig.  261).  In  this  manner  enchondroma  may  be  con- 
verted jnto  osteoma.  The  growths  in  which  this  change  is  observable 
generally  present  roundish  masses.  They  may  be  intensely  hard  or 
eburnated,  or  comparatively  soft  and  cancellated.  This  is  owing  to  the 
bone  texture  being  more  compact  in  the  one  case,  and  more  spongy  in 
the  other.  Externally  they  may  be  covered  with  a  layer  of  cartilage, 
and  a  smooth  membrane  (Fig.  258). 

Bonv  growths  may  more  especially  affect  the  substance  of  bones,  and 
this  in  two  ways.  An  exudation  may  be  poured  into  the  cancelli  of  tlie 
osseous  texture,  which  is  gradually  transformed  into  perfect  bone.  From 
this  cause  its  substance  becomes  much  indurated  and  of  great  density, 
and  the  cancelli  and  medullary  cavity  are  more  or  less  obliterated.  "We 
frequently  observe  this  in  the  long  bones  of  the  inferior  extremity  as 
well  as  in  the  flat  bones  of  the  cranium.  Some  of  the  latter  have  thus 
become  upwards  of  an  inch  in  thickness,  and  on  section  presented  the 
close  texture  and  density,  although  not  the  structure,  of  ivory.  Some- 
times, however,  the  bones,  instead  of  being  condensed  and  thickened, 
become  spongy,  the  cancelli  enlarge,  and  the  whole  assumes  unusual 
lio-htness.  In  this  case,  the  exudation  poured  into  the  cancelli  is  trans- 
formed into  pus,  and  acts  as  a  distending  power,  and  sometimes  collects 
in  a  central  cavity,  causing  at  the  same  time  expansion  and  hypertrophy 
of  the  surrounding  osseous  tissue  (Figs.  191,  192).  On  other  occasions 
the  new  osseous  growth  assumes  the  form  of  spicula,  radiating  fi"om  the 
shaft,  a  result  most  common  in  cases  where  the  bone  is  the  seat  of  sar- 
comatous or  cancerous  formations,  through  which  they  ramif)^  (Fig- 
262). 

Bony  growths  are  sometimes  thrown  out  on  the  internal  surface  of  the 
cranial  bones.  This  occurs  in  a  peculiar  disease  first  described  by  Ro- 
kitansky  in  puerperal  women.  I  saw  this  formation  frequently  in  Berlin, 
on  the  internal  surface  of  the  cranial  bones,  in  the  numerous  dissections 
which  occurred  in  the  Maternity  Hospital  of  that  city  during  an  epide- 


OSSEOUS   GROWTHS. 


193 


mic  puerperal  fever  wliicli  raged  there  in  1840.  Unfortunately,  tliev 
were  not  examined  microscopi- 
callv.  The  internal  table  of  the 
skull  in  all  these  cases  was  so 
soft,  that  the  knife  could  rea- 
dily penetrate  it.  These  de- 
posits, when  dry,  assume  a  gra- 
nular laminated  aspect,  more  or 
less  curled  up  and  separated 
from  the  internal  lamina  of  the 
cranial  bones.  Very  fine  spe- 
cimens of  this  lesion  are  to  be 
found  in  the  pathological  mu- 
seums of  Prague  and  Vienna. 

There  is  a  form  of  growth 
generally  originating  in  bone, 
which  is  soft,  easily  breaking 
down  under  the  finger  like  rice- 
pudding  or  marrow  (hence 
called  myeloid  by  Mr.  Paget). 
It  has  frequently  been  con- 
founded with  soft  cancers,  as 
pointed  out  by  Lebert,  and,  in 
addition  to  fibrous  and  fusiform 
cells,  contains  others  of  a  round 
or  oval  form,  varying  in  size 
from  the  g^^-oth  to  the  g^otli  of 
an  inch  in  diameter,  having  in 
their  interior  from  two  to 
twenty  nuclei.  These  growths 
occur  in  various  situations,  but 
are  most  common  in  bones,  especially  of  the  jaw,  constituting  certain 
forms  of  epulis  (Figs.  263,  264).  The  large  cells  often  contained  in  the 
friable  matter  of  such  growths  (Fig.  264),  closely  correspond  to  the 
many-nucleated  corpuscles  described  by  Kolliker,  as  occurring  in  the 
marrow  of  foetal  bones.*  A  remarkable  example  of  it  is  figured  by  Mr. 
Paget,  occurring  in  the  bones  of  the  cranium,  and  in  the  brain.f 

The  growth  of  neiv  bone,  after  fractures  or  injuries,  takes  place  hi  the 
following--  manner  :  An  exudation  is  poiired  out  from  the  vessels  in  the 
neio-hbourhood,  which  at  first  unites  the  lacerated  edges  of  ruptured 


Fig.  262. 


*  Manual  of  Human  Histology,  vol.  i.  fig  7. 

+  Surgical  Pathology,  vol.  ii.  p.'  222.  The  peculiar  character  and  structure  of  these 
oTOwths°ma}-  ultimately  warrant  theu-  being  classified  among  the  primary  division  of 
tumours,  under  the  name  of  myeloma.  But  at  present  our  acquaintance  with  them 
is  limited,  and  the  many-nucleated  cells,  which  is  their  chief  characteristic,  I  have 
seen  in  growths  presenting  all  the  characters  of  sarcoma,  adenoma,  epithelioma,  and 
enchondroma. 


Fig.  262.  Spicular  growth  of  bone,  in  an  osteo-carcinomatous  tumour  of  the  tibia. 
One-fowih  the  natural  size. — {Syme.) 

13 


194 


PRINCIPLES   OF  MEDICINE. 


periosteum,  muscle,  and  cellular  tissue,  so  as  to  form  a  capsule  around  the 

whole  of  the  denuded  and 
injured  bone.  This  exuda- 
tion, at  first  granular,  is  partly 
transformed  into  fibrous  tis- 
sue, and  partly  into  com- 
pound granular  corpuscles, 
which  may  be  observed  to 
form  an  internal  coating  to 
the  capsule  just  alluded  to. 
The  blood  extravasated  is 
rapidly  absorbed,  and  a  gela- 
tinous exudation,  which  is 
poured  out  from  the  neigh- 


Fig.  263. 


bouring  capillaries,  collects  between  the  capsule  and  denuded  bone.    This, 
at  first  yellowish,  becomes  gradually  lactescent  and  white,  and  assumes 

all  the  characters  of  fibro-carti- 
lage.  (Fig.  265,  a.)  This  car- 
tilage, in  its  turn,  is  transformed 
into  bone,  by  exactly  the  same 
process  as  the  one  structure 
passes  into  the  other  in  the 
normal  state.  As  solidification 
takes  place,  the  soft  parts  are 
absorbed  and  contracted,  whilst 
the  bony  growth,  in  the  form 
of  spicula,  forming  the  boun- 
daries of  large  cancelli  (Fig.  265, 
b),  insinuates  itself  between  and 
around  the  fractured  bones, 
producing  complete  union. 

Certain  textures  have  been 
occasionally  transformed  into 
true  bone.  I  examined  the 
preparation  of  an  eye  at  Munich, 
in  the  possession  of  Professor 
Forg,  which  contained  an  osse- 
ous mass,  attached  internally  to  the  choroid  and  fibrous  structure  of 
the  sclerotic,  and  encroaching  considerably  on  the  space  usually  occupied 
by  the  vitreous  humour.  A  thin  section  of  it  exhibited  numerous  bony 
corpuscles.  A  similar  osseous  transformation  of  the  choroid  membrane 
and  lens  has  been  described  and  figured  by  Dr.  Kirk,*  in  a  diseased  eye 
of  thirty  years'  standing  (Figs.  267,  268,  269).  I  have  seen  true  bone 
formed  in  the  substance  of  the  dura  mater,  where  it  has  been  exposed 

*  Monthly  Journal  of  Medical  Science,  November  1853. 

Fig.  263.  Epulis  removed  from  the  upper  jaw.     Natural  size. — (Syme.) 

Fig.  264.  Cells  with  many  nuclei  in  epulis. 

Fig.  265.  a,  Fibro-cartilage  formed  between  the  separated  portions  of  a  fractured 
cervix  feinor is ;  b,  new  osseous  structure,  in  the  form  of  a  bony  spiculum  or  trabe- 
cula  between  the  large  cancelli,  from  the  same  fracture. — ( Wedl.)  250  diajn. 


Fig.  265. 


OSSEOUS  GROWTHS. 


195 


after  removal  of  a  portion  of  the  cranium  by  the  trepan.     The  osseous 
lamina?,  sometimes  found  on  the  surface  of  the  spinal  arachnoid,  also 


Fis.  266. 


Fi?.  267. 


Fis.  263. 


possess  the  true  bony  structure  (Fig.  269).     Ligaments  have  occasionally 
been  transformed  into  osseous  texture  (Henle)  -,  "the  calcareous  concretions 


^^-^ 


^ 


Fis.  269. 


occasionally  found  in  the  centre  of  fibrous  tumours,  though  generally  com- 
posed of  amorphous  mineral  matter,  are  sometimes  formed  of  true  bone 

Fig.  266.  Spiculum  of  bone  projecting  from  the  choroid  membrane. — {Kirk.) 

Fig.  267.  Section  from  the  centre  of  the  crystalline  lens,  of  stony  hardness  from 
osseous  transformation.  In  the  centre  are  spheroidal  mineral  masses,  composed 
of  carbonate  mixed  with  phosphate  of  lime. — {Kirk.) 

Fig.  268.  Loose  membranous  matter,  like  the  collapsed  pith  inside  a  quill,  found 
in  the  anterior  chamber  of  the  same  eye.  On  one  of  its  surfaces  were  projecting 
tubercles  with  a  radiated  structure. — (Kirk.) 

Fig.  269.  Ossified  excrescence  on  the  arachnoid  of  the  thoracic  portion  of  the 
spinal  cord;  at  a,  a  portion  is  cut  across. — {Wedl.) 

Fig,  270.  a,  Bony  laminae  arranged  concentrically;  b,  others  arranged  irregularly 
in  partially  ossified  "fibrous  tumour  of  the  uterus. — (  Wedl.)  250  diani. 


196 


PRINCIPLES   OF  MEDICDSTE. 


(Fig.  270,  a,  b);  and  Dr.  Wilkinson  of  Manchester  communicated  to  the 
Pathological  Society  of  that  city  an  instance  where  numerous  muscles  of 
the  body  had  undergone  a  like  transformation.  In  all  these  cases  the 
osseous  structure  is  formed  on  a  fibrous  and  not  on  a  cartilaginous  basis, 
an  occurrence  which  may  be  accounted  for  by  the  analogy  which  exists 
between  cartilage  and  certain  forms  of  fibre  cells.  Many  kinds  of  morbid 
fibrous  growth  contain  cells  and  nuclei,  which  present  all  degrees  of  inter- 
mediate formation  observable  in  those  of  fibrous,  cartilaginous,  and  osseous 
textures.*     (Compare  Figs.  163,  246,  265  o,  269,  27o") 

Of  earthy  depositions  which  to  the  naked  eye  frequently  resemble 
them,  whether  amorphous  or  assuming  a  regular  form  from  accidental 
circumstances,  I  shall  speak  more  at  length  under  the  head  of  Con- 
cretions. 

Cancerous  Growths. —  Carcinoma. 

By  a  cancerous,  as  distinguished  from  any  other  kind  of  growth,  may 
be  understood  nucleated  cells,  presenting  the  characters  previously  de- 
scribed and  figured  (p.  134,  et  aeg.),  infiltrated  among  the  meshes  of  a 
fibrous  stroma,  or  among  the  normal  structure  of  an  organ.  If  the  fibrous 
clement  be  in  excess,  it  constitutes  scirrhus  or  hard  cancer ;  if  the  cells 
be  numerous,  we  have  encephaloma  or  soft  cancer ;  and  if  the  fibres 
form  loculi,  containing  a  gelatinous  or  glue-like  matter  in  which  are  the 
cells,  it  is  colloid  cancer.  All  these  forms  of  cancer  may  occasionally 
be  observed  in  the  same  growth,  the  fibres,  cells,  and  gelatinous  fluid, 
heing  more  or  less  abundant  or  isolated  in  diff'erent  places      The  cha. 


0/1 


'■^mffiiB^ 


Fi2.  -271. 


Fis.  272. 


racter  of  nucleated  cells,  imbedded  in  a  tissue,  separates  cancer  from  all 
other  growths,  with  the  exception  of  fibre  cartilage,  in  which,  how^ever, 
the  translucent  appearance  of  the  cells,  and  their  different  behaviour 
under  the  action  of  acetic  acid,  are  sufificiently  distinctive.   (See  p.  188.) 


Fig.  271.  Carcinoma  of  the  breast,  at  an  early  stage  (Scirrhus),  after  being  cut 
out  and  bisected,  the  nipple  retracted. — {Liston.) 

Fig.  272.  Returning  carcinoma  in  the  breast,  after  operation,  presenting  a  series  of 
nodules  in  and  around  the  cicatrix.    One  in  the  centre  has  ulcerated. — {Cruveilhier.) 


GENERAL  PATHOLOGY  OF   MORBID   GROWTHS. 


197 


Fig.  27y. 

In  no  general  consideration  of  morbid  growths  can  cancer  be  over- 
looked ;  but,  like  pus,  it  is  an  exudative  growth,  and  foreign  or  hetero- 
logous to  the  tissues.  Hitherto,  however,  it  has  so  mingled  itself  in  all 
our  notions  concerning  tumours,  and  practically  it  so  meets  us  when  we 
come  to  consider  their  diagnosis  and  treatment,  that  we  are  constrained 
in  our  general  views  of  this  subject,  constantly  to  keep  it  in  view.  Hence, 
as  a  growth,  we  shall  in  the  "following  remarks  speak  of  it  under  the 
name  of  Carcinoma,  the  general  aspect  of  which  is  represented  in  the 
preceding  figures,  showing  the  scirrhoid,  recurrent,  and  fungoid  appear- 
ances of  the  disease,  when  it  attacks  the  mamma. 

General  Pathology  of  Morbid  Growths. 

The  general  pathology  of  morbid  growths  comprehends  a  considera- 
tion of  their  origin,  development,  propagation,  and  decline.  It  is  impos- 
sible to  over-estimate  the  importance  of  this  subject,  as  only  through  a 
knowledge  of  it  can  we  arrive  at  correct  principles  of  treatment.  Doubt- 
less many  facts  are  yet  to  be  discovered  as  to  the  structure,  chemical 
composition,  and  mode  of  formation  of  morbid  growths ;_  but  enough  lias 
been  ascertained  of  late  years  from  combined  histological  and  clinical 
research,  to  necessitate  great  modifications  in  tbe  views  hitherto  held 
reo-ardino-  them.  The  following  account  is  derived  not  only  from  care- 
fuf  study  of  what  has  been  written  by  others,  but  from  a  large  amount 
of  original  investigation. 

*  See  Memoir  on  Calcification  and  Ossification  of  the  Testicle,  by  Mr.  J.  S.  Gam- 
gee,  in  Researches  on  Pathological  Anatomy,  etc.,  8vo.  1856. 


Fig.  213.  Advanced  carcinoma  of  the  mamma,  exhibiting  a  prominent,  fungoid, 
and  bleeding  mass. — [Cruveilhier.) 


198  PRIXCIPLES   OF   MEDICINE. 

Origin  of  Morbid  Groioths. — All  morbid  growths  consist — 1st,  Of 
augmented  development  of  pre-existing  textures  (the  so-called  homolo- 
gous or  homeomorphous  growths)  ;  2d,  Of  new  elements  which  have  no 
previous  existence  in  the  economy  (the  so-called  heterologous  or  hetero- 
morphous  growths) ;  and  3d,  Of  these  two  sorts  of  growth  mingled 
together.  The  causes  which  induce  them  are  of  two  kinds — 1st,  Local 
irritation  excited  directly  or  indirectly;  and  2d,  Constitutional  or  un- 
known changes,  supposed  to  operate  through  the  blood.  Thus  the  direct 
stimulus  of  a  blow  may  so  irritate  the  parenchyma  of  a  part,  as  to  excite 
increased  nutritive  action,  and  cause  hypertrophy,  or  it  may  give  rise  to 
an  exudation  ;  and  irritation  at  a  distance  may,  through  the  nervous 
system,  produce  like  eflects,  as  when  the  female  mamma  is  influenced 
by  the  state  of  the  uterus.  If,  on  the  other  hand,  the  constitution  be 
affected,  such  local  changes  may  assume  peculiar  characters.  In  tliis 
manner,  age,  sex,  hereditary  predisposition,  and  various  disorders,  as 
syphilis  and  cancer,  not  only  modify  but  give  rise  to  morbid  growths. 

It  has  been  a  favourite  idea  with  pathologists  that  morbid  growths 
have  fixed  tendencies  from  the  beginning,  such  as  are  impressed  upon 
the  ova  of  various  animals,  in  virtue  of  which  they  are  necessarily  deve- 
loped in  certain  directions.  If  so,  this  is  not  traceable  to  any  pecu- 
liarity of  structure  or  chemical  composition.  In  this  respect  morbid 
growths  are  like  healthy  ones,  which,  however  different  in  ultimate  com- 
position, all  originate  in  a  finely  molecular  blastema.  A  commencing 
small  white  nodule  of  cancer  in  the  stomach,  about  the  size  of  a  split 
pea,  was  ascertained  by  me  to  present  exactly  the  same  kind  of  mole- 
cular matter,  exuded  in  the  areolar  tissue  between  the  muscular  and 
mucous  coats,  as  occurs  in  simple  exudation.     A  careful  observation  of 


Fi?.  274. 


the  subsequent  development  of  these  growths,  however,  seems  to  indicate 
that  specific  differences  are  not  impressed  upon  them  from  the  first — 
that  one  does  not  as  a  matter  of  course  exclude  the  other,  but  that  any 
of  the  classes,  into  which  they  have  been  divided,  may  supervene  upon 
pre-existing  ones.  For  instance,  persons  may  have  a  fibrous  or  glandular 
growth,  and  after  a  time  its  blood-vessels  may  pour  into  it  a  cancerous 
exudation,  or  this  latter  may  undergo  a  fibrous  or  fatty  transfoi'mation. 
It  is  only  in  this  manner  we  can  explain  numerous  cases,  which  are 
daily  observable  in  practice,  where  indolent  fibrous  tumours  suddenly 
assume  increased  power  of  development  and  become  cancers,  or  where 
these  last  slough  out  and  subsequently  cicatrize. 

Besides  these  constitutional  causes,  locality  and  the  nature  of  pre- 


Fig.  274.  Section  of  small  commencing  cancerous  nodule,  growing  from  the 
mucous  coat  of  the  stomach,  showing  molecular  exudation  between  the  epithehal 
and  muscular  coats,     a,  EpitheUum ;  h,  muscular  coat.     Xo  glands  were  visible. 

250  diam. 


GENERAL   PATHOLOGY  OF   MORBID   GROWTHS.  199 

existing  textures  have  a  considerable  influence  on  the  formation  of  morbid 
growths.  Thus,  as  a  general  rule,  fibrous  growths  are  common  in  fibrous 
textures,  cartilaginous  and  bony  growths  in  osseous  ones,  epithelial 
growths  on  epidermic  and  mucous  membranes,  and  so  on.  Yet,  even 
here,  the  particular  states  of  the  system  generally  occasion  diff'erences 
in  their  modes  of  manifestation.  For  example,  osseous  growths  in 
rheumatic  constitutions  occur  at  the  extremities  of  long  bones,  but  in 
syphilitic  ones  are  found  in  their  shafts.  In  youth,  epithelioma  occurs 
in  the  form  of  warts  on  the  hands  ;  in  persons  touched  with  syphilis,  in 
the  genitals ;  in  chimney-sweeps,  on  the  scrotum  ;  in  smokers,  on  the 
lips,  etc.  This  conjoined  influence  of  constitutional  and  local  influences 
indicates  the  complex  nature  of  the  causes  which  produce  these  growths. 
A  study  of  these  causes  is  of  the  greatest  moment  to  the  physician,  who 
is  desirous  of  operating  upon  the  local  disease  through  the  constitution, 
or  the  contrary — as  pi'eviously  explained  in  the  sketch  of  the  function 
of  nutrition. 

Development  of  Morhkl  Groxoths. — Morbid  growths,  once  formed, 
continue  to  grow  according  to  the  histological  laws  which  regulate  deve- 
lopment in  the  textures  generally — that  is  to  say,  after  arriving  at  a 
certain  point,  they  attract  from  the  blood-vessels  in  the  neighbourhood, 
or  from  such  new  ones  as  are  formed  within  themselves,  the  nutritive 
materials,  whereby  they  augment  in  bulk.  In  voluntary  muscular  fibre 
this  appears  to  be  accomplished  by  the  fasciculi  multiplying  fissiparously. 
They  divide  as  represented  (Fig.  139),  and  hypertrophy  is  thus  occa- 
sioned by  multiplication  of  parts.  In  non-voluntary  contractile  fibre, 
also,  the  individual  fusiform  cells  multiply,  enlarge,  and  elongate,  a 
change  well  observed  in  the  pregnant  uterus,  in  which  organ  many  of 
the  small  non-contractile  spindle-shaped  fibres  enlarge,  become  contrac- 
tile, and  then  undergo  the  fattv  degenei'ation,  break  down,  and  ultimately 


X 


disappear  (Figs.  140,  141,  306).     In  the  same  manner  the  elementary 
parts  in  hypertrophies  of  other  textures  augment  fissiparously  or  endo- 

Fig.  2*75.  Appearance  of  cartilage  on  each  side  of  an  incision  made  into  the  patella 
of  a  dog ;  thirty  days  afterwards,  the  cells  were  found  enlarged,  with  internal  mul- 
tipUcation  of  nuclei. — {Redfern.)  250  diam. 


200 


PRINCIPLES   OF   MEDICINE, 


genonsly  as  in  bone  and  cartilage.  Tbat  this  may  be  the  result  of  local 
irritation  is  remarkably  well  shown  by  an  experiment  of  Dr.  Redfern's. 
Having  made  an  incision  into  the  cartilage  of  the  patella  of  a  dog,  he 


Fig.  276. 


found,  on  subsequent  examination,  that  the  cells  had  enlarged  in  the 
neighbourhood  of  the  divided  tissue,  and  nearest  the  osseous  vessels,  as 
seen  Fio;.  275. 


2sS^  Wd^^^wih^ 


m9 


^afe-^.lr.ifS^ 


Other  forms  of  morbid  growth,  especially  tumours,  are  verv  variable 
as  to  rapidity  of  increase ;  but  the  manner  in  which  the  development  is 


Fig.  276.  CartOage  cells  from  a  velvety  articular  cartilage  of  the  condyle  of  the 
femur  of  a  man — (KolUker.)  350  diain. 

Fig.  277.  Cells  li'om  a  cancerous  tumour  of  the  brain. — {Etdjern.)       250  diam. 


GENERAL   PATHOLOGY   OF   MORBID   GROWTHS.  201 

accomplished  is  of  three  distinct  kinds.  1st,  The  elementary  textures 
are  produced  in  the  same  manner  as  they  are  in  adult  tissues.  They 
are  either  more  numerous  or  larger,  but  preserve  their  normal  relation 
and  mode  of  arrangement  (lipoma,  adenoma,  angionoma).  2d,  A  mat- 
ter is  thrown  out  from  the  blood,  which  serves  as  a  blastema  foi-  the 
formation  of  cells,  which  may  be  detected  in  various  stages  of  develop- 
ment, undergoing  the  same  changes  that  similar  textures  are  seen  to 
present  in  the  embryo  (fibroma,  osteoma).  3d,  The  cells,  whether  pre- 
existing or  newly  formed,  assume  such  a  property  of  self-multiplication, 
that  their  normal  relation  and  mode  of  arrangement  is  destroyed  (epi- 
thelioma, enchondroma,  carcinoma).  These  three  modes  of  increase  may 
occur  singly  or  together.  Any  one  or  two  of  them  may  be  superadded 
to  the  third,  and  their  occurrence  at  ditierent  times  and  in  A^aiious  pro- 
portions accounts  to  a  great  extent  for  the  apparent  anomalies  exhibited 
in  the  pi'ogress  of  individual  growths. 

The  third  mode  of  development  just  alluded  to  deserves  special  con- 
sideration. It  consists  of  the  usual  kind  of  endogenous  multiplication 
of  cells,  with  this  diflference,  that  sometimes  these  cells  previously  existed, 
whilst  at  others  they  have  been  newly  formed  in  an  exudation.  To 
explain  my  meaning,  I  must  beg  the  reader  to  consult  the  two  preceding- 
figures — one  by  Kolliker,  representing  cell  structures  in  the  softened 
articular  cartilage  of  man,  and  the  other  by  Redfern,  showing  similar 
formations  in  a  cancerous  exudation  into  the  brain.  In  both  a  similar 
mode  of  cell  development  will  be  perceived,  yet  the  one  takes  its  origin 
in  pre-existing  articular  cartilage  cells,  whilst  the  other  must  arise  in  the 
new  cells  of  an  exudation,  as  the  white  substance  of  the  brain  contains 
no  corpuscles  from  which  they  could  be  developed.  In  the  cornea  and 
epithelium  similar  changes  occur,  as  well  as  in  the  bones  and  mesenteric 
glands.  Yet  these  lesions,  so  closely  allied  in  their  essential  nature, 
have  in  these  different  textures  been  called  by  different  names,  and  have 
been  widely  separated  pathologically.  In  the  non-vascidar  cornea  and 
cartilage,  it  has  been  called  inflammation,  but  in  the  equally  non-vascular 
epithelium,  it  has  been  named  cancer.  Again,  in  the  vascular  bones 
and  glands,  a  cancerous  exudation  has  received  various  names,  such  as 
medullary  or  osteo-sarcoma,  enlarged  glands,  etc. ;  whilst  in  the  brain 
and  other  localities  it  has  been  called  encephaloma,  or  soft  cancer.  It 
seems  to  me  that  in  all  these  cases  the  lesion  is  the  same,  and  therefore 
that  we  ought  in  accordance  with  their  nature  to  group  them  together. 
To  call  some  of  them  inflammation  and  others  cancer,  supposing  the 
first  to  be  innocent  and  the  last  malignant,  is,  I  contend,  incorrect  patho- 
logy. True  theory  points  out  that  all  these  lesions  are  equally  destruc- 
tive, in  consequence  of  increased  endogenous  cell  growth,  and  practical 
experience  has  long  determined  the  question  of  their  being  alike  difficult 
to  control. 

As  a  general  rule,  the  greater  the  number  of  cells  any  growth  contains, 
the  more  rapidly  it  extends.  Hence  a  tumour  is  subject  to  the  laws 
which  govern  the  development  and  multiplication  of  cells,  in  addition  to 
those  connected  with  locality  and  the  general  powers  of  the  constitution. 
Thus,  room  for  expansion  and  a  greater  or  less  amount  of  temperature 
and  moisture  exercise  undoubted  influence  over  morbid  growths.  We 
see  the  influence  of  room  for  expansion  in  the  cases  of  adenoma  and 


202  PRINCIPLES   OF  MEDICINE. 

carcinoma.  In  adenoma  the  cells  are  confined  within  pouches  or  ducts 
(Figs.  195,  198).  They  become  crowded  on  each  other;  and  thus,  by 
means  of  compression,  tend  to  atrophy  and  breaking  down,  rather  than 
to  self-multiplication.  This  is  assisted  if  the  distension  from  within  so 
irritates  the  fibrous  stroma  of  the  gland  that  it  becomes  hypertrophied, 
and  occasions  a  further  obstacle  to  expansion  around  the  seat  of  cell 
increase.  In  carcinoma,  we  observe  that  the  growth  takes  place  in 
extent  and  rapidity,  proportionally  to  the  number  and  power  of  expan- 
sion in  the  cells.  If  compressed  by  much  fibrous  or  hard  tissue,  they 
multiply  slowly ;  but  if  an  ulceration  occurs,  say  in  the  skin,  then  they 
become  developed  rapidly,  and  constitute  the  so-called  soft  fungoid 
excrescences.  Heat  and  moisture,  as  they  are  essential  to  cell  growth 
throughout  the  animal  and  vegetable  worlds  (increased  temperature  with 
fluidity  favouring — cold  and  dryness  checking  it,  within  certain  limits) 
so  the  influence  of  these  physical  agents  may  be  observed  to  be  equally 
powerful  in  morbid  growths.  Rapid  augmentation  of  a  tumour  is 
generally  accompanied  by  increased  heat  and  softening  of  the  parts, 
whilst  colder  and  harder  swellings  develop  themselves  slowly. 

Propagation  of  Morbid  Groivths. — It  has  seemed  to  most  pathologists 
that  while  some  morbi<l  growths  are  local,  and  if  removed  by  the  sur- 
geon do  not  return,  others  are  constitutional  or  general,  and  if  cut  away, 
exhibit  a  great  tendency  to  come  back.  The  former  have  been  called 
innocent  or  benignant,  and  the  latter  malignant.  So  far  has  the  notion 
of  malignancy  in  certain  growths  been  carried,  that  surgeons  have  refused 
to  remove  them,  not  because  they  were  inaccessible,  or  so  connected 
with  parts  as  to  render  the  operation  directly  dangerous  to  life,  but 
simply  because  they  thought  the  disease  was  in  the  blood,  and  that 
cutting  away  the  local  swelling  would  either  be  useless,  or  give  increased 
activity  to  the  lesion. 

Firmly  believing  that  many  lives  have  been  sacrificed  to  this  erroneous 
principle  of  practice,  I  endeavoured  to  combat  it  in  my  work  on  cancerous 
and  cancroid  growths,  published  in  1849.  The  progress  of  medical 
science  since  then  has  fully  confirmed  the  truth  of  my  opinions  on  that 
subject.  Cases  are  now  on  record  which  prove  that  every  kind  of  mor- 
bid growth  is  malignant,  even  in  the  worst  sense  of  those  who  use  that 
term,  and  that  other  growths,  which  the  most  experienced  surgeons,  as 
well  as  histologists,  have  declared  to  present  the  typical  characters  of 
malignancy,  have  been  repeatedly  excised  with  the  greatest  success. 
The  establishment  of  these  facts  by  the  many  recorded  cases  which  may 
now  be  confidently  depended  on  as  having  been  carefully  observed,  will 
go  far  to  prove  the  impropriety  of  this  distinction  between  morbid 
growths. 

Thus  Fibroma,  consisting  of  absolutely  nothing  but  fibres  in  all  its 
forms,  has  frequently  returned  after  operation,  so  that  it  has  received 
the  name  of  recurrent  (Syme,  Paget),  and  it  has  also  invaded  every  part 
of  the  economy.  The  dermoid  variety  has  been  shown  by  Mr.  Paget, 
not  only  to  return  in  the  mamma  after  excision,  but  to  infiltrate  itself 
in  the  form  of  numerous  distinct   nodules  throughout  the  lung.*     A 

*  Surgical  Pathology,  vol.  ii.  p.  151,  et  seq. 


GENERAL  PATHOLOGY  OF   MORBID   GROWTHS.  203 

somewhat  similar  case  is  given  by  Laurence,*  in  an  old  man,  and  another 
in  a  (jirl  aged  six  years.  Lebertf  has  recorded  seven  cases  where  sar- 
coma had  spread  to  the  neighbouring  glands  of  the  original  growth,  and 
to  various  internal  organs.  Professor  Smith  of  Dublin,;];  in  a  magnifi- 
cently illustrated  memoir,  has  published  two  cases  in  which  neuroma 
occui-red  in  all  parts  of  the  body,  and  Yirchow  has  given  a  case  where 
neuroma  returned  in  the  arm  four  times,  and  was  four  times  excised.§ 
Lipoma  may  be  general  in  the  form  of  excessive  obesity,  but  even  when 
local  may  return  after  extirpation. ||  Murchison  has  given  three  cases 
where  multiple  fatty  tumours  were  hereditary .•[  Angionoma  may  be  so 
constitutional  that  cases  have  been  published  in  which  aneurisms  were 
present  in  almost  every  artery  in  the  body.*''  Xaevoid  tumours,  return- 
ing after  operation  in  different  parts  of  the  body,  have  been  described 
by  Miiller  and  Walther  ;t°  and  two  others,  in  which  similar  vascular 
growths  were  disseminated  among  various  textures,  are  given  by  Cru- 
veilhierj"  and  Laurence.§-  As  regards  cystoma,  I  have  frequently  been 
struck  in  opening  dead  bodies  with  the  frequency  and  universality  of 
cystic  formations  in  some  of  them.  In  one  man  I  found  innumerable 
sebaceous  cysts  scattered  over  the  whole  anterior  surface  of  the  thorax 
and  abdomen.  The  constitutional  nature  of  ci/stoma,  moreover,  is  occa- 
sionally demonstrated  in  cases  of  bronchocele  and  molhisca.  Adenoma  is 
eminently  constitutional,  the  glands  being  differently  affected  in  a  variety 
of  general  disorders,  as  plague,  syphilis,  scrofula,  typhoid  fever,  etc. 
Yelpeau  refers  to  several  cases  where  it  recurred  after  operation  in  the 
same  or  opposite  breast,|P  and  Aitken  has  recorded  two  well-observed 
instances  where,  subsequent  to  the  growth  having  recurred  in  the 
mamma,  it  appeared  in  the  lungs,  liver,  and  ovaries.*^^  Ejiithelloma  not 
only  spreads  to  neighbouring  glands,  but  has  also  been  shown  by  Mr. 
Paget  to  infiltrate  the  lungs  and  heart,  after  operations  for  the  removal 
of  similar  growths  in  distant  organs.*'  Enchondroma  has  invaded 
numerous  parts,  and  among  others  in  the  same  case,  the  testicles  and 
lungs.f'  Osteoma,  composed  of  true  bone  (not  cancer  in  bone),  has, 
in  a  case  by  Mr.  Swan,  after  affecting  the  femur,  appeared  secondarily 
in  the  pleura,  lungs,  omentum,  and  diaphragm.|'  A  similar  case  is 
given  by  Laurence.§'    MullerJP   has  also  referred  to  such  constitutional 

*    On  Surgical  Cancer,  p.  73,  1st  edit. :  p.  26,  2d  edit. 

•j-    Traite  d'Anatomie  Pathologique,  p.  194,  et  seq. 

i    A  Treatise  on  Neuroma,  Folio,  Dublin,  1849. 

§    Archiv  fiir  Patholog.  Anat.  Band.  xii.  p.  114. 

II    Sedillot,  Recherches  sur  le  Cancer,  3  849,  obs.  xxix. 

^    Edinburgh  Medical  Journal,  June,  1857. 

*^  Cruveilhier.     Livraison  28.     Scarpa.     Tab.  ix. 

^^  Journal  der  Chir.  u.  AugenheDk,  B.  v.  p.  261.     1823. 

1^  Anatom.  Pathologique  Gen.  torn.  iii.     1856. 

§"  On  Surgical  Cancer,  p.  22,  2d  edit. 

I"  Maladies  du  Sein,  p.  404,  et  seq.  1st  edit. 

V  Medical  Tunes.  April  11,  1857,  p.  359. 

*'  Opus.  cit.  vol.  ii.  pp.  448,  449. 
f  Paget  in  Medico-Chir.  Trans,  vol.  xxxviii.    ♦ichte.  Ueber  das  Enchondrom. 
p.  58.    Laurence.  2d  edit,  p  23.    Richet,  Gazette  desHopitaux,  Nos.  71  and  95.    1855. 
:j:^  Lond.  Pathological  Trans,  vol.  vi.  p.  317. 
§^  On  Surgical  Cancer,  2d  edit.  p.  13. 
P  Archiv  fiir  Anatomie  tmd  Physiologic,  1843,  t.  v.  pp.  396,  442. 


204  PRINCIPLES    OF   MEDICINE. 

osseous  tumours  under  the  name  of  Osteoids.  Of  tlie  constitutional 
characters  of  carcinoma,  I  need  say  nothing. 

It  follows  that  every  kind  of  morbid  growth  may  be  malignant  in 
whatever  sense  that  term  be  employed,  whether  used  to  signify  a  growth 
incurable,  recurring  after  the  operation  or  primary  lesion ;  or  growths 
infiltrating  neighbouring  or  distant  tissues  and  organs,  or  as  con- 
tinuing their  progress,  and  destroying  life  in  spite  of  all  the  resources  of 
art. 

On  the  other  hand,  it  is  easy  to  prove  that  all  these  foi-ms  of  growth 
may  either  disappear  spontaneously,  or  be  cured  successfully  by  opera- 
tion, so  that  the  individual  may  permanently  recover.  With  regard  to 
carcinoma  this  has  been  denied  by  some  and  is  doubted  by  many.  On 
this  subject  I  wrote  in  1849  as  follows,  regarding  the  permanent  recovery 
from  cancer  : — "Doubts  must  always  exist,  regarding  such  cases,  so  long 
as  no  authentic  record  is  preserved  of  the  minute  examination  of  the 
tumour  removed.  Every  experienced  sui'gcon  who  adopts  a  favourable 
or  unfavourable  view  of  this  question  can  point  to  crowds  of  cases  in 
support  of  his  opinion  ;  but  when  he  is  asked  whether  the  growth  ope- 
rated upon  be  truly  cancer  or  not,  it  will  be  found  that  he  has  no  positive 
grounds  on  which  to  form  a  conclusion.  He  considered  it  to  be  cancer, 
nothing  more.  In  the  present  state  of  our  knowledge,  then,  I  believe 
that  there  is  no  possibility  of  pronouncing  accurately  whether  an  opera- 
tion will  be  successful  or  not.  It  appears  to  me  that  all  analogy  opposes 
the  doctrine  of  the  necessarily  fatal  nature  of  cancer,  or  of  any  other 
morbid  alteration  of  the  economy.  There  was  a  time  when  phthisis 
pulmonalis  was  also  thought  to  be  necessarily  fatal,  and  when  recoveries 
from  it  led  practitioners  to  doubt  their  diagnosis  rather  than  the  truth 
of  a  received  dogma.  Morbid  anatomy  has  exploded  that  error,  as  it 
will  doubtless  do  that  in  regard  to  cancer.*" 

Since  then  M.  Velpeau,  in  a  work  published  in  1854,  has  proved  the 
correctness  of  these  statements,  and  has  shown  that  cases  which  not 
only  presented  all  the  characters  of  scirrhoma  and  encephaloma,  but 
which  were  2»'oved  to  be  so  by  careful  histological  examination,  have 
been  successfully  extirpated  without  returning.  Some  of  these  cases  are 
truly  remarkable,  the  disease  having  advanced  apparently  to  its  last 
stage  and  involved  large  masses  of  neighbouring  glands,  so  that  the  ope- 
ration was  performed  under  the  most  unfavourable  circumstances.  In 
these  cases,  however,  the  persons  operated  on  have  lived  since  the  local 
extirpation  of  the  disease  up  to  this  time,  that  is,  from  five  to  nine  years, 
in  perfect  health.f 

While  thus  it  is  contended  that  there  is  no  growth  which  may  not  be 
malignant,  and  none  which  may  not  be  innocent  in  the  sense  inferred, 
it  is  not  denied  that  some  growths  have  a  greater  tendency  to  spread 
and  aftect  the  system  than  others.  In  reference  to  treatment,  therefore, 
it  becomes  of  the  greatest  importance  to  determine  the  laws  which  appa- 
rently govern  the  propagation  and  multiplication  of  different  morbid 
growths,  or  the  circumstances  which  render — say  carcinoma  and  epithe- 

*  Cancerous  and  Cancroid  Growths,  p.  233. 

f  Yelpeau,  Traite  des  Maladies  du  Sein,  etc.,  1854;  and  2d  edition,  1858,  in  the 
preface  to  which  are  enumerated,  p.  xxs.,  no  less  than  26  cases  which  up  to  the 
close  of  that  year  remained  well. 


GENERAL   PATHOLOGY   OF    AIORBID   GROWTHS.  205 

lioma — more  susceptible  of  beino;  communicated  to  neighbouring  and 
internal  organs,  than  purely  fibrous  or  osseous  growths. 

There  is  one  circumstance  in  reference  to  the  removal  of  tumours 
which  is  frequently  overlooked  by  surgeons,  viz.,  that  certain  growths 
abounding  in  cells  have  a  great  disposition  to  infiltrate  themselves  among 
muscles  and  neighbouring  parts,  and  may  be  detected  there  by  the 
microscope,  although  invisible  to  the  naked  eye.  In  one  case  I  found 
numerous  granules  and  commencing  cells  in  the  muscles  of  the  tongue, 
below  an  epithelial  ulcer,  though  it  seemed  healthy  (Fig.  213)  ;  and  in 
the  sterno-mastoid  muscle,  covering  a  tumour  of  the  parotid  gland, 
clumps  of  nuclei  were  developed,  and  the  fasciculi  of  the  muscle  were 
converted  into  fibres  (Fig.  278).  In  this  case  the  muscle  looked  pale 
and  atrophied,  but  exhibited  no  appearance  of  being  infiltrated  with 
cancer. 


_J3 

3 


It  follows  that  in  many  cases  where  the  surgeon  thinks  he  has  I'emoved 
a  morbid  growth,  he  merely  leaves  multitudes  of  germs  behind  which 
continue  to  propagate  the  disease.  Dr.  Handyside  removed  the  inferior 
extremity  of  a  boy  at  the  hip  joint,  in  June,  1843,  for  cancer  of  the 
femur.  I  carefully  examined  a  small  portion  of  one  of  the  upper  flaps, 
which  was  subsequently  cut  away,  on  observing  a  piece  of  the  tumour 
attached  to  it,  and  found  all  the  muscles  fatty  and  infiltrated  with  young 
cancer  cells  (Fig.  279).  In  short,  all  the  muscles  which  formed  both 
flaps  were  already  cancerous,  and  I  told  the  operator  that  the  disease 
would  probably  return  in  the  stump.  The  incisions  healed  favourably, 
but  in  a  few  months  cancerous  nodules  appeared  not  only  in  the  cicatrix 
but  in  other  places,  and  caused  death.*  I  have  also  seen  the  same  mode 
of  propagation  in  nerves,  as  has  been  figured  in  muscles  (Fig.  213,278). 
I  have  found  the  brachial  nerve  in  connection  with  a  cancerous  tumour 
of  the  humerus,  infiltrated  with  granular  masses  and  granules,  some  of 
these  latter  arranged  in  rows,  and  meeting  together,  apparently  to  form 
nuclei  of  new  cells,  as  in  Fig.  280.  Professor  Van  der  Kolk  of  Utrecht 
has  lately  confirmed  these  observations,  and  also  traced  incipient  cancer- 
cells  among  the  tubes  of  neighbouring  nerves. 

Hence  one  of  the  chief  modes  of  propagation  of  morbid  growths,  is 

*  Cancerous  and  Cancroid  Growths,  p.  103. 

Fig.  278.  Fibre  of  the  sterno-mastoid  muscle,  in  the  neighbourhood  of  a  cancer- 
ous growth,  partly  transformed  into  fibres,  with  masses  of  young  cancer-cells. 

250  diam. 


206 


PRINCIPLES    OF   MEDICINE. 


that  the  cells  in  the  process  of  development  become  infiltrated  among 
neighbouring  tissues.     But  how  do  they  accomplish  this  ?     Van  der 


Kolk  suggests  that  the  fluids  which  they  contain  mingle  with  the  juice 
of  the  parenchymatous  substance  around  them,  and  that  in  the  latter 
there  are  deposited  molecules  and  granules,  which,  having  received  from 
the  former  certain  tendencies  to  evolution,  are  ultimately  transformed 
into  similar  structures.  This  view  is  not  only  exceedingly  ingenious 
but  very  probable,  and  will  serve  to  explain  how  the  blood  and  distant 
organs  are  secondarily  aff'ected.  The  notion  of  solid  germs  floating  in  the 
blood  has  no  facts  in  its  support,  but  the  idea  of  a  fluid  secreted  by  cells 
being  absorbed  is  consonant  with  every  known  law  of  nutrition. 

The  fluid,  then,  of  a  moi'bid  growth,  elaborated  in  the  process  of  its 
development,  and  the  result  of  cell  or  other  formation,  would  seem  to 
be  the  most  pi'obable  material  whereby  secondary  growths  are  produced. 
We  have  seen  that  many  tumours  which  have  no  cells,  may  be  recurrent 


iliii 


'1 


Ife 


fig.  2S1.  Fig.  2S2. 

and  attack  tissues  secondarily.     Still  they  all  contain  a  parenchymatous 


Pig.  279.  Fasciculi  of  muscle,  forming  the  flap  in  an  amputation  of  tlie  tliigh, 
already  infiltrated  with  young  cancer  cells,  a,  The  latter,  after  the  addition  of  acetic 
acid. 

Fig.  280.  Granules,  nuclei,  and  granule  cells,  infiltrated  among  the  tubes  of  the 
brachial  nerve,  near  a  cancerous  growth. 

Fig.  281.  Structure  of  the  soft  part  of  tlie  tumour  removed  by  Mr.  Page  of  Car- 
lisle. 

Figs.  282  and  283.  Structure  of  the  more  indurated  parts.  250  diam. 


GENEEAL  PATHOLOGY   OF   MORBID   GROWTHS.  207 

juice,  and  as  a  general  rule  those  that  are  most  soft  and  pulpv  are  most 
liable  to  return.  I  have  recorded  two  singular  examples  of  cancroid 
growths  which  returned  and  proved  fatal.  In  one  of  these,  the  tumour 
was  removed  from  the  breast  by  Mr.  Page  of  Carlisle,  and  consisted  of  a 
pulp}'  fibrous  substance,  in  various  stages  of  development,  and  of  granu- 
lar cells.  Six  months  afterwards  a  similar  growth  of  like  structure 
formed  in  both  thighs,  of  which  the  patient  died  (Figs.  281  to  284). 

In  another  case  the  leg  was  amputated  above  the  knee  by  Mr.  Norman 
of  Bath,  for  a  fungoid  tumour,  below  the  gastrocnemius  muscle.     It  con- 
sisted of  fusiform  corpuscles  in  different  stages  of  development,  mingled 
with  naked  nuclei,  a  multitude  of  mole- 
cules   and  granules,  and   a  few  blood    /-  i  ,,i 
globules,  as  represented  in  the  figure   h                                            ,-;,W 
(Fig.  284).     Two  years  later  a  similar 
tumour   formed    in    the    right    chest.  ,  i 
which  compressed  the  lung,  and  caust-il                                                    _  j 
death.  ! 

These,  together  with  tbe    cases    of 
sarcoma,  neuroma,  enchondroma,   and     ,  '  , ,,, 

epithelioma,    referred   to,    show    that      ^  :^ 

constitutional  tendencies  do  exist,  for  .^   -  ' 

the  reproduction  of  morbid   growths  ^'^-  '^*^  ^'^-  ^^^• 

similar  to  those  which  have  previously  been  formed.  A  recurrence  of 
all  diseases,  and  especially  of  apoplexy,  epilepsy,  rheumatism,  bronchitis, 
etc.,  is  equally  common,  and  appears  to  follow  the  same  law.  But  the 
idea  tbat,  because  they  do  so,  they  should  be  distinguished  by  the  name 
of  "  malignant,"  appears  to  me  unpathological.  AVe  may  just  as  cor- 
rectly talk  of  a  rheumatism  being  innocent  or  malignant,  as  apply  those 
terms  in  different  cases  to  fibrous,  cartilaginous,  osseous,  or  other  kinds 
of  morbid  growth,  for  no  other  reason  than  because  sometimes  they  are 

calized  in  a  part,  and  at  others  are  more  general.* 

Decline  or  Degeneration  of  Morbid  Grou'ths. — In  their  decline,  as  in 
their  development,  the  various  kinds  of  morbid  growths  follow  the  laws 
which  regulate  degeneration  of  texture.  Some,  as  lipoma  and  adenoma, 
have   been    known  to  be  gradually   absorbed   and   disappear.     Others 

*  The  facts  to  which  I  have  alluded,  and  others  of  a  like  kind  that  are  daily 
occurring,  have  induced  M  Yelpeau,  in  the  recent  edition  of  his  work  on  diseases  of  the 
breast  (1858),  to  speak  as  follows  :  — "  J'ai  dit  plus  haut  que,  sans  avoir  de  convic- 
tion absolue  sur  les  transformations  cancereuses.  j'etais  loin,  cependant,  d'etre  aussi 
decide  qu'autrefois  dans  le  sens  negatif.  Les  faits,  en  se  multipliaut  daus  ma  pra- 
tique, ont  fini  par  ebranler  mes  croj'ances  et  meme  par  me  faire  pencher,  sous  ce 
rapport,  vers  la  doctrine  aflSrmative  defendue  avec  talent  en  dernier  lieu  par  M.  Ben- 
nett d'Edimbourg."  He  adds,  much  to  his  honour,  '•  Renoncer  aiusi  a  ses  anciennes 
doctrines,  juste  au  moment  oti  les  autres  savants  oii  la  jeunesse  active  et  laborieuse 
s'en  emparent  et  les  soutiennent  avec  ardeur,  peut  etre  penible  sans  doute,  mais  les 
besoins  de  la  verite  doivent  passer  avant  tout !" 


Fig.  284.  Structure  of  a  fungoid  growth  of  the  leg,  removed  by  Mr.  Norman  of 
Bath. 

Fig.  285.  The  same,  after  the  addition  of  acetic  acid.  250  diam. 


208  PRINCIPLES   OF  MEDICINE. 

undergo  the  albuminous,  fatty,  mineral,  or  pigmentary  transformations  to 
be  subsequently  described.  To  enter  into  tlie  peculiarities  of  each  mor- 
bid growth  in  this  respect  would  lead  me  too  far.  They  will  be  referred 
to  generally  afterwards.  All  I  need  say  here  is,  that  every  kind  of  mor- 
bid growth  may  degenerate  and  prove  abortive  in  one  way  or  another. 
Cancer  even  has  been  known  to  slough  out,  and  heal  by  cicatrix,  besides 
having  been  checked  in  its  development,  and  rendered  abortive  in  every 
known  mode  of  retrograde  transformation.  (See  Morbid  Degenerations 
of  Texture.) 


General  Treatment  of  Morbid  Growths. 

The  treatment  of  morbid  growths  may  be  divided  into  local  and  con- 
stitutional. The  local  treatment  comprehends — 1st.  Means  of  retarda- 
tion and  resolution  ;  2d,  Means  of  extirpation. 

1.  Means  of  Retardation  and  Resolution. — These  consist  in  applying 
all  those  means  which  are  opposed  to  development  of  tissue,  such  as 
topical  cold  and  graduated  pressure,  avoiding  moist  applications  and 
local  irritation.  Such  means,  as  they  are  opposed  to  those  circumstances 
which  are  known  to  favour  cell  growth  in  the  animal  and  vegetable 
worlds,  such  as  heat,  moisture,  stimulants,  and  room  for  expansion, 
might  be  expected  to  retard  the  progress  of  morbid  growths.  Dr.  James 
Arnot  has  in  consequence  found  much  benefit  from  the  application  of 
frigorific  mixtures,  and  Dr.  Niel  Arnot  has  applied  graduated  pressure 
with  occasional  good  effect.  The  difficulty  of  such  treatment  consists 
in  the  frequent  impracticability  of  their  application,  as  they  can  only  be 
serviceable  when  the  growth  is  situated  externally,  and  on  particular 
parts  of  the  body.  Such  treatment  also  is  counteracted  by  the  fact,  that 
although  you  may  freeze  the  external  parts,  the  growth  is  continually 
supplied  with  warm  blood  from  within ;  and  that  when  you  compress 
outside,  you  thereby  run  the  risk  of  causing  extension  towards  the  inte- 
rior. Both  these  means,  however,  which  may  be  carried  on  conjointly, 
are  eminently  deserving  further  trial.  As  moisture  favours,  so  diyness 
is  opposed  to  growth,  and  the  avoidance  of  local  irritations,  as  they  are 
a  common  exciting  cause,  is  obviously  indicated. 

2.  Means  of  Extirj^ation. — These  are  excision  of  the  part,  and  the 
application  of  chemical  agents  which  destroy  texture. 

From  all  we  have  said  as  to  the  origin,  mode  of  development,  and  pro- 
pagation of  morbid  growths,  it  would  appear  that  they  may  all  destroy 
life,  and  that  those  which  exhibit  the  most  rapid  powers  of  spreading 
may  supervene  on  the  more  indolent  ones.  Hence,  as  a  general  rule,  so 
soon  as  it  becomes  evident  that  means  of  retardation  and  resolution  have 
failed  to  arrest  their  progress,  an  operation  should  be  had  recourse  to. 
If  early  excision  were  more  practised,  many  of  the  lamentable  cases 
which  occur  in  practice  would  not  arise.  Should  the  cancerous  growth 
even  be  advanced,  it  should  never  be  neglected  so  long  as  the  diseased 
parts  are  external  and  within  the  reach  of  the  knife.  We  have  also 
seen  that  surgeons,  in  removing  tumours,  have  left  untouched  tissues 


GENERAL  TREATMENT   OF   MORBID   GROWTHS.  209 

infiltrated  with  cells  capable  of  causing  their  regeneration.  Hence  the 
neio-hbouring  textures  should  be  carefully  scrutinized,  and  all  those  por- 
tions of  them  infiltrated  with  cancerous  germs  carefully  removed.  For 
this  purpose  the  microscope  ought  to  be  a  necessary  instrument  in  the 
operating  theatre,  and  every  suspected  tissue  in  the  neighbourhood 
examined  by  experienced  histologists,  before  the  lips  of  the  wound  are 
closed.  This  proceeding,  which  I  recommended  in  1849,  has  not,  so  far 
as  T  am  aware,  yet  been  practised  by  surgeons,  but  its  propriety  has 
been  lately  supported  by  Van  der  Kolk,  and  it  will  yet,  I  believe,  be- 
come generally  practised,  when  a  knowledge  of  the  pathology  of  mor- 
bid growths  is  better  understood.  The  practice  of  M.  Girouard  of 
Chartres,  who  by  caustic  directed  towards  the  neighbouring  tissues 
around  cancers,  has  sought  to  destroy  the  germs  whereby  they  spread, 
and  thus  prevent  return  of  the  growth,  is,  in  this  point  of  view,  highly 
encouraging.* 

The  apptication  of  chemical  means,  as  various  kinds  of  escharotics, 
to  destroy  local  growth,  has  been  extensively  tried,  but  without  as  yet 
having  enabled  practitioners  to  arrive  at  any  definite  results.  The  great 
obstacle  is  the  impossibility  of  attacking  the  entire  growth  ;  and  if  this 
is  not  always  performed  by  excision,  still  less  frequently  is  it  accom- 
plished by  escharotics.  Of  late  years  an  opinion  has  prevailed  that  this 
mode  of  treatment  deserves  further  trial.f  M.  Velpeau  speaks  favour- 
ably of  sulphuric  acid  mixed  with  salTron  ;  and  Mr.  Syme  has  proposed 
sawdust  as  a  cheaper  material  than  salfron,  whilst  its  action  is  confined 
superficially  by  a  wall  of  gutta  percha  made  to  adhere  to  the  skin.J  By 
such  an  escharotic  the  whole  morbid  growth,  it  is  said,  may  be  destroyed 
at  once.  The  immediate  pain  is  prevented  by  bringing  the  patient  under 
the  influence  of  chloroform,  the  slough  is  subsequently  poulticed  until  it 
separates,  and  then  the  granulating  surface  allowed  to  heal.  Great  dis- 
cussion has  recently  occurred  as  to  the  value  of  the  chloride  of  zinc 
applied  by  vertical  scorings  or  slight  incisions,  so  that  it  shall  gradually 
percolate  through  the  entire  growth.  This  mode  of  proceeding  takes 
from  three  to  seven  Aveeks,§  but  is  effectual  in  removing  the  tumour,  as 
all  those  who  have  examined  the  preparations  in  the  Middlesex  Hospital, 
and  such  as  have  been  removed  by  the  same  method  of  alternate  inci- 
sion and  application  of  caustic  by  Mr.  MouUin  of  London,  may  easily 
satisfy  themselves.]!  M.  Maisonneuve  has  employed  Canquoin's  paste, 
composed  of  chloride  of  zinc,  1  part ;  wheat  flour,  3  parts  ;  mixed  up  with 
a  sutficient  quantity  of  water.  This  is  formed  into  ari-ow-shaped  heads, 
dried  and  thrust  into  or  around  the  tumour,  according  to  circumstances.^^ 
Other  chemical  agents  have  been  proposed,  but  the  experience  acquired 
of  these  methods,  and  especially  of  their  ultimate  good  eftects,  is  as  yet 
so  limited  as  to  preclude  the  possibility  of  forming  a  just  estimate  as  to 
their  merits. 

*  Archiv.  Gen.  de  Med.  torn.  xcv.  p.  739. 

f  Langston  Parker,  on  the  treatment  of  Cancerous  Disease  hy  Caustics.     1856. 
t  Ediuburo-h  Medical  Journal ;  November  1857. 
I  Report  of  the  Surgical  Staff  of  the  Middlesex  Hospital,  etc.     1857. 
I  I  have  myself  been  able  to  do  this  through  the  kindness  of  Drs.  Van  der  Byl 
and  Handfield  Jones. 

T[  Journal  of  Practical  Medicine  and  Surgery,  March  1858,  p.  485. 

14 


210  PRIXCIPLES   OF   MEDICIXE. 

Constitutional  Treatment. — We  are  altogether  unacquainted  witli  any 
means  of  counteracting  the  tendency  wliicli  predisposes  to  morbid 
2;rowtlis.  But  considering  that  for  the  most  part  the  constitutional 
change  is  connected  ^vith  excess  of  nutrition,  and  in  this  respect  is  alto- 
gether opposed  to  -what  we  observe  in  cases  of  scrofula  and  tubercle,  we 
may  infer  that  lowering  the  nutritive  processes,  while  we  yet  allow  the 
general  tissues  to  be  supported,  should  be  the  rule  of  practice.  In  car- 
cinoma, and  rapidly  formed  growths,  the  body  (unless  it  produce  emacia- 
tion bv  attacking  the  chylopoietic  viscera)  is  for  the  most  part  fatty,  and 
diminution  of  this  element  in  the  food  should  be  aimed  at.  But  at  a 
later  period,  when  exhaustion  makes  its  appearance,  nutrients  and  stimu- 
lants will  be  required  to  prolong  life. 


MORBID  DEGEXERATIOXS  OF  TEXTURE. 

In  the  same  manner  that  there  may  be  hypertrophy  or  increase,  so 
there  mav  be,  although  from  exactly  opposite  causes,  atrophy  or  diminu- 
tion of  texture.  Atrophy  may  consist  in  simple  decrease  of  bulk,  the  organ 
or  tissue  otherwise  retaining  its  usual  structure  and  function.  There 
mav  be  less  work  to  do,  and  less  force  consequently  required ;  and  for 
thesame  reason  that  the  legs  of  a  dancer  become  larger,  those  of  a  bed- 
ridden individual  become  smaller.  So  also  as  there  may  be  increased 
bulk  with  alteration  of  texture,  so  there  may  be  diminished  size  with 
chano-e  of  tissue.  These  latter  atrophies,  as  they  constitute  true  organic 
diseases,  especially  merit  our  attention  ;  and  they  may  be  arranged  in 
four  a;roups,  viz.— 1st,  albuminous;  2d,  fatty  ;  3d,  pigmentary  ;  and  4th, 
mineral  deo'enerations. 


Albuminous  Degexeratiox. 

We  have  already  seen  how  essential  albumen  is  to  nutrition  ;  and  that 
to  be  made  assimilable  in  various  forms  to  the  tissues  of  the  body,  it 
must  be  subjected  to  certain  processes.  Under  other  circumstances  it 
mav  be  effused,  or  collect  in  particular  parts  of  the  system,  constituting 
oro'anic  diseases.  If  transuded  through  the  vessels  in  a  fluid  form,  that 
is, "dissolved  in  water,  as  we  find  it  in  the  serum  of  the  blood,  it  produces 
what  is  called  dropsy.  If  precipitated  from  its  solution  in  a  solid  foi'm, 
it  mav  constitute  a  variety  of  inorganizable  deposits  presenting  various 
kinds"  of  ultimate  structure.  Lastly,  tissues  composed  of  various  proxi- 
mate principles  may  be  wholly  converted  into  an  albuminous  substance, 
and  thereby  have  their  vital  properties  impaired  or  lost.  We  shall 
notice  these  shortly  in  succession. 

Albumen  in  solution  is  frequently  effused  from  the  blood-vessels  as 
serum,  constituting  dropsy.  It  is  distinguished  from  an  exudation  by 
containing  no  fibrin.  There  is  not,  therefore,  that  disposition  to  rapid 
coagulation  and  formation  of  an  organizable  blastema,  although  there  is 
often  a  precipitation  of  matter,  capable  of  assuming  various  forms.   We 


ALBUMINOUS  DEGENERATION. 


211 


have  seen  tliat  an  exudation  depends  on  an  alteration  of  the  vital  force 
which  governs  the  attraction  and  selection  of  nutritive  materials  from 
the  blood.  Serous  effusion  or  dropsy,  on  the  other  hand,  is  always  indi- 
cative of  mschaaical  obstruction  to  the  return  of  blood  from  the  capilla- 
ries through  the  veins.  Thus,  pressure  of  a  tumour  on  the  large  venous 
trunks,  disease  of  the  heart  and  liver  rendering  the  circulation  diflBcult, 
or  of  the  kidneys  and  skin  diminishing  the  secretion  or  exhalation  of 
fluid,  are  its  most  common  precursors.  In  Bright's  disease  of  the  kid- 
ney, conjoined  with  various  changes  in  the  texture  of  the  organ,  serum 
containing  albumen  passes  off  in  the  urine. 

Jlembranous  Albumen. — Albumen,  in  solution,  if  it  exist  in  tolerable 


Fig.  '286. 

quantity,  is  very  apt  to  be  precipitated  in  flakes  or  membranes.  At  the 
onset  of  vesicular  diseases,  as  pemphigus,  the  fluid  effused  has  been 
observed  on  being  heated  to  contain  smooth  or  folded  laminaj  (Fig. 
286).  The  same  laminae  may  be  produced  artificially  by  bringing 
oil  or  chloroform  in  contact  with  serum.  Hence  they  are  not  fibrinous 
but  albuminous.  The  mere  shaking  of  white  of  egg,  or  manipulating 
serum  in  various  ways,  will  often  cause  these  laminae  to  form  and 
constitute  shreds,  which  resemble  fibres,  but  are  truly  membranous 
(Panum,  Melsens).  Sometimes  such  membranes,  if  produced  slowly, 
collect  round  a  central  nucleus  and  ultimately  form  a  concretion.  The 
same  has  been  observed  by  Wedl  in  the  scrotum,  where  the  skin  was 
converted  into  a  tough  substance  like  caoutchouc  (Fig.  287).  The  con- 
centric laminae  which  form  the  interior  of  aneurisms  present  a  similar 
structure,  and  are  probably  albuminous.     (See  Concretions.) 


Fig.  286.  Structureless  membrane  formed  by  heating:  the  clear  fluid  of  pemphigus. 
On  the  left  hand  the  membrane  is  folded  together. — (  Wedl.)  800  diam. 


212 


PRINCIPLES   OF   MEDICINE, 


(t 


Fiff.  28T. 


Fibroid  Albimien. — Many  tissues,  especially  fibrous  ones,  when  exposed 
to  a  certain  amount  of  pressure,  become  un- 
usually dense.     This  may  be  the  result  of  an 
exudation,  which  undergoes  a  peculiar  trans- 
formation,   the    whole    becoming    Avhite    in 
colour,  hard  and  tough  to  the  feel,  and  con- 
_  sists  of  dense  tine  fibrous  texture.      It  may 
%  also  be  the  result  of  a  peculiar  transformation 
or    fibrillation   of  pre-existing   tissues,    inde- 
pendent of  exudation.     It  has  been  described 
by  Dr.  Handheld  Jones  under  the  name  of 
fibroid   degeneration.     We  find  it  in  various 
situations — 1st,  In  the  areolar  texture  of  the 
skin,  producing   peculiar   indurations,  as    in 
the  hide-bound   integument  of  infants,     2d, 
On  serous    membranes,    where   it    occasions 
opaque  thickenings,  as  in  the  arachnoid,  pleura, 
peritoneum,  and  pericardium.    The  white  spots  in  or  upon  the  pericardium 

covering  the  heart  are  of  this  character,  and 
all  of  them  liave  their  probable  origin  in 
a  chronic  form  of  exudation,  which  is 
subsequently  transformed  into  a  white 
albuminous  mass  (Fig,  147).  The  thick- 
ened valves  of  the  heart,  and  especially 
the  rough  indurated  masses  occupying  their 
free  margins,  are  also  examples  of  this 
lesion,  3d,  In  raucous  membranes  the 
areolar  tissue  between  the  basement  mem- 
brane and  muscular  coat,  and  even  the  non- 
Pig.  288.  Fig.  289.  voluntary  muscular  substance  itself,  is  very 
liable  to  undergo  thickening  and  induration.  We  have  seen  the 
stomach  and  bladder  upwards  of  an  inch  thick  from  this  cause  (Fig, 
288),  4th,  In  the  areolar  texture  of  parenchymatous  organs,  as  in 
the  liver,  kidneys,  lungs,  etc.,  it  constitutes  the  lesion  denominated 
cirrhosis,  which  consists  of  dense  fibrous  deposits,  and  causes  atrophy  of 
the  glandular  substance.  (See  Cirrhosis.)  Dr.  Ilandfield  Jones  considers 
the  white  fibrous  tumours  of  the  uterus  to  belong  to  the  same  class  of 
morbid  alteration,  which  they  no  doubt  do,  as  also  similar  formations  in 
the  placenta,  spleen,  and  other  organs.  This  form  of  degeneration 
gradually  passes  into,  and  may  be  identical  with,  fibrous  growth,  as  the 
result  of  exudation,  5th,  The  remarkable  change  which  takes  place 
in  cartilage  belongs  to  this  head,  and  has  been  ably  described  by 
Redfern,  Under  the  influence  of  a  stimulus,  vital  or  mechanical,  the 
cells   enlarge   and  their  included  nuclei  multiply,  and  the  previously 


Fig.  287.  Edges  of  albuminous  laminae,  in  a  case  of  hydrocele,  where  the  skin  was 
destroyed,  a,  Edges  of  horizontal  laminse;  5,  the  same  in  another  place,  with 
brownish-yellow  pigment  granules. — ( Wedl )  250  diam. 

Fig.  288.  Dense  fibrous  structure,  with  naked  nuclei  from  thickened  and  indurated 
coats  of  the  stomach. 

Fig.  289.  The  same,  after  the  addition  of  acetic  acid. 


ALBUMINOUS  DEGEXERATIOX. 


213 


hyaline  inter-cellular  substance  fibrillates  and  becomes  transformed  into 
bundles  of  fibres  (Fig.  290  and  Figs.  254  to  257). 


Fig.  290. 

Celloid  Albumen. — Cell-walls  are  generally  of  an  albuminous  character, 
but  between  them  and  the  nucleus  there  exists  for  the  most  part  a  fluid, 
so  that  interchanges  are  constantly  going  on  between  the  three  essential 
portions  of  the  cell,  whereby  its  growth  is  kept  up,  and  in  many  cases 
development  carried  on.  It  frequently  happens,  however,  that  even  in 
formative  fluids,  albumen  is  thrown  down  in  globular  masses,  so  as  to 
resemble  cells.  Thus,  1st,  in  pus,  soft  cancer,  and  other  forms  of  mor- 
bid growth,  there  may  frequently  be  seen  diaphanous  bodies  floating 
about,  of  various  sizes,  of  extreme  delicacy,  and  perfectly  globular  in 
shape.  Very  commonly  they  are  homogeneous 
and  perfectly  transparent,  but  sometimes  they 
contain  one  or  more  bright  refi'acting  granules, 
and  at  others  a  cavity  seems  to  have  formed  in  the 
interior,  but  no  nucleus  (Fig.  291).  2d,  Pus  cor- 
puscles (Fig.  41),  and  collections  of  blood  globules 
may  frequently  be  seen  surrounded  by  a  similar 
diaphanous  coating  more  or  less  thick.  In  re- 
cent hemorrhagic  apoplexies  iti  man,  I  have  seen 
collections  of  blood  corpuscles,  surrounded  as  if 
by  a  cell-wall  (Fig.  292),  and  Dr.  J.  B.  Sanderson 
has  produced  them  artificially  in  pigeons,  by 
pricking  the  brain  through  the  cranium  with  needles,  and  causing 
extravasation  of  blood.  A  few  days  after  such  an  experiment,  groups 
of  oval  corpuscles  may  be  found  surrounded  by  a  layer  of  albumen, 
often  presenting  a  series  of  concentric   rings*  (Fig.  293).     There   can 


Fi? 


*  Montlily  Journal  of  iledical  Science,  September  and  December  1851. 


Fig.  290.  Splitting  up  into  fibres  of  the  hyaline  substance  of  cartilage,  in  soft 
velvety  disease  of  an  articular  substance. — {Redfern.) 

Fig.'  291.  Diaphanous  albuminous  bodies,  with  fatty  cancer  cells  from  the  dia- 
phragm. 


214 


PKIXCIPLES   OF   MEDICINE. 


Fig.  292. 


Fig.  293. 


be   no  doubt  that  iu  these   cases  an  albuminous  precipitate  is  formed 

round  the  blood  covpuscles,  which  are 
beginning-  to  break  down  and  decay. 
3d,  Another  form  of  celloid  albumen 
may  be  seen  in  certain  mechanical 
softenings  of  the  brain  and  spinal  cord, 
where  the  nerve-tubes  break  up,  unite 
at  tbeir  edges,  and  form  globules 
bounded  by  double  lines.  I  have  seen 
them    produced    under  the  microscope 

by  mechanical  pressure  between  glasses,  in  the  manner  represented  in 

the  figure  (Fig.  294). 

Molecular  AJhumen. — Some 
textures  assume  a  peculiar  kind 
of  indui'ation,  which,  on  exami- 
nation, is  found  to  consist  of 
molecular  amorphous  matter.  1.  Induration  of  the  brain  consists  of  an 
albuminous  molecular  matter  deposited  among  the  tubes,  rendering  the 
thinnest  sections  opaque,  and  giving  to  the  texture  a  peculiar  toughness. 
This  induration  is  common  around  chronic  abscesses  of  that  organ,  and 
may  have  originated  in  exudation,  which  has  been  transformed  into  the 
substance  described.  2.  Certain  peculiar  yellow  masses,  found  in  the 
kidney  and  spleen,  with  abrupt  margins  of  irregular  outline,  appear  to 
me  to  constitute  a  degeneration  of  a  similar  character.  3.  Certain  forms 
of  tubercle  may  be  said  to  consist  of  the  same  amorphous,  finely  molecular 
albuminous  substance. 

Waxij  Der/eneration. — A  peculiar  change  in  the  pre-existing  texture 
of  various  organs,  known  under  this  appellation,  sometimes  called  brawny 
or  bacony,  as  in  the  case  of  the  liver  and  spleen,  appears  to  me  to  be  a 
form  of  albuminous  degeneration.  1st,  The  liver 
wben  thus  altered  presents  to  the  naked  eye  a 
pale  fawn  colour,  its  tissue  is  of  unusual  density, 
and  its  section  presents  a  smooth  surface,  with 
semi-transparent  edges.  The  hepatic  cells  under 
the  microscope  are  seen  to  be  shrivelled,  colour- 
less, and  of  peculiar  transparency,  with  the  nucleus 
absent,  or  evidently, disappearing  (Fig.  296).  2d, 
In  this  degeneration  of  the  kidneys  the  organ  pre- 
sents the  same  general  aspect ;  and,  on  minute 
examination,  the  glandular  cells  are  found  similarly 
affected  to  tbose  in  the  liver,  and  the  Malpighian  bodies  not  unfrequently 
undergo  the  same  alteration.  (See  Diseases  of  the  Kidney.)  3d,  In  the 
spleen  the  same  characters  are  presented,  both  to  the  naked  eye  and 
under  the  microscope,  the  cells  of  the  parenchyma,  as  well  as  those  in 


Fig.  295. 


Fig.  292.  Groups  of  blood  corpuscles  from  an  apoplectic  extravasation  in  the  human 
brain,  surrounded  by  an  albuminous  layer. 

Fig.  293.  A  similar  albuminous  layer,  round  groups  of  blood-cells  from  the  brain 
of  a  pigeon. 

Fig.  294.  Substance  of  nerve  tube,  by  means  of  traction,  broken  across  and  form- 
ing two  globules,  witli  double  outline. 

Fig.  295.  Ceils  of  the  hver,  in  waxy  degeneration  of  that  organ.  250  diam. 


ALBUMIXOUS   DEGEXERATIOX. 


215 


the  Malpigliian  bodies,  being  compressed  togetber,  shrivelled,  and  pre- 
senting a  similar  pale,  translucent  appearance.  4th,  I  have  seen  the 
same  transformation  in  the  placenta  as  well  as  in  simple  chronic,  cancer- 
ous, and  tubercular  exudations. 

This  lesion  is  not  untVequently  associated  with  the  fatt\'  degeneration, 
next  to  be  spoken  of,  especially  in  the  liver  and  kidney,  when  in  a 
cirrhosed  state.  (See  Fig.  of  Cirrhosed  Liver.)  It  would  appear  from 
analyses  of  the  liver,  mostly  made  by  Dr.  Drummond,  and  collected  by 
Dr.  W.  Gairdner,*  that  the  human  liver,  when  aftected  with  the  waxy 
degeneration,  contains  less  water,  considerably  less  fat,  and  a  greater 
amount  of  solid  constituents  than  natural. 

Colloid  Degeneration. — We  have  previously  seen  that  there  is  a  pecu- 
liar form  of  cancer  called  colloid,  in  which  glue-like  matter  is  associated 
with  cancer  cells.  But  colloid  occurs  independently  of  cancer,  consti- 
tuting the  sole  contents  of  certain  cysts  (see  Cystoma).  It  would  appear 
to  vary  in  chemical  composition,  as  I  have  observed  that  specimens  of  it 
sometimes  coagulate  into  a  solid  mass,  whilst  at  others  they  are  unaf- 
fected by  the  action  of  spirits.  If  not  identical,  it  is  at  least  allied  to 
the  albuminous  degeneration.  The  enlargement  of  the  thyroid  gland  in 
bronchocele,  and  the  contents  of  compound  ovarian  cysts,  are  generall}' 


Fig.  296. 


Fig.  297 


owing  to  the  formation  of  colloid  matter  (Fig.  296).  Not  unfrequently 
colloid  masses  become  indurated,  and  assume  a  radiating  striated  appear- 
ance (Fig.  297). 

*  Monthly  Journal  of  Medical  Science.     May  185-4. 


Fig.  296.  Section  of  the  thyroid  body,  witli  some  of  its  glandular  sacs,  distended 
with  colloid  matter. — {Kblliker.) 

Fig.  297.  Radiated  colloid  masses  from  a  cyst  in  an  atrophied  kidney,  a,  Lines 
radiating  from  a  central  point;  6,  radiated  mass  surrounded  with  a  clear  border; 
c,  radiated  mass  with  a  central  granular  substance  and  radiated  border  c  ;  d,  the 
same  with  an  external  clear  border;  e,  a  mass  with  two  granular  globules  in  the 
centre. — (  Wedl.)  250  diam. 


216  PRINCIPLES  OF   MEDICINE. 


General  Pathology  and  Treatment  of  the  Albuminous  Degeneration. 

It  has  been  previously  pointed  out  tliat  albumen  is  essential  to  nutri- 
tion, and  that  it  forms  the  basis  of  the  blood  and  of  the  tissues.  The 
flesh  which  constitutes  the  food  of  carnivora,  and  the  albumen  which 
comprises  so  large  a  portion  of  the  fodder  of  graminivora,  are  alike,  by 
the  solvent  action  of  the  digestive  juices,  reduced  to  a  fluid  state.  In 
this  condition  it  passes  into  the  blood,  forming  the  walls  of  the  blood- 
corpuscles,  besides  entering  largely  into  the  constitution  of  the  liquor 
sanguinis,  as  serum,  that  is,  albumen  dissolved  in  water.  During  the 
building-up  process  it  undergoes  various  transformations,  among  which 
those  of  its  conversion  into  the  fibrin  of  flesh,  and  the  gelatine  of  bones, 
are  perhaps  the  most  important.  By  its  association  with  the  other  prox- 
imate principles,  also,  it  enters  into  the  composition  of  every  texture  and 
organ  in  the  body,  and  again  joins  the  blood  as  albumen,  mixed  with  a 
minute  portion  of  effete  matter  as  fibrin.  There  can  be  no  doubt,  as 
we  shall  subsequently  see,  that  under  certain  circumstances  it  may  be 
changed  into  fat  also,  so  that  from  multitudinous  transformations  this 
important  element  is  susceptible  of  undergoing,  it  well  merits  the  term 
which,  in  its  pure  state,  Mulder  bestowed  upon  it,  namely,  that  of  "  pro- 
teine." 

As  albumen,  we  have  seen  how  it  may  produce  abnormal  conditions 
of  the  tissues  in  various  forms.  The  essential  conditions  for  this  kind 
of  degeneration  appear  to  be — 1st,  Extreme  slowness  of  effusion  from 
the  blood-vessels,  as  in  cases  of  chronic  tubercle  and  fibroid  transforma- 
tion;  and  2dly,  Mechanical  obstruction  of  the  veins,  in  some  part  of  the 
circulation,  giving  rise  to  dropsy.  In  the  former  case,  it  is  favoured  by 
excess  of  acidity  in  the  primae  vise,  which,  by  its  power  of  dissolving 
the  albuminous  compounds,  must  assist  in  adding  this  element  to  the 
blood  in  undue  proportion.  Why,  on  the  other  hand,  muscles,  cartilage, 
and  the  exudations,  should  sometimes  pass  into  the  albuminous  fibroid 
degeneration,  under  much  the  same  circumstances  that  at  others  they 
become  fatty,  is  a  point  in  pathology  which  is  still  involved  in  obscurity. 

The  treatment  will  depend  on  the  cause,  nature,  and  seat  of  the  dege- 
neration, but  these  in  the  living  body  are  so  obscure  and  deceptive  as 
frequently  to  afford  no  indication  for  remedies.  In  the  albuminous 
tubercular  exudations,  correcting  excess  of  acidity  in  the  stomach  and 
bowels  tends  to  check  its  excess,  whilst  the  administration  of  animal  oils 
favours  its  transformation  into  the  nutritive  molecular  basis  of  the  chyle. 
Wherever  mechanical  causes,  or  interruptions  of  the  venous  circulation, 
give  rise  to  dropsy,  recovery  will  depend  on  the  means  at  our  disposal 
for  their  removal. 

Fatty  Degeneration. 

I  have  previously  described  fatly  growths  (sec  Lipoma),  which,  by 
encroaching  on  neighbouring  tissues,  and  especially  muscles,  cause  their 
atrophy.  I  have  also  shown  how  fatty  matter  accumulated  within  cysts, 
undei'goes  various  transformations,  both  histological  and  chemical,  at  one 
time  presenting  a  granular  form,  and  at  another  a  crystalline  one,  com- 


FATTY  DEGENERATION".  217 

posed  of  cholesterine  or  margerine  (see  Cystoma).  It  is  now  ascer- 
tained that  there  is  no  kind  of  tissue,  whether  healthy  or  morbid,  that 
may  not  undergo  a  fatty  degeneration.  Such  alteration  frequently  causes 
one  of  the  most  formidable  organic  diseases  which  the  physician  is  called 
upon  to  treat. 

Deposition  of  Fatty  Molecules  and  Granules. — Fat  is  as  necessary 
a  constituent  of  the  food  and  of  the  tissues  as  albumen,  and  its  universal 
presence  in  the  organs,  texture,  and  fluids  of  the  bodv,  renders  it  easily 
capable  of  precipitation  and  accumulation,  if  in  excess.  The  moment 
tlie  smallest  particle  of  oil  is  formed,  and  comes  in  contact  with  an  albu- 
minous fluid,  a  membranous  precipitation  of  the  latter  takes  place  around 
it,  which  tends  to  keep  the  various  fatty  molecules  distinct  and  separate 
from  each  other.  No  doubt,  under  the  action  of  heat,  trituration,  pres- 
sure, or  the  action  of  acids,  which  dissolves  the  albuminous  envelope,  the 
molecules  are  sometimes  fused  together,  and  constitute  smaller  or  larger 
globules.  The  great  predominance  of  the  molecular  form  of  fatty  depo- 
sition, however,  is  evident  in  all  morbid  alterations  of  texture.  In  this 
state  we  find  it  constituting  the  substance  of  the  atrophied  supra-renal 
and  thymus  glands  in  the  adult ;  the  exudation  in  chronic  softening  of 
the  brain,  and  other  parenchymatous  oro-ans ;  ,3'.-.-j. •.•;.,  o.soooo  .«>»•«. 
accumulated  within  cvsts,  the  result  of  trans-  •i:-C?4W  o»«^ivo  \of^ 
formation  of  their  contents;  in  the  centre  of 
colloid  masses;  in  chronic  exudations,  and  extra- 
vasations of  blood,  presenting  a  niilky,  yellow, 
or  fawn-coloured  hue ;  or  in  the  blood,  urine,  °"  ^^*' 

and  other  fluids,  giving  them  a  chylous  character.  Indeed,  the  presence 
of  fatty  molecules  may  be  said  to  be  almost  constant  in  morbid  products; 
and,  when  collected  together  in  masses,  they  constitute  organic  lesions 
of  the  greatest  gravity. 

Fatty  Degeneration  of  Cells. — It  was  shown  by  Reinhardt,  that  all 
kinds  of  cell  formation,  under  certain  circumstances,  undergo  the  fatty 
degeneration.  The  manner  in  which  this  is  accomplished  is  in  all  cases 
the  same.  A  few  fatty  molecules  first  form  between  the  nucleus  and 
cell-wall.  These  increase  in  number,  and  some  of  them  apparently  are 
fused  together  to  produce  larger  ones.  This  process  goes  on  until  at 
length  the  whole  contents  of  the  cell  consist  of  fatty  molecules  and 


S;o?S-ii»« 

Fig.  299. 

granules.     The  nucleus  is  now  no   longer  visible,  and  in  many  cases 

Fig.  298.  Fatty  molecules  in  groups,  from  the  opalescent  or  white  opaque  centres 
of  large  colloid  masses  in  the  ovary. 

Fig.  299.  Granular  corpuscles  and  masses  from  cerebral  softening,  a,  Nucleated 
cell  with  a  few  granules ;  b,  granules  within  the  cell,  partly  obscuring  the  nucleus ; 
c,  granules  over  the  nucleus ;  d,  granules  within  the  cell,  no  nucleus  visible ;  e,  cell 
nearly  filled  with  granules ;  f.  cell  completely  tilled  with  granules  ;  g,  cell  contracted 
in  its  middle ;  h,  granular  mass,  the  cell-wall  having  dissolved ;  i  and  k,  granular 
masses  peeled  ofl'  from  the  vessels. 


218  PRINCIPLES  OF  MEDICINE, 

wastes  awa}^  as  if  from  pressure.  Occasionally,  this  fatty  deposition  of 
molecules  takes  place  within  the  nucleus  in  the  "first  instance.  (Fig.  92.) 
In  either  case  the  cell-wall,  distended  by  the  accumulation  of  fatty  par- 
ticles, at  length  gives  way,  and  the  included  oil  granules  either  separate, 
or  for  a  time  adhere  together  in  granular  masses.  Sometimes  these 
bodies  are  easily  ruptured  by  external  violence  ;  at  others  they  are  more 


resistant,  and  the  oily  matter  is  forced  through  the  cell- wall,  and  collects 
outside,  whilst  the  cell  itself  is  more  or  less  collapsed.  In  this  way,  col- 
lections of  fatty  granules  and  granular  cells  take  place  in  the  ducts  of 
all  glands  which  are  lined  by  epithelium ;  in  the  air  vesicles  of  the  luno- 
and  in  the  bronchi ;  in  the  cells  of  the  liver,  causing  fatty  degeneration 
of  that  organ ;  in  the  shut  sacs  of  vascular  glands,  as  the  sple'en,  and  in 
all  cell  formations  in  exudation,  especially  those  of  pus  and  cancer. 

In  stall-fed  animals,  a  moderate  accumulation  of  fatty  granules  in  the 
interior  of  the  hepatic  cells  is  a  normal  condition ;  and  the  amount  of 
fat  in  various  tissues,  which  separates  health  from  disease,  is,  under  a 
variety  of  circumstances,  impossible  to  determine  v/ith  exactitude. 

Fatty  Degeneration  of  Muscle. — There  can  be  no  doubt  that  the  fibro- 
albuminous  substance  constituting  flesh  is  capable  of  undergoing  a  trans- 
formation into  fat.     Of  the  exact  chemical  nature  of  that  transformation 


.ffc' 


"^  _ ,    i-P:ia^li     )i?U?:H'^  P^/^f.*l  a^     ..%«^ti^VJi'^': 


I 


w- 


mmMm  ^^     mmM4Mm  Ifl     ^^^^^ ' 

Fig.  801.  Fig.  302.  '  Fig.  303. 

we  have  yet  to  be  informed ;  but  it  may  not  only  be  observed  in  the 
dead  body,  but  may  be  produced  artificially,  by  exposing  muscle  to  a 
running  stream  of  water,  whereby  it  is  changed  into  adipocere.      In 

Fig.  300.  Granular  corpuscles  acted  upon  by  pressure,  a,  Some  of  t]ie  oily  gra- 
nules made  to  coalesce;  b,  oil  forced  through  the  cell-wall;  c,  the  same  with  collapse 
of  the  cell-wall;  d,  rupture  of  the  cell-wall;  e,  dislocation  of  the  nucleus.    250  dia7n. 

Fig.  301.  Early  stage  of  fatty  degeneration  of  voluntary  muscle,  a,  The  muscle 
breaking  across;  b,  the  fibrilhe,  easily  separated.  In  both  specimens  the  tissue  is 
soft,  although  the  transverse  strife  are  still  visible. — ( Wedl.) 

Fig.  302.  Advanced  stage  of  fatty  degeneration  in  the  muscular  fosciculi  of  the 
heart.  The  transverse  striaj  have  disappeared,  and  the  fasciculi  are  wholly  composed 
of  oil  granules  and  globules  more  or  less  aggregated  together. — ( Wedl.) 

Fig.  303.  Another  example  of  advanced  fatty  degeneration  of  voluntary  muscle, 
the  fasciculi  presenting  various  degrees  of  the  alteration.  250  diam. 


FATTY  DEGENERATION.  219 

voluntaiy  muscle,  "vve  observe  tliat  tlie  degeneration  commences  witli 
diminished  distinctness  of  the  transverse  strite,  especially  at  the  circum- 
ference of  the  fasciculus.  As  this  extends  inwards,  minute  molecules  of 
fat  occupy  the  position  of  the  stria?,  and  at  length  obliterate  them ; 
gradually  these  coalesce,  globules  of  various  sizes  are  formed  within  the 
sarcolemma,  and  the  normal  structure  of  voluntary  muscle  disappears. 
During  the  early  changes  the  fasciculus  becomes  soft,  exhibits  a  tendency 
to  crack  crossways,  and  ultimately  is  so  pulpy  as  to  be  capable  of  being- 
squeezed  easily  into  an  amorphous  mass,  from  which  large  oil  drops  exude. 
To  the  naked  eye,  the  muscular  substance  becomes  paler,  and  more  fawn- 
coloured,  and  at  length  yellow,  and  its  normal  density  is  greatly  dimi- 
nished. These  changes  are  easily  observed  in  the  heart,  in  which  organ 
they  have  been  made  the  subject  of  special  research  by  Ormerod,  Paget, 
Quain,  and  others.  The  histological  and  clinical  researches  of  Dr.  R. 
Quain*  on  this  subject  are  of  the  greatest  importance. 

All  the  voluntary  muscles,  however,  are  susceptible  of  undergoing  a 
similar  lesion,  and  it  not  unfrequently  occurs  in  those  of  the  lower 
extremity  after  long  continued  paralysis,  disease  of  the  hip  joint,  or 
other  lesions  which  necessitate  immobility  of  the  parts.  In  this  case, 
and  occasionally  in  the  heart  itself,  in  addition  to  the  transformation  of 
the  muscular  fasciculi  above  described,  adipose  tissue  accumulates  between 
them,  and  by  compressing  their  substance  adds  to  the  rapidity  and  com- 


T^"r^r  f'''''''^'^-^-'f'^f^T^^^^       ^pj^^TWj 


I 


Fig.  304.  Fig.  305. 


pleteness  of  the  transformation.  In  such  cases  the  muscles  are  of  a  pale 
yellow  colour,  yielding  on  section  large  quantities  of  oil,  while  they  pre- 
serve their  usual  form  and  fibrous  look.     I  have  seen  all  the  muscles  of 


*  Med.  Chir.  Trans,  vol.  xsiii. 


Fig.  304.  Fatty  degeneration  of  the  23Soas  magnus  muscle  of  a  lad,  who  died  with 
morbus  coxarius.  a,  Muscular  fasciculi  in  which  no  traces  of  transverse  strife  are 
perceivable.  The  longitudinal  stria?  are  still  not  quite  obliterated,  although  mingled 
with  numerous  fattj-  granules,  b,  Muscular  fasciculi,  whollj'  composed  of  minute 
molecules  and  granules,  with  no  traces  of  either  transverse  or  longitudinal  strisB. 
c,  Fat  cells  of  various  sizes,  running  between  and  encroaching  upon  the  flisciculi. 

Fig.  305.  Other  fasciculi  from  another  portion  of  the  same  muscle,  after  the  addi- 
tion of  aether.  The  adipose  cells  have  been  made  round  and  somewhat  flaccid ;  the 
nucleus  consists  of  a  congeries  of  brownish  granules.  250  diam. 


220 


PEINCIPLES   OF   MEDICINE. 


the  lower  extremities  so  affected.  Occasionally,  while  some  muscles 
exhibit  this  transformation  in  its  most  advanced  stage,  others  close  beside 
them  present  their  normal  red  colour,  so  that  the  limb  on  dissection 
resembles  the  alternate  red  and  fatty  streaks  of  bacon.  In  this  case  the 
degenerated  muscle  has  the  whole  of  its  fasciculi  transformed  into  adi- 
pose cells,  with  nuclei,  as  seen  in  Fig.  305. 

In  involuntary  muscles  fatty  degeneration  may  also  be  observed, 
althougli  it  is  by  no  means  so  common  as  in  voluntary  ones.  In  this 
case  oily  molecules  are  deposited  in  the  elongated  fusiform  cells  compos- 
ing the  texture,  and  by  their  pressure  on  the  nucleus  cause  its  disap- 
pearance. "Whether  the  distended 
pregnant  uterus  shrinks  to  its  nor- 
mal proportions  after  delivery 
wholly  in  consequence  of  such  a 
degeneration  (Heschl)  is  a  point 
not  yet  determined.  But  there 
can  be  no  doubt  that  many  of  the 
greatly  enlarged  fusiform  cells  of 
the  organ  (Fig.  141),  do  become 
more  or  less  crowded  with  fatty  granules  (Fig.  306). 

Fatty  Degeneration  of  Blood-vessels. — The  lai'ger  blood-vessels,  espe- 


Fig.  306. 


Fig.  80r. 


Fig.  808. 


.^feo*^* 


Fis 


cially  the  arteries,  are  very  commonly  the  seat  of  a  fatty  degeneration, 
generally  called  atheroma.  It  presents  the  appearance  of  a'whitish  or 
yellowish  cheesy,  but  sometimes  indurated  and  brittle  substance,  de- 
posited between  the  coats  of  the  vessel,  and  often  protruding  on  its 
inner  surface.     This  deposit  consists  of  numerous  fatty  granules,  mingled 


Fig.  306.  Enlarged  fusiform  cells  of  the  pregnant  uterus,  after  delivery,  filled  with 
fatty  granules.  250  diam. 

Fig.  307.  Atheroma  of  a  blood-vessel.     Natural  size. 

Fig.  308.  Fatty  granules,  oil  drops  and  granule  cells,  with  crystals  of  cholesterine 
from  broken  down  atheroma  of  an  artery. 

Fig.  309.  a  and  h.  Two  groups  of  fatty  molecules  from  atheroma  of  artery, 

250  diam. 


FATTY   DEGENERATION. 


221 


with  crvstals  of  cliolesterine  (Gulliver),  to  which,  when  hard  and  brittle, 
are   added   calcare-  . ._— pn,,,--— ^^^  .-__^ 

salts  pll'r-    ■     !^^V 


ons  amorphous 
(Figs.  307  to  310). 
The  smaller  ves- 
sels and  capillaries 
are  frequently  seen 
to  be  covered  with 
patches  of  fattygran- 
nles,  which  vary  in 

number  from  two  or    ,,_^^^„„,„___        _ 

three,  to  large  mas-  \     \  ^.Yusio.d^  Y 

ses  of  them,  which  '^     ^  c     ^  a  e 

infiltrate  the  neighbouring  tissue.  The  various  appearances  of  these 
were  carefully  described  and  figured  by  me  in  1842,*  and  attributed 
to  exudations  thrown  out  from  the  vessel.  In  1849  Mr.  Pagptf 
also  described  the  same  facts,  and  attributed  them  to  fatty  degeneration 
of  the  vessels  themselves.  Now,  without  denying  the  occasional  fatty 
transformation   of   the  walls  of  minute  vessels,  and  the  accumulation 


Fis.  311. 


Fig.  312. 


of  fattv  molecules  within  the  nuclei,   it  may  readily  be  seen   that  for 
the  most  part  the  fatty  granules  are  outside  the  vessels.     Indeed,  the 


*  Edin.  Med.  and  Surg 
\  Medical  Gazette. 


Journal,  vols.  Iviii.  and  lix. 


Fio-  310.  Transverse  section  through  the  coats  of  the  popliteal  artery  of  an  aged 
woman,  who  had  gangrene  of  the  feet,  a,  Inner  coat ;  6,  longitudinal  fibre ;  c,  cir- 
cular fibres :  d,  fimbriated  and  elastic  coats  loaded  witli  fatty  granules ;  e,  external 
areolar  tissue.— (TFerfZ.)  ^  200  diani 

Fig.  311.  Cerebral  vessels  of  an  aged  individual  who  died  of  apoplexy,  a,  Ulti- 
mate^'capillaries  ;  h,  larger  vessel ;  c,  small  artery,  with  fatty  granules  scattered  over 
its  surface. — ( Wedl.)  ,     .  ,  j 

Fio-  312  Vessels  fi-om  softening  of  the  corpus  striatum,  coated  with  granules  and 
granSiar  masses.— ( Wedl.)  250  dmm. 


222 


PRINCIPLES   OF   MEDICINE. 


extreme  tenuity  of  the  capillary  wall  does  not  permit  of  their  forma- 
tion in  its  substance,  as  it  is  much  thinner  than  the  granules  themselves. 
Besides,  it  may  frequently  be  observed  that  the  large  amount  of  fatty 
granules  outside  the  vessels  is  enormously  disproportioned  to  the  bulk  of 
the  latter,  and  altogether  inexplicable  by  supposing  them  to  be  formed 
in  and  given  off  by  the  vascular  walls  themselves,  which  for  that  purpose 
must  assume  a  secretive  function.  I  have  also  seen  and  figured  cell- 
formations  in  every  stage  in  the  granular  fatty  matter,  constituting  soft- 
ening of  the  brain.  (See  Fig.  "l  13.)  Of  these  Mr.  Paget  wrote  in 
1853,* — "  Produced  as  they  are  in  parts  of  the  brain  and  cord  in  which 
no  cell  structures  naturally  exist  (for  they  may  be  as  abundant  in  the 
white  substance  as  in  the  gray),  we  have  yet,  I  believe,  to  trace  the 
source  and  method  of  their  formation."  This  admission  appears  to  me 
altogether  hostile  to  the  idea  of  their  originating  in  a  degeneration  of 
the  vessels,  whilst  their  formation  in  an  exudation,  as  I  have  previously 
described  (p.  131),  is  consonant  with  every  known  fact.  The  true  soft- 
ening of  the  brain  from  deficiency  of  nutrition  frequently  exhibits  struc- 
tural changes  altogether  different,  as  I  shall  subsequently  demonstrate. 
(See  Diseases  of  the  Nervous  System — Softening.) 

Fatty  Der/eneration  of  the  Placenta. — The  lesion  which  has  received 
this  name  from  Dr.  Barnes  and  others,  was  figured  by  me  in  1844,f  and 
likened  to  that  which  occurs  in  certain  softenings  of  the  brain.  I  still 
hold  the  same  opinion  with  regard  to  it,  and  consider  the  fatty  molecules 
and  granule  cells  not  to  be  formed  by  a  transformation  of  placental 
tissue  itself,  but  of  the  exudation  or  extravasation  of  blood  which  is 
poured  out  from  its  vessels.     The  yellowish  or  fawn-coloured  deposits 


may  be  infiltrated  throughout  the  tissue  of  the  placenta  over  a  greater 
or  less  space,  or  they  may  occur  in  isolated  spots  forming  nodules.    They 

*  Surgical  Pathology,  vol.  i.  p.  146. 

f  Treatise  oa  Inflammation.     Plate — Fig.  10. 


Fig.  313.  Villi  from  the  placenta  of  a  six  months'  foetus,  a  and  b,  The  vessels 
coated  with  molecular  fatty  matter ;  c,  exudation  from  the  vessel,  nearly  occupying 
the  whole  substance  of  the  villus ;  d,  chronic  exudation  outside  the  vessel,  converted 
into  brown  pigment. — ( Wedl.) 


FATTY  DEGENERATION". 


223 


are  generally  somewhat  indurated,  and  give  rise  to  the  idea  that  they 
are  coagulated  fibrin.  I  have  frequently  examined  them  and  traced  all 
the  changes  intermediate  between  a  coagulated  exudation  or  extravasa- 
tion of  blood,  and  the  ultimate  conversion  of  the  foreign  matter  into  a 
mass  of  molecules  filling  up  the  intervascular  spaces.  Similar  observa- 
tions have  been  more  recently  ma<le  by  Drs.  Handfield  Jones*  and  Cowan.f 
In  many  cases  the  fatty  material  may  be  seen  forming  a  layer  separate 
from  the  vessel  and  inside  the  limitary  membrane  of  the  villus.  In  most 
cases,   also,  the  texture  of  the  placenta  is  pale  from   compression,  or 


shrunken,  but  still  intact,  and  the  vessels,  though  coated  externally  with 
oil  granules,  are  themselves  quite  healthy.  Occasionally,  in  atrophied 
placenta,  a  quantity  of  brownish  pigment  is  deposited  between  the  vascu- 
lar wall  and  limitary  mem- 
brane of  the  villus,  which 
is  probably  owing  to  a  modi- 
fication of  the  fatty  matter 
or  of  the  colouring  material 
of  the  blood  (Fig.  329,  a). 
(See  Pigmentary  Degene- 
ration.) 

Fatty  Degeneration  of 
Cartilage. — The  cells  of  car- 
tilage are  liable  to  undergo 
the  same  fatty  degeneration  as  is  observable  in  other  cells.    The  molecules 


Fi£r.  317. 


*  British  and  Foreign  MecL-Chir.  Rev.  vol.  ii.  p.  354. 
•)-  Edin.  Med.  and  Surgical  Journal,  April  1854. 


Fi».  314.  Fatty  granules  coating  the  blood-vessels,  withm  the  placental  villi — 
(  Covjan.) 

Fig.  315.  Groups  of  fatty  granules  scattered  through  the  substance  of  a  placental 
villus. — ( Cowan.) 

Fig.  316.  Fatty  granules  both  coating  the  vessels,  and  scattered  through  the 
villous  substance. — (Coimn.) 

Fig.  317.  Cells  in  fatty  tracheal  cartOage.  They  are  filled  -with  fatty  brown  mole- 
cules, and  the  secondary  cells  contain  oil  globules. — (  Wedl.)  250  diam. 


224 


PEINCIPLES   OF  MEDICINE. 


at  first  formed,  however,  are  exceedingly  minute,  thus  communicating 
a  brownish  opaque  aspect  to  the  interior  of  the  cell  (Fig.  317). 
Subsequently  they  coalesce  and  form  larger  granules,  which  again  unite 
to  produce  drops  of  oil  of  considerable  size.  During  this  change  the 
nucleus  disappears,  and  sometimes  the  hyaline  intercellular  substance 
presents  a  multitude  of  brownish  points,  which  communicate  to  it  a 
marked  opacity  (Fig.  328).  At  others  it  undergoes  the  fibroid  transfor- 
mation formerly  described  (Figs.  254  to  257,  and  290). 

Fatty  Degeneration  of  Bone, — Wedl  has  described  the  cancelli  of  bone 
in  syphilitic  caries  as  being  dilated  and  filled  with  fat,  owino-  to  the  exu- 


Fis.  31S, 


Fig   321. 


dation  poured  into  them  having  undergone  the  fatty  degeneration  (Fig. 
320),  and  in  most  cases  of  ulcerated  bone  a  large  formation  of  oily  mole- 
cules and  loose  globules  of  oil  may  frequently  be  observed.  Yirchow 
has  detected  similar  molecules  in  the  lacunte  and  canaliculi.  The  molli- 
fies ossium,  or  malacosteon  of  adults,  is  also  a  form  of  fatty  degeneration 
of  bones  (Paget),  in  which  the  cancelli  are  loaded  with  large  oil  drops, 
often  tinted  red.  Combined  with  these,  there  is  a  foimation  of  numerous 
cells,  which  vary  in  size  from  the  T2V ott'  to  the  -j^oth  of  an  inch  in 
diameter,  and  contain  a  round  nucleus,  also  varying  much  in  size,  and 
occasionally  showing  various  stages  of  division  and  of  endogenous  deve- 
lopment (Fig.  321).  This,  like  so  many  other  of  the  so-called  fatty 
degenerations  of  texture,  is  probably  owing  to  an  exudation  from  the 
blood-vessels,  mingled  with  moi'e  or  less  extravasation  of  the  coloured 


Fig.  318.  Horizontal  section  of  the  occipital  bone  in  a  case  of  syphilis,  a,  Dense 
external  table,  the  internal  composed  of  dilated  cancelli  fiUed  with  fat,  seen  by 
reflected  light. — ( Wcdl.)  3  diam. 

Fig.  319.  Thin  section  of  the  same  bone  showing  one  of  the  cancelli  enlarged  and 
filled  with  fat  globules,  surrounded  by  empty  lacuna;. — ( Wedl.) 

Fig.  320.  Tliin  section  of  the  outer  table  of  the  same  bone.— ( Wedl.) 

Fig.  321.  Xew  cells  formed  in  malacosteon.  a,  From  the  marrow  of  the  femur; 
h,  others  with  developing  nuclei ;  c,  fi-om  a  rib  in  another  case,  in  which  some  organs 
were  cancerous. — {Wedl.)  250  diam. 


FATTY  DEGEXERATIOX. 


225 


corpuscles,  in  which  we  find  new  cells  developed,  combined  with  fatty 
transformations  of  the  albuminous  and  fibrinous  materials.  In  this 
respect  it  differs  from  the  softening  of  bone  in  rachitis,  which  may  be 
regarded  as  arrested  development  of  bone  with  increased  growth  of  car- 
tilage cells  (Kolliker). 

Fatty  Degeneration  of  other  Textures. — It  would  occupv  too  much 
space  for  us  to  describe  or  even  particularise  every  tissue  that  is  now 
known  to  undergo  a  fatty  degeneration.  All  the  glands  may  iindergo 
this  change.  Xervous  texture  may  soften,  break  up,  its  fatty  material 
be  liberated,  and  accumulate  in  oil  drops  of  greateiyor  less  size.  In  em- 
phvsema,  the  pulmonary  texture  is  sometimes  fatty.  (Raiuev.)  The 
cornea  (Canton)  and  the  lens  (Dalrymple,  Lebert),  also  may  be  similarly 
affected,  forming  soft  cataract.  Indeed,  under  various  circumstances,  it 
may  be  said  that  there  is  no  organ  or  texture  of  the  body,  which  in  some 
form  or  other  may  not  undergo  this  degeneration. 

Fatty  Degeneration  of  the  Exudations. — We  have  already  seen  that 
what  has  often  been  called  fatty  transformation  of  tissue,  is,  in  fact, 
fatty  transformation  of  the  constituents  of  the  blood,  which  have  been 
exuded  or  extravasated.  Simple  exudation  is  constantly  undergoing 
fatty  degeneration.  I  have  seen  the  false  membrane  of  pleurisv  con- 
verted into  a  creamy  substance,  composed  of  innumerable  fatty  molecules, 
granular  masses,  and  granule  cells.  Pus  cells  may  frequently  be  observed 
to  contain  fatty  granules,  and  to  present  all  the  intermediate  stages  of 
conversion  into  the  granule  cell,  and  the  same  may  be  observed  in  the 
pus  and  fibre  cells  of  granulating  sores.  In  Cancerous  exudation^  the 
fatty  degeneration  is  so  common,  as  to  have  attracted  peculiar  attention, 
under  the  name  of  "Eeticulum."     This  occurs  in  two  forms.     In  one 


Fis.  323. 


Fiff.  324 


Fis.  325. 


it  is  seen  on  a  fresh  cut  surface,  scattered  throughout  the  growth  to  a 
greater  or  less  extent,  as  a  network,  more  thick  and  abundant,  however, 
in  some  places  than  in  others.  In  the  other  it  exists  in  masses  of  a  bright 
yellow  or  orange  colour;    sometimes    closely  resembling   tubercle,    for 


Fig.  322.  Retrograde  cancer-cells,  granules  and  granular  masses,  with  crystals  of 
cliolesterine,  from  the  reticulum  of  cancer  of  a  lymphatic  gland. 

Fig.  323.  Fatty  and  broken  down  cancer-cells,  with  crystals  of  margarine,  from 
the  reticulum  of  cancer  of  the  liver. 

Fig.  324.  Fatty  granular  matter  from  the  softened  reticulum  of  a  cancer  of  the 
breast. 

Fig.  325.  Liberated  and  altered  nuclei,  with  fatty  molecules  from  the  reticulum  of 
a  cancer  of  the  testicle.  250  diam. 


15 


226  PRINCIPLES  OF   MEDICINE. 

which  it  has  often  been  mistaken.  In  the  first  form,  granule  cells,  loose 
oil  granules  more  or  less  mingled  with  deca\'ed  and  broken  down  cancer- 
cells,  are  common.  In  the  second,  irregular  bodies,  resembling  tubercle 
corpuscles,  resulting  from  alteration  in  the  form  of  the  nucleus,  after 
the  cell-wall  has  been  broken  down,  are  numerous  (Fig.  325).  In  some 
retrograde  cancers  I  have  seen  large  portions  of  the  growth  entirely 
composed  of  such  corpuscles,  and  not  unfrequently  these,  as  well  as  can- 
cer-cells in  all  stages  of  decay,  are  associated  with  crystals  of  choleste- 
rine  or  margarine  (Figs.  322,  323).  Tubercular  exudation  may  always 
be  observed  to  contain  a  greater  or  less  number  of  fatty  granules  em- 
bedded in  it,  as  well  as  contained  in  the  tubercle  corpuscles.  What  is 
called  the  softening  of  tubercle  is  owing  to  an  increase  of  these,  by  the 
gradual  transformation  of  the  albuminous  pait  of  the  exudation  into 
fatty  molecules,  whereby  the  whole  is  rendered  soft  and  pulpy.  (See 
Fig.  133.) 

Fatty  Defeneration  of  Morh'id  Growths.  All  these  are  susceptible  of 
becoming  fatty,  and  consequently  soft  and  pultaceous;  tlie  transforma- 
tion is  accomplished  in  a  manner  exactly  similar  to  what  we  have 
described  as  occurring  in  the  tissues  of  which  they  are  composed,  or  of 
the  exudations  which  are  conjoined  with  them. 

General  Patholor/y  and  Treatment  of  Fatty  Degeneration. 

The  causes  of  fatty  degeneration  are  to  be  sought  in  all  those  circum- 
stances which  weaken  the  vital  action  of  a  part,  but  do  not  interfere 
materially  with  the  assimilation  of  hydro-carburets.  The  disease,  how- 
ever, is  not  purely  local,  as  it  may  frequently  be  observed  that  the  kid- 
neys, liver,  heart,  and  other  textures,  are  prone  to  undergo  the  fatty 
change  in  the  same  person.  Hence  everything  that  increases  fatty  mat- 
ter in  the  blood,  such  as  its  introduction  by  means  of  assimilation,  or  its 
not  passing  oflF  in  consequence  of  diminished  excretion,  tends  to  its 
deposition.  Thus  indulgence  in  rich  food,  and  alcoholic  liquors  abound- 
ing in  carbon,  especially  if  there  be  little  exercise,  occasions  it.  AVhether 
the  fatty  matter  be  deposited  directly  from  the  blood,  or  Avhether  it  be 
the  subsequent  result  of  a  chemical  transformation  of  tissue  or  exudation, 
has  excited  discussion.  Dr.  Quain  supports  tlie  latter  view,  and  has  per- 
formed experiments,  whereby  it  would  seem  that  liealthy  muscular  fibrin 
may  be  rendered  fatly  artificially,  by  digesting  it  for  a  fortnight  in  water. 
I  have  repeatedly  seen  muscles  and  bones  converted  into  adipocere, 
during  the  maceration  in  water  necessary  to  clean  the  latter,  and  have 
frequently  examined  the  former  during  the  process,  so  as  to  satisfy  myself 
that  the  fibrinous  material  of  flesh  undergoes  a  chemical  transformation 
into  fat.  I  believe  with  Dr.  Quain  that  the  same  thing  occurs  in  the 
living  body,  not  only  when  dead  tissues  are  enclosed  in  it,  as  in  the 
experiments  of  Wagner,  but  slowly  in  living  texture,  until  its  vigour  is 
at  length  so  impaired  that  it  is  incapable  of  performing  its  function. 
This  view  in  no  way  excludes  the  probability  of  the  fact  that  in  certain 
cases  fatty  matter  may  transude  through  the  vessels  in  a  fluid  state,  and 
collect  outside,  or  be  infiltrated  to  a  certain  extent  among  neighbouring 
textures  in  a  molecular  form.  Further,  we  have  seen  that  fat  may  occur 
within  cells  as  a  secretion,  and  by  its  accumulation  cause  not  only  atrophy 


PIGMENTARY   DEGENERATION.  227 

of  the  nucleus,  but  also  obstruction  of  tubes  and  an  endless  variety  of 
organic  and  functional  derangement  in  the  economy,  according  to  the 
extent  and  seat  of  the  degeneration. 

The  treatment  of  this  lesion  is  a  field  of  inquiry  which  as  yet  has 
scarcely  been  entered  upon.  In  most  cases,  indeed,  its  diagnosis  in  the 
living  subject  is  very  uncertain.  But  the  cultivation  of  histology,  by 
gradually  enlightening  us  concerning  those  degenerations  which  are 
essentially  fatty,  and  enabling  physicians  to  recognize  them  as  the  cause 
of  symptoms  with  which  he  has  been  long  familiar,  will  assuredly  at  no 
distant  day  lead  to  more  correct  principles  of  practice.  Already  we 
begin  to  see  indications  of  this  in  our  notions  regarding  Bright's  disease, 
and  in  the  results  of  organic  chemistry  applied  to  clinical  medicine.  At 
present  it  would  be  premature  to  speculate  on  this  subject,  and  what  lit- 
tle there  is  to  be  said  will  be  found  under  the  head  of  special  diseases. 


Pigmentary  Degeneration. 

The  formation  of  pigment  in  plants  and  animals  is  essentially  connected 
with  that  of  fat,  most  colours  either  being  different  kinds  of  tinted  oil,  or 
secreted  in   cells   at  the  expense  of  carbonaceous  products,  which  are 
readily  transformed  into  fatty  compounds.     In  mor- 
bid conditions  we  find  several  of  the  textures  of  ^ 
different  tints,  but  more  especially  red,  yellow,  brown,      A  ^^,  + 
green,  or  black,  from  chemical  alteration  in  the  col-    /   \  \^ 
ouring-matter,   of  blood   or   bile.      Sometimes  the  /      /  %^ 
change  of  colour  is  the  result  of  peculiar  secretions  ;  \l  \c3 
at  others,  of  the  deposition  of  carbon. 

Red  Pigments. — All  red  colouration  in  the  human  — — s^ 

body  is  owing  to  the  presence  of  blood,  the  colour-       Ms^^^M 
ing  principle   of  which  has  been  called  hematine. 
When  observed  in  an  isolated  blood  coi-puscle,  in       ^^^     |^.,„^^ 
wdiich  it  is  secreted,  the  real  colour  is  seen  by  trans-       ^     ^~3 
mitted  light  to  be  yellow,  although,  as  occurs  with  a 
strong  infusion  or  tincture  of  saffron,  it  looks  red  to  7 

the  naked  eye  when   concentrated.     Unless,  how- 
ever, it  were  known  that  the  real  colour  of  the  blood        «^  '^^^  ^ 
is  yellow,  it  would  be  impossible  to  undei-stand  the       <^  ^> 
presence  of  this  latter  tint  around  ecchymotic  spots,  Vx 

and  in  other  situations.     Virchow  first  described  in  ^.    „„. 

•  1  Fig  326. 

extravasations  of  blood  prismatic  crystals,  with 
rhomboidal  bases,  often  approaching  a  needle  shape,  of  a  yellowish  or 
deep  ruby  colour,  which  he  denominated  hematoidine.  They  are  most 
frequently  found  in  the  sanguineous  extravasations  of  the  brain,  in  the 
corpora  lutea  of  the  ovaries,  and  in  chronic  haemorrhages  of  the  liver,  ot 
hydatid  cysts,  and  of  other  textures,  but  rarely  in  pulmonary  or  cancer- 
ous extravasations.  In  size,  they  vary  from  the  3  oVo^li  to  the  ^^otli  of 
an  inch  in  their  long  diameter  (Fig.  326).     They  are  transparent,  and 

Fig.  326.  Crystals  of  hematoidine.    a,  Large  oblique  rhombic  prisms;  at  +,  oblique 
six-sided  prism;  b,  smaller  forms. — (Wedl.)  250  dmrn. 


228 


PRINCIPLES   OF   MEDICINE. 


strongly  refractive,  insoluble  in  alcohol,  aether,  dilute-mineral  acids  and 
alkaUes.  Concentrated  mineral  acids  caiise  them  to  assume  the  shades 
of  green,  blue,  rose-tint,  and  finally  a  dirty  yellow. 

Yelloiv  Pigment. — The  real  colour  of  the  blood  corpuscles  is  yellow, 
and  so  is  the  liquor  sanguinis  in  which  they  are  dissolved,  and  conse- 
quently all  recent  exudations  of  lymph,  as  well  as  most  kinds  of  pus  and 
tubercle.  Blood,  after  being  extravasated,  is  broken  down  and  absorbed  ; 
and  as  the  colouring  matter  becomes  less  intense,  it  generally  assumes 
a  yellowish  tint,  as  around  ecchymotic  spots,  and  old  extravasations. 
Hence,  also,  the  colour  of  the  corpora  lutea,  and  the  yellow  softenings 
of  the  brain,  as  well  as  the  de^p  orange  tint  occasionally  observed  as 
the  result  of  hsemorrhages.  The  adipose  texture,  as  well  as  the  morbid 
accumulations  of  fatty  matter,  assumes  a  yellow  tint,  as  when  muscle 
undergoes  the  fatty  degeneration,  and  the  reticulum  previously  described 
forms  in  cancer. 

There  is,  however,  another  source  of  this  colour  in  the  bile,  as  it  con- 
tains a  deep  yellow  pigment,  which,  when  absorbed  into  the  blood, 
tinges  all  the  textures,  and  passes  otf  in  large  quantities  by  the  skin  and 
kidneys.  The  urine,  when  impregnated  with  it  in  considerable  quantity, 
has  the  colour  of  porter  to  the  naked  eye.  When  bile,  diluted  with 
water,  is  treated  with  nitric  acid,  a  marked  series  of  changes  in  colour 
ensue.  A  little  acid  renders  it  green,  a  larger  quantity  blue,  pui'ple, 
violet,  and  lastly,  a  dull  red  or  brown  yellow.  These  changes  are  sup- 
posed to  be  owing  to  the  existence  of  three  colouring  matters  in  the  bile, 
one  brown,  the  cholepyrrhin^  another  yellow,  the  bilifuh'in,  both  disco- 
vered by  Berzelius,  a  third  the  hiUphcein  of  Simon.  AYhether  these  pig- 
ments are  derived  from,  or  convert- 
ed into  hematine,  has  not  yet  been 
ascertained,  though  Virchow  suspects 
that  they  are  the  same,  from  the 
similar  changes  produced  in  crystals 
of  hematoidine  by  the  action  of 
acids. 

Brown  Pigments. — During  the  de- 
composition of  extravasated  blood, 
it  has  often  been  observed  that  the 
tints  it  sometimes  presents  are  of  a 
reddish,  and  sometimes  of  a  bistre 
brown.  Bile,  also,  when  in  mass,  and 
inspissated,  often  assumes  this  colour. 
Different  ganglia  scattered  through 
the  nervous  system  owe  their  colour 
to  the  formation  of  brown  pigment 
molecules,  which  are  deposited  in 
the  nerve  cells.  The  skin,  in  some 
races,  is  naturally  brown  or  swarthy ;  the  areolae  round  the  nipples  as- 

Flg.  327.  Wartlike  brown  ncevus  innternm  of  the  female  mamma,  a,  Epidermic 
cells,  with  their  nuclei  concealed  by  a  dark  bro'mi  pigment ;  i,  the  nuclei  surrounded 
with  a  simOar  pigment ;  c,  cells  without  pigment ;  d,  reddish-brown  pigment,  in  the 
substance  of  an  hjpertrophied  papilla ;  e,  nuclei  in  fibrous  texture ;  /,  vascular  loop. 
— ( Wedl.)  ^ 


V 

Fi?.  327. 


^^^^«P) 


PIGMENTARY   DEGENERATION". 


229 


surae  this  tint  during  pregnancy;  exposure  to  the  sun  induces  this 
colouration  of  the  skin,  and  causes  freckles,  and  often  large  brown 
patches  to  appear  on  it  in  the  fairest  women ;  many  warts  and  naevi  are 
also  of  this  colour.  In  all  these  cases  the  colour  arises  from  the  deposi- 
tion of  a  brown  molecular  pigment,  in  the  deeper  cells  of  the  epidermis, 
and  sometimes,  as  in  warty  "naevi,  from  accumulation  of  dark  pigment 
in  minute  sacs  (Fig.  327). 

Not  unfrequently  brown  pigment  may  be  observed  collected  within  car- 
tilage cells,  when  that  texture  is  diseased  in  the  neighbourhood  of  necrosed 
bone,  or  in  death  of  cartilage  itself  (Fig.  328).  Occasionally,  also,  it  isfound 
covering  placental  villi,  or  situated  between  the  vessel  and  limitary  mem- 
brane of  the  tuft,  evidently  the  result  of  changes  occurring  in  extravasated 
blood  (Fig.  329). 

Dr.  Addison  has  described  a  form  of  anamiia,  in  which  the  skin  assumes 
a  peculiar  colouration,  in  connection  with  a  diseased  condition  of  the 


.«        i 


Fi?.  82S. 


Fig.  329. 


supra-renal  capsules.  It  presents  "  a  dingy  or  smoky  appearance,  or 
various  tintsor  shadesof  deep  amber  or  chestnut  colour;  and  in  oneinstance 
the  skin  was  so  universally  and  so  deeply  darkened,  that,  but  for  the 
features,  the  patient  might  have  been  mistaken  for  a  mulatto."*  Eleven 
cases  have  been  published  by  Dr.  Addison,  and  several  others  subse- 
quently by  Mr.  Hutchison,f  where,  co-incident  with  more  or  less  of  this 
bronzing  of  the  skin,  the  suprarenal  capsules  were  indurated,  cancerous, 
or  otherwise  diseased.  The  presumed  connection  between  the  functions 
of  these  glands,  and  the  secretion  of  pigment  in  the  integuments,  has 
excited  the  attention  of  physiologists  and  pathologists.  The  experiments 
of  the  former  and  observations  of  the  latter  have  recently  shown  that 

*  On  the  constitutional  and  local  effects  of  disease  of  the  supra-renal  capsules.   1855. 
f  Medical  Times  and  Gazette. 

Fig.  328.  Atrophied  bronchial  cartUage,  with  deposition  of  brown  pigment,  a. 
Cells  containing  brown  granular  pigments;  h^  cells  containing  large  fat  globules; 
c,  secondary  cells  with  fatty  granules.  The  intercellular  substance  is  loaded  with 
and  obscured  by  brown  pigment  granules. — (  Wedl.) 

Fig.  329.  Placental  villi,  containing  brown  pigment  from  an  aborted  foetus,  18 
inches  long.  a.  Villus,  at  its  termination  loaded  with  brown  pigment ;  h,  one  only 
partially  so  filled  at  its  summit,  but  with  molecular  pigment  scattered  through  its 
substance.— (Wed?.)  2h^  diam. 


230  PRINCIPLES   OF   MEDICHSTE. 

there  is  no  real  relation  between  disease  of  these  glands  and  the  amount 
of  pigment  in  the  skin.  Dr.  Harley,*  more  especially,  has  demonstrated 
that  their  excision  in  white  and  piebald  rats,  causes  no  alteration  in  the 
health  or  external  appearance  of  the  animals.  Numerous  cases  also  are 
now  on  record  of  bronzed  skin  without  alteration  in  the  supra-renal  cap- 
sules, and  of  extensive  lesion  of  these  glands  without  bronzed  skin. 

Green  Pigment. — The  cause  of  green  pigment  has  not  yet  been  deter- 
mined. AYe  have  seen  that  nitric  acid  produces  a  grass-green  colour 
when  added  to  bile,  and  it  is  possible  that  the  addition  of  some  acid 
matter  to  hematine  in  certain  states  of  combination  may  produce  a  similar 
result.  Abscesses  of  the  brain  not  unfrequently  contain  pus  of  a  decided 
green  colour,  and  vomited  matters  occasionally  present  the  same  hue. 
The  fceces  in  young  children  are  sometimes  of  a  spinach  green,  which  is 
supposed  to  result  from  an  altered  condition  of  bile,  or  from  the  presence 
of  blood.  The  contents  of  cysts  frequently  contain  fluid  of  different 
shades  of  green.  In  mortification  and  putrefaction  after  death,  the  inte- 
guments frequently  assume  a  greenish  hue.  Lastly,  morbid  growths, 
especiallv  in  the  bones  of  the  cranium,  have  been  described  and  figured 
of  a  decidedly  green  colour  [Chloroma)  by  Balfour,t  King,;};  and  Lebei-t.§ 

Black  P'uimeni. — Black  pigment  is  by  far  the  most  common  degenera- 
tion met  with,  and  is  found  in  various  situations.  Thus  ecchymotic 
^^.  extravasations  generally  assume  a  dark  purple  or 

-..,.• -.-"'^^^'i'r..         black  colour.     Vomitings  of  blood  in  yellow  fever 

•.^^^;'^^*?*v^'       and  gastric  cancer  are  frequently  dark  brown  or 

«%;^ '^-     ''•^.¥;;''  ~i   black;  so  also  are  the  foeces  after  blood  has  been 

^r^':'~  _  ''^ii  mixed  with  them   [Mekena),  or  after  taking  fer- 

''\y.         ruginous   medicines ;    certain    softenings    of  the 

V -r  :■■  stomach  itself,  of  the  intestinal  glands,  and  of  the 

entire  mucous  membrane  in  cases  of  dysentery ; 
i  •-   -  '•  the  contents  of  ovarian  cysts  and  other  encysted 

tumours  ;  intestinal  and  ovarian  cicatrices  ;  the  sordes  on  the  teeth  and 
o-ums  in  cases  of  fever ;  and  mortified  or  dead  parts.  "When  morbid 
growths  are  black  they  have  received  the  name  of  Melanoma,  and  the 
black  colouration  of  the  collier's  lung  and  bronchial  glands  has  been 
called  Palse  Melanosis  or  Black  Phthisis.  Nothing  is  more  common 
than  to  see  chronic  tubercle  surrounded  by  black  pigmentary  deposit. 
Scattered  tubercles  on  the  peritoneum  are  often  surrounded  by  a  black 
rino^,  which,  when  magnified,  presents  the  appearance  represented 
(Fig.  330.) 

Black  patches  have  occasionally  been  produced  on  the  skin,  appa- 
rentlv  from  the  secretion  of  pigmentary  matter  on  the  surface,  which  is 
capable  of  being  washed  off.     A  case  of  this  kind  is  recorded  by  Mr. 

*  Brit,  and  For.  Med.  Chir.  Review,  vol.  xxL  1858. 
\  Edin.  Med.  and  Surg.  Journal,  vol  xliil  p.  319. 
t  Monthly  Journal  of  Medical  Science.     Aug.  1853. 
g  Anatoniie  Pathologique,  Planche  xlv. 

Fig.  330.  Ring  of  black  pigment  masses  (a)  and  molecules  (6)  round  a  tubercle 
of  the  peritoneum.  The  black  tint  disappeared  after  some  days'  immersion  in 
alcohol.  250  diam. 


PIGMENTARY  DEGENERATION. 


231 


Teevan,*  in  the  person  of  a  young  girl,  aged  15,  tlie  upper  part  of  whose 
face  was  covered  with  a  black  discolouration.  The  colouring  matter 
was  analysed  by  Dr.  Rees,  who  found  in  it  carbon,  associated  under  the 
microscope  with  short  liairs,  epithelial  scales,  and  granules  and  globules 
of  fat. 

Portions  of  necrosed  bones  are  often  of  a  black  colour,  a  change 
which  according  to  AVedl  commences  at  the  external  portion  of  the 
systems  of  bone  corpuscles,  disposed  round  the  Haversian  canals.  The 
blackening  is  probably  owing  to  a  chemical  change  of  the  osseous  tex- 
ture, similar  to  what  occurs  in  caries  of  teeth  from  the  action  of  acid 


Fis.  332. 


Fig.  334. 


Fig.  335. 


saliva.     It  is  not  dependent  on  an  exudation,  which  in  sections  of  a  bone 
so  afi'ccted  is  nowhere  visible  (Fig.  331). 

Black  pigment  may  exist  in  the  form  of  minute  granules  (Fig.  332), 
or  of  irregular  masses  scattered  throughout  a  texture  (Fig.  333).  Some- 
times the  former  are  found  within  cells  which  may  be  round,  Hattened, 
many-sided,  or  have  irregular  prolongations  (Fig.  334,  336).  This  occurs 
in  the  choroid  membrane  of  the  eye ;  in  the  skin  of  men  and  animals 
during  health ;  in  the  melanotic  growths  so  common  in  grey  horses 
(Fig.  335),  in  the  epithelial  cells  of  the  collier's  lung,  and  in  certain 
forms  of  cancer  (Figs.  336,  337).  In  all  these  cases  the  nucleus  is  some- 
times clear  and  colourless,  and  at  other  times  obscureil  by  the  black  pig- 
ment. Black  pigment  may  also  occur  in  the  crystalline  form,  associated, 
with  hematoidine,  in  old  sanguineous  extravasations.  It  has  then  been 
called  Melanin. 


*  London  Medico-Chir.  Transactions,  vol.  xxviii. 


Fig.  331.  Transverse  section  of  a  necrosed  Tibia,  a,  Medullary  canals  divided 
transversely ;  h,  pigment,  formed  at  the  junctions  of  the  concentric  bone  systems ; 
c,  radiating  bone  canaliculi. — (  Wedl.)  90  diam. 

Fig.  332.  Black  pigment  molecules  from  the  lung. 

Fig.  333.  Black  pigment  irregular  masses  semi  crystalline,  from  an  intestinal  aggre- 
gate gland. 

Fig  33-i.  Polygonal  cells  loaded  with  pigment,  from  the  surfece  of  the  pericardium. 

Fig.  335.  Cells  loaded  with  pigment,  having  clear  nuclei,  from  a  melanotic  tumour 
of  the  horse.  250  diam. 


9R9, 


PEIXCIPLES   OF   MEDICINE. 


It  may  be  easily  shown  that  the  black  pigment  granules,  cells,  and 
crystals,  foimd  in  morbid  products,  although  thev  may  closely  resemble 
each  other  to  the  naked  eye,  and  even  under  the  microscope,  are  different 
in  their  chemical  compositions.  Thus  one  kind  of  black  pigment  loses 
colour  on  the  addition  of  nitro-muriatic  acid  or  chlorine  water,  whilst 
another  resists  not  only  these  agents,  but  even  the  action  of  the  blow- 
pipe. It  follows  that  the  latter  consists  of  carbon,  while  the  former 
is  a  peculiar  secretion  formed  within  cells,  or  a  transformation  of  the 
colouring  matter  of  the  blood. 

Blue,  jjurple,  and  other  Pigmeiits. — Blue  pigment  has  been  described 
as  occasionally  occurring  in  urine.     This  was  first  ascertained  by  Prout 


to  be  due  to  blue  indigo,  and  it  appears  probable  from  the  researches  of 
Schunk  and  others,  that  all  the  blue  and  purple  colourations  which  have 
been  seen  in  urine,  are  due  to  the  decomposition  of  Indican  (a  normal 
constituent  of  this  excretion)  and  the  formation  of  blue  and  red  indigo. 
The  addition  of  strong  sulphuric  acid  to  an  equal  quantity  of  urine,  at 
once  produces  these  colourations. — (Carter.) 

General  Pathology  and   Treatment  of  Pigmentary  Degeneration. 

The  formation  and  modifications  of  pig-ment,  as  observed  in  plants 
and  animals,  is  a  subject  which  has  been  little  studied,  and  opens  up  a 
wide  field  of  inquiry  for  the  chemical  histologist.  In  endeavouring  to 
ascertain  the  causes  which  give  rise  to  change  of  colour  in  the  textures, 
we  must  attend  to  the  following  circumstances : — 

1st.  Colouring  matter  bejirs  a  certain  relation  to  the  non-nitrogenous 
and  oily  constituents  both  of  plants  and  animals.  Thus,  vegetable  oils 
and  resins  are  seen  to  form  in  plants  where  starch  or  chlorophyle  is  col- 
lected, the  latter  substances  disappearing  in  the  cells,  as  the  quantity  of 
oil  increases  in  them.     In  animals  we  almost  always  find  pigment  asso- 


Figr.  336.  Cells  in  a  melanotic  cancer  of  the  cheek,  the  black  pigment  in  which 
disappeared  on  the  addition  of  hydrocliloric  acid. 

Fig.  337.  Cells  in  the  black  sputum  of  the  coUier,  the  pigment  of  which  is  per- 
sistent under  the  action  of  every  known  chemical  agent.  250  diam. 


PIGMENTARY  DEGEXEEATIOX.  233 

dated  with  fat.  The  brilliant  colours  of  the  invertebrata  are  so  many 
coloured  fats,  and  the  pink  fat  of  the  salmon,  and  green  fat  of  the 
turtle,  indicate  the  same  relation  in  animals  higher  in  the  scale.  The 
epidermic  appendages,  which  are  generally  coloured,  are  always  covered 
with  fat,  secreted  bv  a  special  apparatus — the  sebaceous  glands.  The 
blood  corpuscles  are  intimately  associated  with  the  chyle,  which  is  an 
oily  emulsion,  and  the  bile  is  rich  in  fat.  In  diseased  conditions  of  the 
liver,  the  hepatic  cells  often  contain  oil  to  the  exclusion  of  the  yellow 
pigment. 

2d.  It  would  appear  that  light,  heat,  and  exposure  to  atmospheric 
air,  are  connected  with  the  production  of  pigment.  The  young  leaves 
of  plants  are  much  lighter  in  colour  than  those  which  are  older,  and  the 
hair  of  young  animals  is  not  so  dark  as  that  of  the  adult.  In  autumn 
the  leaves  fade,  and  become  brown,  reddish,  or  yellow,  and  in  man  we 
observe  that  the  pigment  of  the  hair  ceases  to  be  formed  in  advanced 
age,  which  at  length  becomes  Avhite.  Young  fruit  is  green,  and  as  it 
ripens,  the  part  exposed  to  the  sun  is  most  coloured.  Exposure  of  the 
skin  of  man,  as  is  well  known,  renders  it  darker,  and  the  fairest  skin- 
ned individuals  (whose  integuments  are  well  loaded  with  fat)  are  those 
who  are  most  subject  to  freckles.  Then  it  must  be  remembered,  that 
while  light  evolves  colour  in  living,  it  destroys  pigment  in  dead 
textures. 

Now  the  decomposition  of  the  atmosphere  is  carried  on  in  vege- 
tables bv  the  leaves,  under  the  stimulus  of  light,  and  in  animals  by  the 
luno-s  and  skin.  In  plants  the  leaves  fix  the  carbon  and  give  off  the 
oxvo;en ;  in  animals  the  lungs  receive  oxygen,  while  carbon  is  separated 
in  the  form  of  carbonic  acid  by  the  same  organs,  and  oxygen  in  combi- 
nation with  water,  in  the  form  of  exhalation,  is  given  off  both  by  the 
lungs  and  skin.  That  the  skin  is  connected  with  respiration  is  proved 
by  the  fact,  that  if  its  fanctions  are  interrupted,  pulmonary  diseases  and 
even  asphyxia  are  the  common  results.  Carbon  is  also  separated  in  the 
form  of  oily  matter  largely  by  the  skin  and  by  the  liver,  an  organ  also 
connected  with  respiration.  Hence  why  Europeans  in  .tropical  climates, 
bv  breathing  a  rare  atmosphere,  eating  much,  and  taking  little  exercise, 
are  liable  to  hepatic  diseases.  Thus  the  lungs,  skin,  and  liver,  are  inti- 
mately associated,  in  the  function  of  excreting  carbon,  and  it  is  curious 
that  these  are  the  three  oi-gans  in  which  pigment  is  formed. 

3d.  There  seems  to  be  a  certain  connection  between  the  materials 
introduced  into  the  structure  of  the  plant  or  animal  by  means  of  the 
soil  and  of  food.  Some  plants  are  rich  in  acids,  others  in  alkalies,  or 
various  salts  originally  derived  froai  the  soil,  and  we  have  seen  that  these 
re-ao'ents  operate  on  colouring  matter.  Although  this  subject  has  been 
very  slightly  investigated,  we  can  still  perceive  how,  by  the  evolution 
of  chemical  products,  acting  on  different  pigments,  the  various  shades 
of  colour  may  be  occasioned,  which  we  observe  in  most  plants  and. 
some  animals  at  certain  seasons.  Thus  green  chlorophyle  may  be 
changed  in  one  place  into  a  yellow  resin,  and  in  another,  by  the  forma- 
tion of  ulmic  or  other  acids,  be  transformed  reddish  or  brown.  In 
animals  the  influence  of  nutrition  is  traced  with  more  difficulty,  but 
even  here  we  may  discern  that  at  certain  seasons  (such  as  that  of  breed- 
ing) new  products  are  evolved,  which,  by  operating  on  the  blood  or  the 


234 


PRINCIPLES   OF   MEDICINE. 


vital  properties  of  cells,  may  eliminate  more  or  less  colour.  Accord- 
ing to  Heusinger,  carbonaceous  food  used  in  excess  tends  to  tlie  pro- 
duction of  pigment,  and  hence  he  explains  how  the  Greenlanders,  not- 
withstanding the  cold,  are  dark  coloured,  from  their  constant  consump- 
tion of  fat. 

For  the  pathology  of  carbonaceous  deposit  in  the  lungs  of  the  collier, 
I  must  refer  to  the  special  diseases  of  the  respiratory  system.  (See 
Carbonaceous  Lungs.) 

The  treatment  of  pigmentary  degenerations  is  most  uncertain,  but  if 
the  preceding  observations  are  in  any  way  well  founded,  it  must  be  clear 
that  the  management  of  this  lesion  must  be  directed  to  removing  the 
physiological  conditions  on  which  it  depends. 

Mineral  Degeneration. 

By  this  term  is  understood  the  infiltration  or  deposition  of  mineral 
matter  into  a  texture,  in  such  a  way  that  it  is  no  longer  capable  of  per- 
forming its  functions.  We  have  already  seen  that  sometimes  this  takes 
place  in  such  a  regular  manner  as  to  form  bone,  which  replaces  the  pre- 
existing texture,  as  in  muscle,  membrane,  or  certain  exudations  and 
tumours.  But  at  others  it  enters  into  the  constitution  of  a  texture  dis- 
solved in  fluid,  and  is  thus  deposited  in  or  throughout  its  substance, 
changing  its  physical  and  destroying  its  vital  characters.  In  this  way 
we  separate  mineral  degenerations  from  concretions,  which   are  acci- 


dental collections  in  hollow  viscera,  although  undoubtedly  they  insensibly 
pass  into  one  another.  There  is  scarcely  perhaps  any  tissue,  whether 
elementary  or  compound,  that  may  not  undergo  the  minei'al  degenera- 
tion.    But  it  is  frequently  observed  in  the  coats  of  blood-vessels  more  or 

Fig.  338.  Structure  of  mineral  degeneration  of  tlie  walls  of  an  aneurism,  a,  The 
internal  membrane  witli  groups  of  fatty  granules;  b,  horizontal  section  of  the  creta- 
ceous middle  coats,  presenting  irregular  spaces,  of  various  dimensions,  filled  with 
carbonate  of  lime;  c,  globular  masses  of  mineral  matter,  in  the  lighter  portions  of 
the  section  6. — {Wedl.)  2h0  diam. 


MINERAL  DEGENERATION, 


235 


less  associated  with  atheroma;  in  exudations;  in  certain  morbid  growths 
— rarely  in  nervous  texture. 

Mineral  Degeneration  of  Blood- Vessels. — Nothing  is  more  common 
than  to  find  the  large  arteries  brittle  from  the  deposit  of  mineral  matter 
in  their  coats,  often  associated  with  fatty  degeneration  or  atheroma ; 
sometimes  the  one  lesion  and  sometimes  the  otLer  having  the  predomi- 
nance. Plates  and  patches  of  mineral  matter  may  in  this  way  often  be 
observed,  which  on 
stripping  off  the  inter- 
nal membrane  (Fig. 
338,  o)may  be  seen  em- 
bedded in  the  middle 
coat,  b.  These  never 
present  the  structure 
of  bone,  but  either  an 
amorphous  conglome- 
ration of  mineral  mat- 
ter, or  an  amalgama- 
tion of  round  globules, 
similar  to  those  which 
Czermakhas  described 
as  sometimes  occur- 
ring in  dentine  (Fig. 
338,  c).     Occasionally 


Fig.  839. 


though  more  rarely,  the  smaller  vessels  undergo  a  similar  degeneration. 
In  tliis  case  mineral  matter  is  deposited  in  their  coats,  which  when 
Avidely  scattered  also  presents  a  globular  form,  closely  resembling  drops 
of  oil,  for  which  they  are  apt  to  be  mistaken,  unless  mineral  acids  are 
added,  when  they  dissolve 
with  effervescence.  Fig. 
339  represents  tliis  de- 
generation in  the  small 
vessels  of  the  brain  as  de- 
scribed by  Dr.  Bristowe 
and  Mr.  Rainey.* 

Mineral  Degeneration 
of  Nervous  Texture. — 
Deposition  of  mineral 
matter  in  the  tubes  or 
ganglionic  cells  of  nervous 
substance  is  a  rare  occur- 
rence in  man,  although 
more  common  in  sheep 
and  other  of  the  inferior  animals 


Fig.  340. 

Foerster,  however,  has  recorded  the 


*  London  Pathological  Transactions,  vol.  iv.  p.  118. 


Fig.  339.  Incrustation  of  the  small  vessels  of  the  brain,  with  carbonate  and  phos- 
phate of  lime,  in  the  form  of  globules,  some  masses  of  which  are  separated,  whUst 
others  are  aggregated  together  outside  the  vascular  wall. — [Bristowe  and  Rainey.) 

Fig.  340.  Mineral  degeneration  of  the  nerve-cells  and  tubes  of  the  spinal  cord. — 
{Foerster.)  250  diam. 


236 


PRINCIPLES   OF   MEDICINE. 


case  of  a  boy  ^ho  had  paralysis  of  the  lower  extremities,  and  in  whose 
spinal  cord  after  death,  the  nerve-cells  and  tubes  were  found  encrusted 
with  mineral  deposits,  as  seen  in  Fig.  340.  In  this  case,  also,  the  creta- 
ceous closely  resembled  fetty  matter  ;  but  on  the  addition  of  hydrochloric 
acid,  the  granules  were  dissolved  with  eflFervescence.* 

In  other  Textures  mineral  matter  may  be  deposited  occasionally  in 
their  interstices,  but  if,  as  in  muscular  tissue,  it  does  not  assume  the  form 
of  a  bony  growth  to  which  we  have  previously  alluded  (p.  194),  it  is 
usually  the  result  of  an  exudation.  The  fibrous  membranes  of  the  brain 
not  nnfrequently  in  this  way  contain  calcareous  laminated  depositions. 
In  certain  parts  of  the  pia  mater,  and  the  choroid  plexus  especially,  we 
often  find  mineral  bodies  of  a  round  or  oval  form  resembling  starch  cor- 
puscles.    (See  Amyloid  Concretions.) 

Mineral  Degeneration  of  the  JE. nidations. — All  the  forms  of  exudation 
after  their  soft  parts  are  absorbed,  may  occasionally  leave  behind  them  a 
greater  or  less  quantity  of  mineral  matter.  Thus,  on  serous  membranes, 
in  areolar  textures,  in  the  sinuses  leading  from  chronic  abscesses  and  so 
on,  masses  of  earthy  matter  are  met  with,  formed  of  amorphous  mineral 


Fig.   841. 


Fig.   342. 


Fig.   84;3.J 


substances,  composed  of  phosphate  and  carbonate  of  lime.  These  are 
evidently  the  result  of  a  simple  exudation,  the  animal  matter  of  which 
has  been  absorbed,  whilst  the  mineral  constituents  in  excess  are  ao-gre- 
gated  together,  and  form  laminae  on  membranes,  or  nodules  in  parenchy- 
matous organs.  I  have  seen  the  gall-bladder  in  this  way  converted  into 
a  calcareous  shell,  and  the  pericardium  into  an  unyielding  mineral  box, 
inclosing  the  heart.  The  cardiac  valves  are  also  especially  liable  to  these 
mineral  incrustations.  A  cancerous  exudation  in  the  same  manner  under- 
goes the  calcareous  transformation.  The  mesenteric  glands  mav  not 
unfrequently  be  observed  to  be  partly  cancerous  and  partly  cretaceous. 
On  one  occasion  I  examined  a  large  cancerous  growth  of  the  omentum 
and  peritoneum,  which  was  so  loaded  with  phosphatic  salts,  that  slices 
of  it  when  dried  lost  little  of  their  bulk.  The  juice  squeezed  from  this 
tumour,  besides  masses  of  mineral  matter,  was  seen  to  contain  cancer- 
cells  in  various  stages  of  disintegration,  naked  nuclei,  fusiform  cells,  and 
a  multitude  of  molecules,  some  fatty  and  some  mineral  (Fig.  341).     On 

*  Mikroskopischen  Pathologischen  Anatomie,  TaC  xv. 


Fig.  341.  Mineral  masses  ia  a  degenerated  cancerous  tumour  of  the  omentum. 

Fig.  342.  The  same,  in  a  degenerated  cancerous  mass  in  the  Hver. 

Fig.  343.  Cancer-cells  infiltrated  with  cretaceous  molecules,  in  a  mesenteric  gland. 


COXCRETIOXS. 


237 


another  occasion  I  found  the  cancer-cells  embedded  in  and  infiltrated 
throughout  with  minute  cretaceous  molecules  (Fig.  343).  In  cancer,  as 
in  atheroma  of  arteries,  the  mineral  is  often  associated  with  the  fatty 
degeneration.  A  Tubercular  Exudation  passes  more  readily  into  creta- 
ceous and  calcareous  transformation  than  either  the  simple  or  cancerous 
forms.  Indeed,  it  may  be  said  that  the  natural  mode  of  arresting  the 
advance  of  tubercle  is  by  converting  it  into  mineral  matter.  I  possess 
specimens  of  miliary  as  well  as  of  infiltrated  tubercle,  arrested  in  all 

Fig.  345. 

stages  of  their  progress,  by  cretaceous  transformation,  in  which  case,  on 
microscopic  examination,  it  is  seen  to  consist  of  mineral  masses  associated 
with  a  few  tubercle  corpuscles,  debris  of  the  tissue  in  which  it  occurs, 
and  occasionally  a  few  crystals  of  cholesterine  (Fig.  344). 

Mineral  Degeneration  of  Morbid  Groicths. — Mineral  deposition  may 
occur  in  all  kinds  of  morbid  growths,  but  is  most  common  in  fibroma 
and  cystoma.  In  enchondroma  the  tendency  is  to  form  bone.  The 
white  "fibrous  tumours  of  the  uterus,  we  have  previously  seen,  may 
undergo  the  osseous  transformation  (Fig.  2V0) ;  but  this  is  an  occurrence 
of  extreme  rarity.  Far  more  commonly  the  centres  of  such  growths  are 
composed  of  amorphous  mineral  depositions  (Fig.  345),  which  frequently 
increase,  and  invade  their  whole  substance,  causing  arrest  of  their  pro- 
gress. I  have  often  found  embedded  in  the  uterine  walls,  mineral  masses, 
varying  in  size  from  a  hen's  egg  to  that  of  a  cocoa-nut,  formed  in  this 
manner.  Fine  preparations,  showing  the  same  fact,  may  be  seen  in  the 
Edinburgh  University  Museum, 


COXCRETIONS. 

Bv  concretions  are  understood  non-organized  and  non-vascular  pro- 
ductions, formed  bv  the  mechanical  aggregation  of  various  kinds  of  matter, 
generally  in  the  ducts  or  cavities  of  the  hollow  viscera.  It  has  already 
been  pointed  out,  that  although  they  pass  gradually  into  the  class  of 
deo-enerations,  several  of  which  closely  resemble  concretions,  still  they 
are  distinguished  from  them  by  their  never  having  been  organized,  or 


Fig.  344.  Mineral  masses  in  a  cretaceous  tubercle  of  the  lung. 
Fig.  34.5.  Section  of  an  amorphous  mineral  mass  forming  a  calcareous  nucleus  of 
a  uterine  fibrous  tumour. — (  WedL)  250  diam. 


238 


PRINCIPLES   OF   MEDICESTE. 


Fig.  346. 


formed  out  of  an  organic  structure.     They  possess  a  remarkable  dispo- 
sition, however,  to  collect  round  a  central  nucleus,  which  may  be  organic 

or  non-organic,  and  often  present  as  the 
result  of  pure  accident.  Hence  they 
generally  exhibit  a  tendency  to  assume  the 
globular  or  oval  shape. 

Albuminous  Concretions. — It  has  al- 
ready been  explained  that  albumen  may 
be  precipitated  fi-ora  its  solutions  in  the 
form  of  membrane  (p.  211).  This  is 
sometimes  so  effected  as  to  produce  con- 
cretions, of  which  I  have  long  possessed 
a  remarkable  specimen,  found  loose  in  the 
cavity  of  the  abdomen.  Mr.  Shaw  has 
described  a  similar  specimen,  about  one-half  the  size  of  mine,  con- 
taining a  nucleus  of  fat — also  formed  in  the  peritoneal  cavity.*     It  was 

excised  from  a  hernial  sac,  and 
consisted  of  aggregated  layers  of 
albuminous  substance,  as  seen  in 
iigs.  346,  349,  350.  The  con- 
centric layers  of  aneurismal  co- 
agula,  and  some  so-called  fibrin- 
ous depositions  on  the  valves  of 
the  heart,  which  subsequently  be- 
come white  and  indurated,  are 
of  a  similar  character.  The  sec- 
tion of  the  nucleus  in  my  speci- 
men (Fig.  347)  is  represented 
magnified  fifty  diameters.  Fig. 
348,  showing  the  adipose  cells  of 
the  structure,  loaded  round  the 
circumference  with  mineral  mat- 
ter. In  all  other  respects  it  re- 
sembled Mr.  Shaw's  specimen. 
Fatti/  Concretions. — These  constitute  gall  stones,  which  for  the  most 
part  are  formed  of  laminae  of  cholesterine,  associated  with  inspissated 
bile.  They  are  found  in  the  gall  ducts  or  bladder,  and  vary  in  colour, 
size,  form,  and  number.  They  may  be  perfectly  white,  and  then  they 
consist  almost  wholly  of  pure  cholesterine.  Sometimes  they  are  brown, 
and  at  others  jet  black,  approaching  carbon  in  chemical  composition. 
There  may  be  only  one  large  gall  stone,  nearly  filling  the  gall  bladder. 
^Yhen  there  is  only  one,  it  is  oval  in  form,  but  when  there" are  several 
stones  present,  they  take  a  many-sided  form,  in  consequence  of  pressure 

*  Loudon  Pathological  Trans,  vol.  vi.  p.  205. 


Fig.  34S. 


Fig.  346.  Longitudinal  section  of  the  albummous  concretion  referred  to,  and  its 
encysted  nucleus  of  fat. — {Shaw.)— Natural  size. 

Fig.  347.  Section  of  the  nucleus  of  an  albuminous  concretion. — Natural  size. 

Fig.  348.  Section  of  the  nucleus  of  an  albuminous  concretion,  showing  the  circum- 
ference loaded  with  mineral  matter,  and  the  cell  structure  of  the  interior.     50  diam. 


CONCRETIONS. 


239 


on  each  other.  In  one  case,  as  many  as  2000  minute  biliai^y  concretions 
were  counted  in  the  gall  bladder.  The  black  gall  stones  are  often 
rough,  round,  and  spiculated.  On  section  they  generally  pi'esent  a  nu- 
cleus which  is  composed  of  inspissated  bile,  and  mucus,  surrounded  by 
concentric  rings.  Occasionally,  the  centre  of  the  stone  is  liollow,  and 
the  substance  "lining  the  cavity  crystalline.  The  tough  white  masses 
occasionally  found  in  cystic  tmnoms  {cholesteatoma)  are  also  fatty  concre- 
tions. Sometimes  also  fatty  masses  have  been  passed  by  stool,  more 
especially  when  the  pancreas  has  been  diseased. 

Pifimentary  Concret'mis. — These  are  most  common  in  the  lungs  and 
bronchial  glands  of  colliers,  from  which  I  have  often  dug  out  masses 
varying  in  size  from  a  millet  seed  to  that  of  a  pea,  with  shiny  smooth  frac- 
tured surfaces,  composed  of  pure  carbon.  Occasionally  1  have  seen  a 
bronchial  gland  converted  into  a  cyst,  filled  with  a  thick  black  fluid,  like 
inspissated  paint,  principally  composed  of  carbonaceons  matter,  which 
would  doubtless  in  time  also  have  formed  an  indurated  concretion. 


Fia.  849. 


Fis.  350. 


Mineral  Concretions. — This  is  by  far  the  most  common  foi-m  of  con- 
cretion found  in  the  body,  and  usually  results  from  the  deposition  of 
various  salts  from  their  solutions,  often  round  a  nucleus  of  foreign  mat- 
ter, so  as  to  form  solid  masses  varying  in  size,  form,  and  general  arrange- 
ment of  parts.  Not  unfrequently  the  nucleus  may  be  a  portion  of  coa- 
gulated blood  or  inspissated  mucus,  so  that  mineral  concretions  are 
sometimes  found  in  the  veins  [phleholiles)  and  in  all  mucous  passages, 
such  as  the  salivary,  bronchial,  pancreatic,  hepatic,  renal,  etc.  Frag- 
ments of  degenerated  mineral  texture  may  also  be  pushed  out  from  the 
walls  of  such  passages  and  constitute  a  nucleus,  which  collects  mineral 
matter  around  it.  In  almost  all  such  cases,  the  mineral  is  composed  of 
phosphate,  with  varying  })roportions  of  carbonate  of  lime,  and  the  foi-m 
of  the  concretion  will  be  influenced  by  the  size  and  shape  of  the  cavity  in 
which  it  is  found.  An  excellent  example  of  this  may  be  seen  by  exa- 
mining the  grains  of  sand  in  the  pineal  gland,  which  will  be  found  to 


Fig.  349.  Portion  of  one  of  tiie  concentric  lamellaj,  of  the  same  concretion. 
Fig.  350.  Transverse  section  of  the  edges  of  the  concentric  lamellaa — (Shaw.)- 

250  cUam. 


240 


PRINCIPLES   OF   MEDICINE. 


consist    of  botryoidal  masses  vaiyino;  in  size,  but  constituting  mineral 
moulds  of  the  glandular  shut  sacs  in  which  they  were  produced. 


Fig.  351. 

Urinary  Concretions. — Mineral  concretions,  however,  are  by  far  m 
common  in  the  urinary  apparatus,  and  may 
be  formed  in  the  tubules  or  pelvis  of  the 
kidney,  in  the  ureter,  or  in  the  urinary 
bladder.  In  the  tubules  of  the  kidnev  they 
usually  assume  the  character  of  amorphous 
deposits,  filling  up  and  distending  the  tube, 
and  presenting  radiating  white  lines  in  the 
secreting  cones.  They  may  be  composed 
of  phosphate  of  lime  or  urate  of  ammonia 
(Fig.  .'S52).  Occasionally  masses  of  a  putty- 
like substance  are  formed  in  the  substance 
of  the  kidney  by  the  accumulation  of  such 
deposits,  which  in  time  would  have  consoli- 
dated into  calculi.  More  rarely  the  entire 
kidney  is  so  infiltrated  with  mineral  mat- 
ter, that  its  functions  are  destroyed.  I 
possess  a  specimen  of  this  kind,  where  the 
organ  might  be  supposed  to  be  petrified,  and  others  exist  in  the  Ed 
burgh  University  Museum. 


ost 


rite.  352. 


Fig.  351.  Various  forms  of  biliary  concretions.  /  White  biliary  concretions,  com- 
posed cliiefly  of  cholesterine.  c,  Irregular  biliary  concretions  of  inspissated  bile.  5, 
Black  biliary  concretions,  chiefly  carbonaceous,  d,  Yellow  biliary  concretions,  with 
spicula  formed  in  the  ducts  of  the  liver,  e,  Section  of  a  dark-brown  biliary  calculus, 
so  indurated  as  to  be  capable  of  receiving  a  polish,  showing  the  concentric  arrange- 
ment of  its  substance,  f,  Section  of  a  large  white  biliary  concretion,  showing  the 
radiated  as  well  as  concentric  arrangement. — Natural  size. 

Fig.  352.  Vertical  section  of  the  kidney,  a,  Some  of  the  tubules  filled  with  urate 
of  ammonia,  and  presenting  irregular  black  streaks,  with  lateral  branches  and  twigs, 
60  di.  b,  The  molecules  of  urate  of  ammonia  aggregated  together  in  masses. — 
(Wedl.)  250  diam. 


CONCEETIONS. 


241 


When  calculi  form  in  tlic  pelvis  of  the  kidney,  they  assnme  the  form 
of  the  cavitv,  which  varies,  however,  in  ditFereut  cases,  being  contracted 

in  some  and  dilated  in 
others.  The  accompa- 
nying figure  of  a  renal 
^^"\  calculus  exhibits  regu- 
^^  lar  protuberances,  jut- 
ting out  between  the 
urinarv  cones  from  a 
mass    formed   in  the 
pelvic     cavity     (Fig- 
Fig.Sog.  Fig.  354.  358).      Renal  calculi 

generally  give  rise  to  constant  irritation  and  surrounding  suppuration, 
constituting  what  Raver  has  called  calculous  pyelitis.  Their  chemical 
constitution  is  usually  uric  acid,  or  phosphate  of  lime,  alone  or  united  in 
various  proportions. 


Fi?.  355. 


Fi£r.  356. 


The  most  frequent  seat  of  urinary  calculi  is  in  the  bladder,  whence, 
from  the  circumstance  of  their  giving  occasion  for  one  of  the  most  im- 
portant operations  in  surgery,  they  have  been  made  the  subject  of  care- 
ful study.  Here  they  vary  in  size,  general  appearance,  and  chemical 
constitution.  In  size"  they  range  from  that  of  a  millet-seed  or  grains 
(known  under  the  name  of  gravel),  which  may  pass  along  the  urethra, 
to  that  of  a  body  weighing  several  ounces,  and  occupying  nearly  the 
■whole  bladder.  In  form  they  may  be  round,  oval,  flattened,  irregular, 
or  nodulated,  and  in  chemical  constitution  may  consist  of  phosphate  of 
lime,  triple  phosphate  of  ammonia  and  magnesia,  uric  acid,  oxalate  of 
lime,  or  xanthic  oxide.  Not  unfrequently  in  one  calculus  may  be  ob- 
served   deposits    of   varying    chemical    compositions,   round   a    central 

Fio-.  353.  External  view  of  a  remarkable  renal  calculu.?,  with  projections  on  all 
sides  of  it  but  one,  impacted  in  the  pelvis  of  the  kidney. — Real  size. 

Fio-.  354.  Section  of  the  same  calculus,  with  nucleus  of  uric  acid  and  oxalate  of 
lime. 

Fig.  355.  Calculus  with  lithic  acid  nucleus,  surrounded  by  oxalate  of  hme,  and 
covered  externally  with  laminas  of  lithic  acid. — (Syme.) 

Fig.  356.  Triangular  formed  calculus  of  lithic  acid  deposited  round  a  phosphatic 
nucleus  at  one  corner. — {Sy/ne.) 

16 


242 


PEINCIPLES   OF   MEDICINE. 


nucleus,  iudicating  the  salts  predominant  in  the  urine  during  the  period 
of  its  formation  (Figs.  355  to  361). 


Fi^'.  862. 


Tig.  360.  Fig.  861. 

One  of  the  most  remarkable  circumstances  connected  with  vesical 
calculi  is,  that  the  nucleus  may  be  composed,  not  only  of  various  kinds 

of  salts  or  of  fragments  of  other  calculi, 
but  even  of  foreign  substances  which 
have  been  introduced  from  without. 
Thus  various  rounded  bodies  thrust 
down  the  urethra  may  form  the  cen- 
tres of  these  concretions.  Fig.  362 
represents  a  piece  of  slate  pencil  as 
the  nucleus  of  a  phosphatic  concre- 
tion. Mr.  Syme  removed  it  by  the  ope- 
ration of  lithotomy,  and  the  man  confessed  he  had  introduced  the  foreign 
body  himself,  which  had  slipped  from  his  fingers,  and  entered  the  bladder 

Fig.  357.  Oval  calculus  of  lithic  acid,  having  a  litliic  acid  nucleus,  surrounded  by 
oxalate  of  lime. — {Lision.) 

Fig.  358.  Oval  calculus  of  uric  add. — (Lision.) 

Fig.  359.  The  triple  phosi^hate  surrounding  a  mulberry  concretion  of  oxalate  of 
lime. — (Lision.) 

Fig.  360.  Nodulated  mulberry  calculus  composed  of  oxalate  of  lime. — (R.  Mac- 
kenzie.) 

Fig.  361.  Phosphatic  calculus  formed  round  a  fragment  of  uric  acid  calculus,  pre- 
viously broken  up  by  lithotrity. — (Syme.) — Real  size. 

Fig.  362.  Phosphatic  calculus  formed  I'ounda  piece  of  slate-pencil,  which  had  been 
introduced  into  the  bladder  through  the  urethra. — (Syme.) — Real  size. 


COXCRETIOXS. 


2^3 


two  years  previouslv.     One  of  the  most  extraordinary  cases  of  this  kind 


Fig.  3C3. 

is  that  recorded  by  the  Lite  Dr.  E.  Mackenzie,  in  which  a  man  in  a  state 
of  intoxication  was,  dm-ing  a 
quarrel,  knocked  down  by 
his  comrades,  who  cruelly 
thrust  several  horse  beans 
into  his  urethra.  Six  months 
subsequently  he  was  operated 
upon  for  stone,  and  five  cal- 
culi removed,  each  of  which 
on  being  cut  open  was  found  to 
contain  a  bean,  surrounded  by 
a  shell  of  triple  phosphate* 
(Fig.  363).  Dr.  Dunsmure 
has  also  related  a  case  of  li- 
thotomy, where  the  nucleus  of 
the  stone  originated  in  the 
man's  falling  with  ^^olence 
across  the  gunnel  of  a  boat 
in  such  a  way  as  to  lacerate 
the  perineum,  and  force  a 
portion  of  his  woollen  trousers 
into  the  bladder.  I  examined 
the  nucleus  of  the  calculus  after  removal,  and  found  the  fibrous  substance 
it  was  composed  of  to  consist  of  wool.* 

*  Montlily  Journal  of  Medical  Science,  January  1853. 

Fig.  363.  Sections  and  external  appearance  of  the  calculi  in  i£r.  Mackenzie's  case, 
formed  round  horse  beans,  introduced  into  the  bladder  in  the  manner  described. — 
(/?.  Mackenzie.) — Real  size. 

Fig.  364.  Prostatic  calculi  exhibiting  the  concentric  laminse,  and  nuclei  of  these 
bodie's.— ( Wedl.)  250  diam. 


Tis.  364. 


244 


PRIXCIPLES   OF  MEDICEN'E. 


Prostatic  Concretions. — The  adult  prostate  gland  almost  invariably 
will  be  found  to  contain  a  number  of  calculi,  which  increase  in  number 
with  the  age  of  the  individual,  and  are  often  very  numerous  when  the 
gland  is  enlarged.  They  are  of  a  yellowish  colour,  vary  iu  size  from  g-oVtl^ 
to  the  yjo^t  of  an  inch  in  diameter,  and  are  characterised  by  their  con- 
centric laminae,  surrounding  a  single  or  double  nucleus,  which  also  varies 
greatly  m  size.  Dilute  mineral  acids  cause  the  calcareous  matter  to  be 
dissolved,  leaving,  however,  the  structural  appearance  unaffected,  and 
rendering  them  occasionally  soft  and  compressible.  In  this  respect  they 
resemble  the  amyloid  bodies  which  occur  in  the  arachnoid,  and  like  them 
thev  may  possibly  be  colloid  masses,  throughout  which  mineral  matter 
is  imbibed  in  a  fluid  state,  so  as  graduallv  to  convert  them  into  calculi. 


ri?.  365. 


Hairy    Concretions. — Balls  composed  of  hair   are   not  unfrequently 

Fig.  365.  Mass  of  hair  found  in  the  human  stomach,  as  described  above.  Infe- 
riorly  it  was  encrusted  with  a  layer  of  altered  food,  a  fragment  of  which  has  been 
removed  towards  the  left,  showing  the  hair  beneath. — {Ritchie.) — Three-fourths  the 
reaJ,  size. 


CONCRETIONS. 


245 


found  in  the  stomacli  and  alimentary  canal  of  the  inferior  animals,  es- 
pecially such  as  are  in  the  habit  of  licking  their  hairy  coats.  Rare 
cases  have  been  recorded  where  similar  masses  have  been  found  in 
the  stomach  of  the  human  subject.  One  of  these  has  been  published 
by  Dr.  Ritchie  of  Glasgow.*  It  was  that  of  a  factory  girl,  aged  21, 
vfho  had  contracted  the  habit  of  pulling  hair  from  her  head,  while  em- 
ployed at  work,  and  swallowing  it.  She  had  ileus,  followed  by  symptoms 
of  rupture  of  the  intestine.  On  dissection,  the  ma^s  here  figured,  form- 
ing a  mould  of  the  stomach,  composed  of  moist  female  hair,  was  disco- 
vered, and  two  smaller  ones  were  found  in  the  intestines  (Fig.  365). 
Similar  cases  with  hairy  concretions  are  recorded  by  Pollockf  and  May.;]; 

Vegetable  Fibrous  Concretions. — These 

are  only  found  in  the  alimentary  canal, 

and   in  man  are  most  common  in   the 

\      intestines.      The    largest    collection    of 

;\    them  extant  is  in  the  Edinburgh  TJni- 


t^^a**'^ 


-;V 


Fiff.  366 


Fig    367. 

versify  Museum,  which  was  made  by  the 
second  Monro.  An  admirable  dissertation 
reo-arding  them  was  published  by  his  son, 
Monro  tertius.§  ^\"ollaston  first  demon- 
strated that  they  were  principally  compos- 
ed of  the  fibrous  matter  of  the  oat  seed,  a 


fact  confirmed  by  the  careful  researches  and  published  figures  of  Dr.  Douglas 

*  Monthly  Journal  of  Medical  Science,  July  1849. 

f  Pathological  Transactions  of  London,  1851-2. 

j  Association  Journal.  No.  156,  1856. 

§  Morbid  Anatomy  of  the  Human  GuUet,  Stomach,  and  Intestines,  Edinburgh,  1811. 


Fig.  366.  Section  of  a  remarkably-shaped  intestinal  concretion,  a,  Nucleus  of 
extravasated  blood;  b,  b,  b,  concentric  laminse.  It  weighed  14^  ounces,  measured  7 
inches  in  length,  and  was  evacuated  by  the  rectum.— {Hiiss  and  Mosander.)—Half 

fJlP  T€.Q.\  StZ€ 

Fig.  367.  Section  of  an  intestinal  concretion,  with  a  plum  stone  for  its  nucleus,  in 
the  Mom-o  collection  of  the  Edinburgh  University  ILuseum.—Beal  size. 


246 


PRINCIPLES  OF   MEDICINE. 


Maclagan.*  These  concretions  vary  in  size  from  a  pea  to  tliat  of  an  orano-e. 
They  are  round  or  oval  in  shape  if  isolated,  but  are  frequently  compressed 
or  flattened  at  the  sides,  and  occasionally  of  very  irregular  sliapes,  according 
to  the  amount  of  pressure  or  impaction  to  which  they  have  been  subjected. 
In  colour  they  are  of  a  yellowish  brown,  but  are  much  lighter  if  intiltrated 
with  earthy  salts  to  any  unusual  extent.  They  easily  crumble  down 
under  firm  pressure,  and  present  a  short  fibrous  texture,  like  the  felt  of  a 
hat.  On  section  with  a  sharp  instrument,  they  present  on  the  cut  surface 
a  series  of  concentric  lines,  which  are  often  of  a  lighter  colour  and 
harder  consistence  than  the  general  substance  of  the  concretion.  In  the 
centre  may  fi-equently  be  observed  a  nucleus  composed  of  some  foreign 
body,  such  as  a  plum  or  cherry  stone,  a  piece  of  bone,  etc.  Chemically, 
they  consist  principally  of  fibrous  vegetable  matter  and  phosphate  of 
lime,  mingled  w  ith  small  proportions  of  water,  soluble  vegetable  matter, 
fat,  foeces,  and  a  little  silica  derived  from  the  structure  of  the  oat — 
(Maclagan). 

On  examining  a  small  fragment  of  these  concretions  under  a  power  of 
200  diameters  linear,  they  are  seen  to  be  made  up  of  an  ago-regation  and 
mingling  together  of  vegetable  fibres,  principally  derived  from  the  carrj- 
opsis  of  the  oat,  mingled  in  recent  specimens  with  numei'ous  irregular 
crystals  and  amorphous  precipitate  of  the  phosphate  of  lime.  The 
fibres  vaiy  greatly  in  length  and  diameter,  but  in  form  are  pointed  at  one 

extremity,  truncated  at  the 
other,  with  a  central  canal, 
which  gradually  diminishes  to- 
wards the  pointed  extremity. 
The  accompanying  figure  repre- 
sents a  fragment  taken  from  the 
concretion  represented  Fig.  368, 
from  the  Monro  collection,  in 
which,  besides  the  vegetable 
fibres  alluded  to,  masses  of  mo- 
lecular mineral  matter  may  be 
■^''■^^"'"  observed  soluble  in  dilute  nitric 

acid,  of  which  the  white  concentric  lines  were  principally  composed 
(Fig.  373.) 

As  regards  the  manner  in  which  these  concretions  are  formed,  it  is 
to  be  observed,  that  the  fibres  of  the  caryopsis  of  the  oat  possess,  in 
a  remarkable  degree,  the  property  of  felting,  which,  as  pointed  out  by 
Dr.  Carmichael  of  Buckie,f  is  prevented  by  oil,  and  favoured  by  the  use 
of  dry  substances,  as  fuller's  earth.  Both  these  substances  are  used 
largely  in  wool  manufactories,  the  one  for  carding  and  the  other  iov  felt- 
ing. I  am  indebted  to  that  gentleman  for  some  specimens  of  concre- 
tions, formed  of  oat  dust  (that  is,  the  hairy  covering  of  the  oat),  simply 
by  the  rotatory  or  oscillatory  motion  of  the  wirecloth  sieve  of  a  mill. 
From  thence  may  always  be  collected  soft  concretions  of  various   sizes, 

*  Monthly  Journal  of  Medical  Science,  Sept.  6,  1841. 
f  Ibid.     June  1848. 


Fig.  368.  Hairs  from  the  caryopsis  of  the  oat,  felted  together,  and  mingled  with 
granular  masses  of  the  phosphate  and  carbonate  of  lime.  250  diam. 


C0XCRETI0X3. 


247 


formed  round  pieces  of  thread,  or  other  foreign  bodies.  The  same 
thing  appears  to  result  in  the  animal  body,  from  the  peristaltic  action  of 
the  intestines,  when  the  fibrous  dust  is  imperfectly  separated  from  the 
meal,  as  was  formerly  the  case  in  the  outmeal  used  largely  as  food  for 
man  in  Scotland.  Since  the  employment  of  winnowing  machines,  and 
greater  consumption  of  meat  and  oleaginous  substances,  the  formation 
of  these  concretions  has  become  very  rare.  In  horses,  however,  they 
are  still  common,  and  it  is  remarkable  that  in  remote  districts,  w^here 
meal  is  still  imperfectly  prepared,  cases  still  occasionally  occur,  such  as 
the  one  recorded  by  Dr.  Turner  of  Keith,*  of  a  man  who,  in  1841, 
passed  fourteen,  and  in  1845-6,  other  eighteen  of  these  concretions. 

Amyloid  and  Amylaceous  Concretions. — Yalentin,f  Lebert.J  Gluge,§ 
and  others,  have  figured  rounded  mineral  bodies  with  concentric  circles, 
frequently  present  in  the  brain's  substance,  and  more  or  less  soluble  in 
mineral  acids.  In  April  1847,||  I  presented  a  portion  of  a  tumour  to 
the  Pathological  Society  of  London,  which  was  attached  to  the  tento- 
rium, and  crowded  with  similar  bodies.  They  were  evidently  mineral 
concretions,  formed,  however,  on  an  organic  base,  varying  in  size  from 


the  — ^-oth  to  the  .toV o-th  of  an  inch  in  diameter.     Their  fracture  was 
exacUy  like  that  ot'  starch  corpuscles,  but  they  were  not  rendered  blue 

*  Monthly  Journal  of  Medical  Science,  Sept.  1841  and  January  184S. 

f  Handworterbuch  der  Pli3-siologie,  Taf.  1,  Fig.  2. 

t  Physiologie  Pathologique,  PI.  xi.  Fig.  10. 

§  Pa"thologi?che  Anatomie,  Liv.  16,  Taf.  2. 

II  Proceedings  of  Pathological  Society  of  London,  1S46-7,  p.  17. 


Fio-.  369.  Amyloid  bodies  embedded  in  a  seemingly  amorphous  matter. 

Fi°.  370.  The" same,  after  dilution  with  water,  now  seen  to  be  invested  with  a 
fibrous  sheath,  and  surrounded  by  fusiform  cells  and  naked  nuclei. 

Fig.  371.  The  same,  after  the  addition  of  acetic  acid. 

FiS.  373.  The  same,  after  the  addition  of  nitric  acid,  a,  One  of  tliese  bodies  with 
a  thick  investing  capsule ;  l,  c,  and  d,  others  showing  the  various  ways  in  which 
they  crack  on  pressure;  e,  cylindrical  form  produced  by  rolling  them  between 
glasses. 


250  diam. 


248 


PEINCIPLES   OF   MEDICINE. 


on  the  addition  of  iodine.  Nitric  acid  dissolved  the  mineral  matter, 
and  showed  them  to  be  composed  of  concentric  fibres,  surrounding  a 
nucleus,  with  distinct  nuclei  (Fig.  372).  They  were  embedded  in  a 
fibro-nucleated  structure,  which  foi'med  a  sheath  round  eacli  concretion. 
Since  then,  I  have  frequently  seen  similar  bodies  in  the  arachnoid  mem- 
brane and  substance  of  the  brain,  and  they  have  been  also  observed  by 
Dr.  Quain,  and  many  others.     These  ai'e  amyloid  bodies. 

Yirchow*  was  the  first  to  point  out  that  several  of  these  bodies  in  the 
brain  assumed  a  pale  blue  tint  on  the  addition  of  iodine,  and  subse- 
quently became  violet-colour  on  being  treated  with  sulphuric  acid.  He 
considered  them  to  be  cellulose,  a  principle  which  he  also  had  show^n  to 
exist  in  other  pathological  formations.     Mr.  Buskf   demonstrated  that 


il»°^^rvO  •••"^  ^f.'i  --"^  •'So'."'  -v.     ■  - 


Fisr.  3T3. 


Fig.  874 


these  bodies  were  optically  as  well  as  chemically  identical  with  starch, 
and  that  they  were  true  corpoj-a  amylacea.  They  have  been  found  in 
various  tissues  and  fluids  by  subsequent  observers,  and  have  been  made 
the  special  subject  of  research  by  Dr.  Carter,^  who  has  demonstrated 
their  existence  in  almost  every  tissue  and  fluid  of  the  human  body,  and 
in  every  kind  of  morbid  product.  They  are  of  two  varieties,  the  one 
(described  by  Mr.  Busk)  resembling  wheat  starch,  the  other  and  rarer 
kind  corresponding  in  every  particular  with  that  derived  from  the 
potato. 

It  follows,  that  there  exist  concretions,  some  of  which  resemble  while 
others  really  are  starch  corpuscles.  The  former  are  amyloid,  and  the 
latter  amylaceous  concretions.  Both  these  bodies,  without  the  action  of 
re-agents,  are  not  only  liable  to  be  confounded  with  each  other,  but  with 
colloid  and  fat  masses.  It  is  questionable,  indeed,  whether  the  amyloid 
concretions  are  colloid  bodies,  which  have  subsequentlv  become  impreg- 
nated with  mineral  matter,  or  whether  they  are  starch  corpuscles  that 
have  undergone  a  mineral  degeneration.  But  the  relation  of  these  two 
kinds  of  concretions  to  one  another,  to  fat  and  colloid  masses,  are  points 

*  Archives,  Band  vL  s.  125.     1854. 

f  Quarterlj^  Journal  of  Microscop.  Science,  vol.  ii.  p.  106.     1854. 

X  Edinburgh  Medical  Journal,  August  1855,  and  Graduation  Thesis,  1856. 


Fig.  373.  Small  corpora  amylacea,  in  the  auditory  nerve  of  a  deaf  individual,  with 
several  granule  cells. — {Foerster.) 

Fig.  374.  Variouslj'-shaped  and  sized  corpora  amylacea,  from  the  human  pancreas, 
a,  Nucleated;  i),  c,  rf,  variously-shaped :  e,  seen  edgeways. — {Carter.)     250  dia7n. 


CONCRETIONS.  249 

which  have  not  yet  been  investigated.  The  presence  of  sugar,  which 
has  recently  been  shown  to  be  always  a  constituent  of  normal  blood,  in 
that  part  of  the  circulation  which  lies  between  the  hepatic  and  pulmo- 
nary veins,  may  also  be  connected  with  the  formation  of  one  or  more 
of  these  non-nitrogenous  substances.  All  speculation  on  this  subject, 
however,  is  at  piesent  highly  hypothetical,  and  it  is  only  from  the  progress 
of  organic  chemistry  that  we  can  hope  to  derive  a  satisfactory  explanation 
of  these  transformations  which  go  on  in  the  blood  tissues,  so  that  we 
may  determine  the  laws  regulating  the  production  of  the  amylaceous 
and  amyloid  concretions. 


SECTION  III. 


ox  THE  RECEXT  CHAXGES  IX  THERAPEUTICS,  OCCA- 
SIOXED  BY  AX  ADVAXCED  KXOWLEDGE  OF  DIAGXO- 
8IS   AND   PATHOLOGY. 

ly  the  previous  two  sections  I  liave  endeavoured  to  a'ive  a  condensed 
account  of  the  present  state  of  diagnosis,  and  of  the  pathology  of  organic 
diseases.  A  practical  knowledge  of  the  one,  aTid  a  better  appi-eciation 
of  the  other,  have  been  very  widely  diffused  witliin  the  last  sixteen  years. 
In  consequence  a  change  almost  amounting  to  a  complete  revolution  in 
our  treatment  of  disease,  has  taken  place  within  that  short  period.  It  is 
true  that  this  change  is  not  yet  reflected  in  our  systematic  works, 
although  clinically  it  is  everywhere  recognized.  "When  we  compare  the 
actual  practice  of  medicine  with  what  it  was,  or  with  what  it  is  repre- 
sented to  be,  even  in  modern  books  on  the  theory  and  practice  of  physic, 
the  discrepancy  must  strike  even  the  least  observant.  It  seems  to  me 
that  the  time  has  now  arrived  for  calling  the  attention  of  the  profession, 
and  more  especially  of  its  youthful  members,  to  the  causes  which  have 
produced  so  important  a  result,  and  for  pointing  out  some  of  those 
principles  on  which  an  improved  medical  art  for  the  future  must  necessa- 
rily be  based. 

I  ha\'e  already  alluded  to  the  general  treatment  required  in  diseases  of 
nutrition  (p.  107),  and  have  endeavoured  to  show  that  a  knowledge  of 
the  various  processes,  of  which  that  function  is  made  up,  is  a  necessary 
preliminary  step  to  correct  medical  practice.  Our  agents  for  combatino- 
this  class  of  disorders,  are  nutrients,  hematics,  eliminatives,  astringents, 
etc.  Diseases  of  innervation  require  for  their  proper  management  the 
same  previous  knowledge,  and  demand  as  remedies  stimulants,  sedatives, 
narcotics,  etc.  The  mode  of  applying  these  can  only  be  learnt  by  treat- 
ing maladies  in  detail,  whilst  for  what  is  known  of  the  general  principles 
of  their  action  I  must  refer  to  special  works  on  this  subject*  Remedies 
have  hitherto  been  employed  too  much  in  reference  to  symptoms,  and 
with  too  little  regard  to  the  pathological  states  which  produce  those 
symptoms,  or  to  the  intimate  relations  winch  exist  between  the  nutritive 

*  See  especially  Headlam  on  the  Action  of  Medicines. 


FALLACIOUS   CHARACTER   OF   PAST   EXPERIENCE.  251 

and  nervous  functions.  Thus,  for  instance,  impaired  digestion  may  cause 
headache  and  sleeplessness.  Now,  we  can  relieve  the  latter  symptoms  by 
morphia ;  but  if  this  remedy  increase  the  want  of  appetite,  as  it  really 
does,  what  have  we  gained  ?  The  urgent  symptoms  are  temporarily  pal- 
liated, but  their  cause,  so  far  from  being  removed,  is  actually  intensified. 
This  distinction  between  a  palliative  and  a  curative  treatment  has  been  too 
much  overlooked  in  medical  practice.  Drugs  have  been  given  to  relieve 
symptoms,  while  the  causes  producing  them  have  not  been  sufficiently 
attended  to.  Need  it  then  excite  surprise  that  as  our  knowledge  of 
pathology  lias  advanced,  and  our  means  of  diagnosis  have  improved,  this 
discrepancy  has  become  more  apparent,  and  that  we  now  direct  atten- 
tion more  to  the  causes  and  less  to  the  eft'ects  of  disease  ? 

The  chano-es  which  have  recently  taken  place  in  medical  practice,  as 
a  result  of  this  mode  of  viewing  diseases,  will  be  referred  to  in  the  spe- 
cial part  of  the  work.  Two  great  facts,  however,  seem  to  me,  from  their 
especial  importance,  to  demand  attention  here.  These  are— Is?,  The 
diminished  employment  of  blood-letting  and  other  antiphlogistic  reme- 
dies in  the  treatment  of  acute  exudations,  or  so-called  inflammations  ; 
and  2d,  The  power  which  it  has  been  demonstrated  may  be  exercised 
over  certain  diseases  of  innervation,  through  the  influence  of  suggestion 
or  strong  impressions  made  upon  the  mind.  Both  these  fects  have  re- 
cently excited  great  attention  and  discussion  ;  their  influence  on  medical 
theory  and  prjrctice  has  already  been  great,  and  their  explanation  on 
scientific  gronnds  seems  to  be  called  for,  with  the  view  of  establishing 
correct  principles  for  our  future  guidance. 


THE  DIMINISHED  EMrLOYMENT  OF  BLOOD-LETTING  AND 
OTHER  ANTIPHLOGISTIC  REMEDIES  IN  THE  TREATMENT 
OF  ACUTE  INFLAMMATIONS. 

It  must  be  admitted  by  all  who  contemplate  the  actual  state  of  medi- 
cal practice  in  this  country,  that  the  use  of  blood-letting,  and  of  other 
antiphlogistic  remedies,  lias  within  a  recent  period  greatly  declined. 
According  to  Dr.  Alison,*  such  remedies,  and  more  especially  blood- 
letting, wCTe  formerly  highly  successful  in  arresting  the  disease,  but  fail 
to  do'so  now,  and  are  even  injurious;  and  the  inference  he  draws  from 
these  supposed  facts  is  that  inflammation  itself  is  no  longer  the  same, 
that  its  tvpe,  and  more  especially  the  febrile  symptoms  accompanying  it, 
have  altered  from  an  inflammatory  to  a  typhoid  character.  In  short,  it 
seems  to  be  Dr.  Alison's  opinion,  that  our  advanced  knowledge  of  diagno- 
sis and  pathology  has  had  httle  influence  in  producing  this  great  revo- 
lution in  our  treatment,  but  that  the  human  constitution  (in  a  manner 
which  is  not  explained)  is  fundamentally  altered,  and  that  medical  men 
were  as  rio-ht  in  bleeding  twenty  years  ago  as  they  are  correct  in  now 
abstaiuino-  from  it.  In  opposition  to  these  views,  it  will  be  ray  endeavour 
to  show^— l.s/,  That  little  reliance  can  be  placed  on  the  experience  of 
those  who,  like  Cullen  and  Gregory,  were  unacquainted  Avith  the  nature 

*  Edinbure,h  Medical  Journal,  March,  1856. 


252  PRINCIPLES   OF   MEDICINE,. 

of,  and  mode  of,  detecting  internal  inflammations.  2d,  That  inflammation 
is  the  same  bow  as  it  has  ever  been,  and  that  tl\e  analogy,  songht  to  be 
established  between  it  and  the  varying  types  of  essential  fevers^  is  falla- 
cious. .3f7,  That  the  principles  on  which  blooddetting  and  antiphlogistic 
remedies  have  hitherto  been  practised  are  opposed  to  pathology.  4/A, 
That  an  inflammation  once  established  cannot  be  cut  short,  and 'that  the 
object  of  judicious  medical  practice  is  to  conduct  it  to  a  favourable  ter- 
mination, bth,  That  all  positive  knowledge  of  the  experience  of  the 
past,  as  well  as  the  more  exact  observation  of  the  present  day,  alike 
establish  the  truth  of  the  preceding  propositions  as  guides  for  the  future. 


Pkoposition  1. —  TJtnt  little  reliance  can  he  placed  on  the  experience  of 
those  ivho,  like  Cullen  and  Gregory,  loere  unacquainted  rvith  the  nature 
of,  and  the  mode  of  detecting,  internal  injiammations. 

Inflammation  for  many  years  was  generally  recognised,  especially  in 
external  parts,  by  the  existence  of  pain,  heat,  redness,  and  swelling,  and 
in  internal  parts  by  fever,  accompanied  by  pain,  and  impeded  function 
of  the  organ  aff"ected.  In  short,  groups  of  symptoms,  in  accordance  with 
the  nosological  systems  of  the  day,  constituted  inflammation.  But  the 
school  of  morbid  anatomy,  by  showing  that  inflammation  was  a  diseased 
condition  of  a  part,  entirely  overthrew  the  errors  and  confusion  inherent 
in  all  such  nosological  systems.  Clinical  observation,  based  on  a  more 
correct  diagnosis  and  pathology,  has  since  demonstrated  that  artificial 
nosological  groups  of  symptoms  bear  no  relation  whatever  to  the  inter- 
nal inflammations  they  were  formerly  supposed  to  indicate,  and  has  led 
to  a  mass  of  information,  connected  with  internal  disease,  which,  up  to 
this  time,  has  never  been  correctly  systematised.  Again,  more  recent 
histological  research,  by  exhibiting  to  us  that  inflammation  is  in  truth  a 
disease  of  nutrition,  governed  by  the  same  laws  that  determine  the 
growth  and  functions  of  cells,  as  thev  exist  in  the  embryo  and  in  healthy 
tissues,  has  united  physiology  and  pathology  into  one  science,  and  has 
removed  our  present  knowledge  still  further  from  the  traditional  errors 
of  the  past.  Why,  then,  should  we  on  our  onward  course  be  governed 
by  the  opinions  of  Cullen  and  Gregory,  of  Gaubius  and  Sydenham,  of 
Aretseus  and  Hippocrates  ?  These  distinguished  men  all  advanced 
medicine  in  their  day,  as  far  as  they  were  enabled  to  do  so  by  the  then 
state  of  science  and  the  means  within  their  reach ;  but  the  princi2:)les 
wdiich  guided  them  ought  no  more  to  be  considered  laws  to  be  followed 
now  by  practical  physicians,  than  should  the  exploded  astronomical  doc- 
trines of  Copernicus  and  Tycho-Brahe  be  acted  on  by  practical  naviga- 
tors. It  is  not  my  intention,  therefore,  to  enter  into  a  lengthened 
refutation  of  the  opinions  of  former  writers,  or  even  of  many  modern 
ones,  in  determining  what  pathologists  now  understand  by  the  term 
inflammation.  What  I  mean  by  it  in  the  following  remarks,  is  an  exu- 
dation of  the  normal  liquor  sanguinis  ;  and  Dr.  Alison  evidently  means 
the  same  thing,  when  he  acknowledges  "that  exudation  of  lymph  is 
essential  to  almost  all  changes  of  structure  produced  by  inflammation." 
Whatever,  then,  may  have  been  formerly  understood  by  this  word  in- 
flammation— in  whatever  wa)'  it  may  be  now  applied — whether  to  the 


THE   UNCHANGEABLE   NATURE    OF   INFLAMMATION,        253 

congestion  of  tlie  blood-vessels,  the  exudation  of  liquor  sanguinis,  or  to 
the  change  in  the  texture  causing  these  phenomena — it  is  important  to 
remember  that  in  speaking  of  it  both  Dr.  Alison  and  myself  mean  an 
alteration  in  a  part  characterised  by  the  exudation  of  lymph  through  the 
walls  of  the  minute  vessels,  resulting  from  changes  moi'e  or  less  well 
marked  in  the  nervous,  vascular,  sanguineous,  and  parencliymatous  ele- 
ments of  that  part.  (See  p.  12';,  et  seq.,  also  Dr.  Alison's  observations 
in  the  Note  to  this  subject,  at  p.  279.) 

As  regards  diagnosis,  it  must  be  acknowledged  by  all  parties  that,  up 
to  a  recent  period,  internal  inHaramations  were  sought  to  be  recognised 
only  by  svmptoms.  But  medical  men,  who  have  of  late  years  studied 
these  iiiflaunuations  by  physical  signs  as  well  as  by  symptoms,  must 
have  coiue  to  the  conclusion,  that  symptoius  alone  are  altogether  insuffi- 
cient to  enable  us  to  determine  the  existence  of  internal  inflammations. 
This  is  a  point  which,  if  necessary,  could  be  established  by  innumerable 
facts,  which  show,  1st,  That  all  the  symptoms  of  inflammation  may  be 
present,  and  yet  iwHt-mortem  examination  demonstrate  the  absence  of 
lesion  ;  and,  2dly,  That  inflammation  has  been  the  cause  of  numerous 
deaths,  without  one  of  the  symptoms  generally  supposed  to  be  its 
accompaniments  having  been  present.  But  here,  also,  it  is  unnecessary 
for  me  to  enter  at  any  length  into  this  question,  because  it  is  admitted  by 
Dr.  Alison  that  we  can  now  detect  inflammation  of  the  lungs  "  in  cases 
where  there  is  so  little  of  pain,  or  cough,  or  dyspnoea,  or  inflammatory 
fever,  that  we  should  not  in  former  times  have  given  them  the  name  of 
pneumonia."  But  when  he  goes  on  to  say  that  "  the  cases  of  pneumonia 
thus  overlooked  were  attended  with  little  or  no  immediate  danger,"  I 
am  constrained  to  dissent  from  this  opinion,  for  it  appears  to  me  that 
many  of  these  cases,  especially  such  as  are  complicated  and  occur  in  old 
age  (so-called  latent  pneumonia),  are,  at  this  moment,  the  most  fatal, 
and  that  they  always  must  have  been  so.  On  the  other  hand,  the 
symptonas  which  formerly  were  supposed  to  indicate  pneumonia,  viz., 
pain,  cough,  dyspnoea,  rusty  sputa,  and  fever,  we  now  know  are  met  with 
in  a  variety  of  lesions,  independent  of  pneumonia,  especially  in  certain 
cases  of  bronchitis  in  young  subjects,  or  engorgements  and  apoplexy  of 
the  lung,  associated  with  fever  or  heart  disease  in  older  persons.  Hence, 
formerly,  bleeding  was  not  practised  in  many  cases  where  pneumonia 
was  present,  whilst  it  was  largely  resorted  to  in  others  where  that 
disease  never  existed  at  all. 

Other  writers  besides  Dr.  Alison  have  endeavoured  to  show,  and  not 
unsuccessfully,  that  what  was  formerly  understood  by  pneumonia  or 
peri-pneumonia,  is  altogether  diff"erent  trom  what  we  now  mean  by  these 
terms.  But  they  have  not  been  so  siiccessful  in  deducing  from  the 
experience  possessed  by  former  physicians  in  treating  symptoms,  what 
ought  to  be  the  rule  of  practice  for  those  in  modern  times  who  recognise 
the  anatomical  lesions  of  organs.  If,  indeed,  it  could  be  shown  that  the 
group  of  symptoms  formerly  called  inflammatory  always  indicated  the 
same  morbid  lesion,  former  experience  might  still  be  useful  to  us.  But 
wc  contend  that  this  is  what  clinical  observation  proves  to  be  im- 
possible. Such  are  the  contradictory  statements  and  the  confusion 
resulting  from  the  unacquaintance  of  the  past  race  of  practitioners  with 
a  correct  diagnosis  and  pathology,  that  no  confidence  whatever  can  be 


254  PRINCIPLES   OF   MEDICINE. 

placed  in  their  impressions,  as  to  wliat  cases  were  or  were  not  benefited 
by  bleeding. 

Hence,  although  I  am  far  from  repudiating  experience  in  cases  which 
in  the  present  day  are  clearly  recognizable  as  true  inflammations,  it  is 
surely  unreasonable  to  be  guided  by  that  experience  in  cases  where  it  is 
acknowledged  that  the  observations  are  imperfect  and  vague,  and  which, 
even  among  those  who  desire  to  take  advantage  of  it,  causes  endless 
differences  of  opinion  as  to  what  was  meant  or  intended.  Medicine  is 
not  a  scientific  art  which  is  dependent  for  its  principles  on  the  study  of, 
and  commentary  on,  the  older  writers.  What  they  thought  and  what 
they  said,  are  not,  and  ought  not,  in  a  question  of  this  kind,  to  be  our 
guide,  as  to  what  was  or  is.  On  the  contrary,  it  is  the  book  of  nature, 
Avhich  is  open  to  all,  that  we  ought  to  peruse  and  study,  and  why  should 
we  read  it  through  the  eyes  of  past  sages,  when  the  light  of  science  was 
comparatively  feeble  and  imperfect,  instead  of  bringing  all  the  advanced 
knowledge  of  the  present  time  to  elucidate  her  meaning?  The  lesson, 
which  a  careful  study  of  the  history  of  medicine  has  forced  upon  me,  is 
the  necessity  of  re-investigating,  with  all  our  improved  modern  appli- 
ances, the  correctness  or  incorrectness  of  existing  dogmas,  in  order  to 
establish  an  improved  practice  for  the  future. 


Proposition  2. —  That  injlammation  is  the  same  now  as  it  has  ever 
been,  and  that  the  analogy  sought  to  he  established  between  it  and  the 
varying  tyjies  of  fevers  is  fallacious. 

The  essential  nature  of  inflammation  has  been  already  alluded  to, 
viz.,  a  series  of  changes  in  the  nervous,  sanguineous,  vascular,  and 
parenchymatous  functions  of  a  part  terminating  in  exudation  of  the 
liquor  sanguinis,  or  what  some  call  effusion  of  lymph.  Now  what 
proof  is  there  that  any  of  these  necessary  changes  have  of  late  years 
undergone  modifications  ?  If  a  healthy  man  receive  a  blow,  or  any 
other  injury  on  his  person,  are  the  resulting  phenomena  in  these  days  in 
any  way  difterent  from  those  which  took  place  in  the  days  of  Cullen  and 
Gregory  ?  Were  the  effects  which  followed  wounds  received  at  the 
battle  of  the  x\lma  different  from  those  which  resulted  from  similar 
injuries  at  the  battle  of  Waterloo  ?  This  has  not  yet  been  shown.  Do 
we  observe  any  essential  difference  in  our  civil  hospitals  in  the  effects  of 
injuries,  or  in  the  process  of  healing,  after  wounds  and  operations? 
This  also  has  not  been  shown.  Again,  if  a  healthy  individual  now-a- 
days  be  exposed  to  cold  or  wet,  and  be  seized  with  an  inflammation  of 
the  lungs  or  pleura,  is  not  the  lung  hepalized  in  the  one  case,  and  do 
not  layers  of  organizable  lymph  form  in  the  other,  in  exactly  the  same 
way  as  formerly  ?  If  so,  is  not  hepatization  removed,  and  does  not  the 
lymph  conti-act  adhesions  in  the  same  manner  now,  as  in  the  days  of 
Cullen  and  Gregory  ?  If  these  changes  have  been  materially  modified 
in  recent  times,  I  again  urge  that  such  modifications  have  not  been 
shown  ;  and  if  they  have  not,  in  what  can  it  be  said  that  inflammation 
and  i(s  results  have  changed  within  the  last  twenty  years? 

To  this  question,  notwithstanding  repeated  careful  perusal  of  Dr. 
Alison's  paper,  I  am  obliged  to  say  I  can  find  no  answer.     It  is  true  he 


THE   UNCHANGEABLE  NATUKE   OF   INFLAMMATION.       255 

points  out  that  the  sj/mptoms  of  pneumonia  of  Cullen  differ  from  those 
of  the  pneumonia  of  GrisoUe.  lie  also  contends  that  it  is  only  from 
the  symptoms  that  we  can  judge  of  the  effects  of  remedies.  But  before 
we  can  draw  a  comparison  between  variations  in  such  symptoms  as 
indications  of  the  value  of  treatment,  or  found  upon  them  a  doctrine 
like  the  change  of  type  in  any  given  disease,  it  must  be  shown  that 
the  symptoms  observed  formerly  and  those  seen  now  belong  to  the  same 
lesion.  No  such  comparison,  however,  can  be  drawn,  because  what 
Cullen  meant  by  pneumonia  were  the  symptoms  themselves,  whereas 
now  such  symptoms  are  known  to  be  in  no  way  necessarily  indicative  of 
pneumonia,  as  I  have  previously  explained. 

Under  these  circumstances  nothing  can  be  more  unsatisfactory  than 
to  enter  into  an  inquiry  as  to  whether  the  inHanimatory  fever  and  hard 
pulse  of  Cullen's  pneumonia — which  may  or  may  not  have  been  pneu- 
monia at  all — does  or  does  not  differ  from  a  true  inflammation  of  the 
lung,  as  we  now  recognise  it.  Dr.  Alison,  by  drawing  a  comparison  be- 
tween the  two,  seems  at  least  to  think  they  are  allied,  and  he  ai'gues 
that  the  fever  accompanying  the  one  was  inflammatory,  whilst  that 
accompanying  the  other  is  typhoid.  Hence  the  reason  why  he  thinks 
the  first  did,  whilst  the  last  does  not  bear  bleeding.  He  has  also  long 
argued*  that  these  differences  are  still  observable  in  private  or  dispen- 
sary, and  in  hospital  practice.  But  I  have  had  abundant  opportunity 
of  satisfying  myself  that  a  true  pneumonia  is  the  same  under  everv  cir- 
cumstance. During  a  seven  years'  tolerably  constant  attendance  as 
physician  to  the  Royal  Dispensary  of  this  city,  I  have  seen  pneumonia 
as  typhoid  as  it  can  well  be;  and  in  the  Infirmary,  during  the  last  nine 
years,  I  have  seen  it  attack  vigorous,  healthy  young  men,  and  present 
all  the  characters  of  the  inflammatory  type.  These  last  are  exactly 
those  cases  which  do  best  without  bloodletting,  whilst,  at  the  same  tiu:!e, 
they  are  those  also  which  bear  bleeding  well.  The  explanation  of  these 
(to  some)  apparently  contradictory  facts  will  be  given  subsequently. 

Another  idea  very  extensively  prevails  on  this  subject,  and  is  urged  by 
Dr.  Alison,  viz.,  that  inasmuch  as  fevers  undoubtedly  present  chano-es  in 
type,  inflammation  may  do  so  likewise.  That  essential  fevers  at  difter- 
ent  times  are  typhus,  typhoid,  or  ephemeral,  cannot  be  doubted,  but  this 
is  evidently  produced  by  variations  in  the  intensity  or  the  nature  of  the 
exciting  cause.  On  what  these  differences  depend  is  not  yet  deter- 
mined. I  have  watched  extensive  epidemics  of  fever  in  France  and  in 
the  Rhenish  provinces,  where  almost  every  case  was  typhoid,  and  con- 
nected with  intestinal  lesion,  and  observed  others  in  Edinburgh,  where 
nearly  every  case  w^as  typhus,  and  free  from  organic  lesion.  I  also 
noticed  that,  when  owing  to  failure  in  the  potato  crop,  as  in  1846,  the 
food  of  the  people  was  materially  changed  for  the  worse,  the  fever  in 
Edinburgh  assumed  far  more  of  the  typhoid  type;  and  I  have  no  doubt 
that  changes  in  diet,  in  locality,  in  climate,  in  atmospheric  influences, 
and  a  variety  of  causes,  may  induce  modifications  in  fever.  But  surely 
no  analogy  ought  to  be  drawn  between  the  undoubted  changes  produc- 
ing such  varieties  of  fever,  and  those  causing  an  inflammation,  which  in 
all  countries,  and  under  every   variety  of   external   circumstance,  are 

*  Outlines  of  Pathology  and  Practice  of  Medicine.     First  Edition,  p.  221. 


256  PRINCIPLES   OF   MEDICINE. 

always  the  same.    Even  the  resuUs  are  said  to  be  distinguishable  only  by 
a  change  in  the  force  of  the  pulse. 

But  what  should  this  asserted  change  in  the  force  of  the  pulse  lead  us 
to  infer?  Is  it  said  that  instead  of  being  strong  and  hard  in  cases  of 
pneumonia,  as  it  used  to  be,  it  is  now  more  soft  and  indicative  of 
debility  ?  Is  it  then  argued  that  the  whole  people  of  this  country,  since 
the  davs  of  Cullen  and  Gregory,  have  become  so  debilitated  and  deterio- 
rated— that  their  constitutions  have  been  so  altered  for  the  worse,  that 
attacked  by  the  same  lesion  and  to  the  same  extent,  there  is  no  longer 
the  same  reaction  ?  and  that  the  strong  man  of  the  present  day  labour- 
ing under  inllamniation  presents  the  symptoms  which  twenty  years  ago 
distinguished  the  weak  one?  If  so,  where  is  the  evidence  of  this?  Are 
our  soldiers  and  sailors,  workmen  or  others,  physically  less  capable  of 
exertion  than  formerly  ?  Is  it  true,  that  the  strength  of  mankind  has 
so  radically  altered  for  the  worse  during  the  last  twenty  years,  as  to 
account  for  the  supposed  fact  that  inflammation  formerly  required 
excessive  loss  of  blood  to  check  its  progress,  whereas  now  it  stops  of 
itself?  For  my  own  part,  I  have  earnestly  sought  for,  but  cannot  dis- 
cover, a  shadow  of  evidence  for  sucli  a  belief.  Sloreover,  I  have  a  most 
lively  remembrance  of  all  the  facts  and  circumstances  connected  with 
the  bleedino-  of  many  patients  thirty  yeais  ago,  when  I  first  commenced 
the  study  of  medicine,  as  well  as  of  such  as  took  place  in  the  Royal 
Infirmary  of  Edinburgh,  when  I  was  a  student  in  this  University  in 
1833  ;  and  my  impression  is,  that  not  the  slightest  difference  exists 
between  the  character  of  the  pulse  now  and  what  it  was  then.  Since 
this  question  has  been  raised,  I  have  had  frequent  occasion  to  point  out 
in  the  wards  of  the  Infirmary  cases  of  pneumonia  in  vigorous  persons,  in 
whom  the  pulse  as  formerly  has  been  full  and  strong.  (See  pneumonia 
cases  of  R.  M'Farlane  and  John  Macfarlane.) 

I  have  been  informed  by  some  Indian  practitioners  that  in  the  East 
blooddettino-  is  now  as  little  practised  as  it  is  among  ourselves — so  that 
if  Dr.  Alison's  theory  be  correct,  inflammation  among  the  Asiatic 
nations  and  Hindoo  tribes  has  undergone  the  same  change  of  type  as  is 
alleged  to  have  taken  place  in  Great  Britain.  But  I  have  also  heard 
that  in  Italy  large  blood-lettings  are  still  practised  as  they  were  for- 
merly ;  and  I  know  from  actual  observation  that  M.  Bouillaud  still  pur- 
sues the  coup  sur  coup  treatment  in  acute  inflammations  in  his  wards  of 
La  Charite  Hospital,  Paris.  On  visiting  him  there  in  the  August  of 
1856,  I  saw  several  patients  (all  young  persons)  whom  he  had  treated  in 
this  way,  and  who  were  then  convalescent.  On  asking  him  whether  he 
had  observed  any  change  in  the  character  of  the  pulse,  or  a  more 
typhoid  character  of  the  fever  in  recent  times,  his  reply  was  emphati- 
cally, "  certainly  not."  A  similar  reply  was  made  to  the  question  by 
every  practitioner  I  interrogated  in  Paris,  who  attributed  the  general 
diminution  of  blood-letting  in  France  to  the  gradual  emancipation  of 
medical  men's  minds  from  the  doctrines  of  Broussais.  Is  it  not  more 
reasonable  then  to  think,  that  the  change  of  practice  in  India  results 
from  an  alteration  in  precept  and  example,  and  that  the  continuance  of 
the  practice  in  Italy  and  in  the  wards  of  M.  Bouillaud,  is  owing  to  the 
absence  of  such  change  rather  than  to  suppose  that  inflammation  alters 
its    type,   just   where   the   practice    alters,  but   remains   stationary    in 


FORMER  REASONS  FOR  BLEEDING  ERRONEOUS.     257 

those  countries,  and  even  in  those  wards  of  an  hospital  where  it  does 
not? 

Hence  I  am  firmly  of  opinion,  that  inflammation  in  a  part  is  the  same 
now  as  it  has  ever  been,  and  is  only  subject  to  the  variations  which 
occur  in  all  diseases,  such,  for  instance,  as  are  dependent  on  differences 
of  a<re,  sex,  vigour  of  constitution,  complications,  etc.  etc.  These  are 
also  "alike  at  all  times,  and  consequentl}-  the  recent  revolution  in  the 
treatment  of  inflammation  by  bleeding  cannot  be  accounted  for  by  the 
theory  of  change  of  type. 

Proposition  3. —  That  the  principles  on  which  blood-letting  and  anti- 
phlor/istic  remedies  have  hitherto  been  practised  are  opposed  to  a  sound 
pathology. 

Large  and  early  bleedings  have  been  practised  under  the  idea  that 
by  diminishing  the  amount  of  the  circulating  fluid — 1st,  The  materies 
morbi  in  the  blood  would  be  diminished  ;  2dly,  Less  blood  would  flow 
to  the  inflamed  parts ;  3dly,  The  increased  quantity  of  blood  in  the  part 
would  be  lessened  ;  and  4thly,  The  character  of  the  pulse  was  the 
proper  index  to  the  amount  of  blood  that  ought  to  be  drawn.  Let  us 
examine  these  four  principles  of  practice — 

1st.  Can  the  Materies  Morbi  in  the  blood  be  diminished  bg  bleeding  ? 
It  was  to  its  influence  on  the  blood  that  the  older  writers  especially  attri- 
buted the  good  eft'ects  of  venesection.  This  fluid,  according  to  them,^ 
was  thrown  into  a  state  of  ebullition  or  fermentation,  which  worked  oft' 
the  morbid  elements;  and  this  termination  was  favoured  by  removing  so 
much  of  it  by  blood-letting.  On  the  other  hand,  if  the  morbid  matters 
were  not  readily  removed,  they  fell  upon  internal  organs  causing  inflam- 
mation. This  ^dea  led  to  tlie  absti-action  of  blood,  under  the  notion 
that  that  fluid  was  diseased  first,  and  local  lesions  supervened,  as  in  the 
case  of  plague  or  small-pox.  Thus  Sydenham  apparently  had  no  idea 
of  inflammation  distinct  from  fever.  He  says: — "I  think  pleurisy  is  a 
fever  originating  in  a  proper  and  peculiar  inflammation  of  the  blood — 
an  inflani^mation  by  means  of  which  nature  deposits  the  peccant  matters 
on  the  pleurae.  Sometimes  she  lays  it  on  the  lung  itself,  and  then  there 
comes  a  peripneumony.  This  differs  from  pleurisy  only  in  degree. 
They  exhibit  the  results  of  the  same  cause  with  greater  intensity.  In 
my  treatment  I  have  the  following  aim  in  view— to  repress  the  inflam- 
mation of  the  blood,  and  to  divert  those  inflamed  particles,  which  have 
made  an  onset  upon  the  lining  membrane  of  the  ribs  (and  have  there 
lit  up  so  much  mischief),  into  their  proper  outlets.  For  this  reason  my 
sheet  anchor  is  venesection."*  Such  was  the  pathology  and  practice  of 
Sydenham,  the  latter  following  consistently  enough  on  the  former;  and 
the  essential  idea  of  diminishing  the  morbid  matters  in  the  blood  has 
not  only  descended  from  Hippocrates  to  the  days  of  Sydenham,  but  has 
come  down  from  his  to  our  own  times. 

Now,  in  one  sense,  it  is  true  that  there  is  no  disease  whatever,  even 
the  most  local,  that  is   not  also  associated   with  a  general  change  of 

*  Sydenham  Society's  Translation.     Vol.  i.  p.  247. 
17 


258  PKINCIPLES   OF   MEDICINE. 

the  system.  As  before  stated  (p.  106),  all  the  nutritive  functions  are 
connected  with  one  another,  and  an  excess  or  diminution  of  local  growth, 
by  subtracting  from  or  adding  to  the  constituents  of  the  blood,  must 
produce  an  alteration  in  that  fluid  both  as  to  quantity  and  quality.  The 
idea  of  Treviranus,  viz.,  that  "  each  single  part  of  the  body,  in  respect  of 
its  nutrition,  stands  to  the  whole  body  in  the  relation  of  an  excreted 
substance,"  has  been  ably  shown  by  Mr.  Paget  to  account  for  various 
processes  in  health,  under  the  name  of  "  complemental  nutrition."*  The 
same  notion  has  been  still  further  extended  by  Dr.  Wm.  Addison,  who 
correctly  points  out  that  in  the  distinctive  eruptive  fevers,  such  as  small- 
pox, the  numerous  small  abscesses  in  the  skin  eliminate  the  morbid  poi- 
son which  formerly  existed  in  the  blood,  and  are  in  this  way  essential  to 
the  cure.  This  provident  action  he  denominates  "  cell-therapeutics."f 
In  all  such  cases  experience  has  shown  that  time  and  a  natural  sequence 
of  changes  is  necessary  for  a  restoration  to  health,  and  it  is  now  recog- 
nised that  the  idea  of  cutting  short  such  changes  by  bleeding,  is  alike 
erroneous  in  theory,  and  injurious  in  practice. 

NoAv  exactly  the  same  principle  ought  to  guide  us  in  cases  of  inflam- 
mation, where,  in  addition  to  the  local  changes  in  the  part,  there  must 
necessarily  be  more  or  less  disturbance  of  secretion  and  excretion.  The 
blood  in  consequence  must,  and  does,  as  is  now  well  known,  undergo  defi- 
nite alterations,  which,  it  is  true,  organic  chemistry  has  not  yet  fully 
explained  to  us,  although  we  have  at  least  learned  by  it  that  the  parti- 
cular secretion  suppressed  is  always  accumulated  in  the  blood,  which 
also  contains  an  excess  of  fibrin.  The  careful  investigations  of  chemists, 
and  especially  of  Becquerei  and  Rodier,  have  further  shown  us,  that 
whilst  venesections  greatly  deteriorate  the  blood,  rendering  it  poorer  in 
corpuscles  and  richer  in  water,  they  have  no  effect  on  the  fibrin  what- 
ever. It  follows  that  an  elimination  of  the  morbid  products  can  only  be 
accomplished  in  inflammation  by  the  conjoined  action  of  cell  growth  in 
the  part,  and  a  peculiar  vital  chemistiy  going  on  in  the  blood  (as  will 
be  subsequently  explained),  neither  of  which  can  in  any  way  be  faci- 
litated, but,  on  the  contrary,  are  both,  in  the  vast  majority  of  cases, 
impeded  by  blood-letting. 

2d.  Is  it  good  2iractice  to  diminish  the  flow  of  Hood  to  the  ^mH? 
The  increased  throbbing  and  circulation  of  blood  in  the  neighbourhood 
of  an  inflamed  part  may  be  shown  not  to  be  the  cause  of  inflamma- 
tion, but  the  result  of  it.  The  idea  of  so-called  determination  of  blood 
being  the  cause  of  disease  is  thus  set  forth  by  Dr.  C.  T.  B.  Williams  :J — 
"  In  the  frog's  web,  gently  irritated  by  an  aromatic  water,  we  see  the 
arteries  become  enlarged,  supplying  a  larger  and  more  impulsive  flow  of 
blood  to  the  capillaries  and  veins,  which  all  become  enlarged  also ;  and 
the  whole  vascular  plexus,  including  vessels  which  before  scarcely 
admitted  red  particles,  then  become  the  channels  of  a  much  increased 
current.  This  is  determination  of  blood."— P.  203.  Again,  "  We  may 
affirm  from  direct  observation,  as  well  as  from  reasoning,  that  determi- 
nation of  blood   is  caused  by  enlargement  of  the    arteries  ;  and   this 

*  Lectures  on  Surgical  Pathology,  Lecture  ii. 
\  Addison  on  Cell-Therapeutics.     1856. 
\  Principles  of  Medicine.     (Third  Edition.) 


FORMER  REASOXS  FOR  BLEEDIXG  ERRONEOUS.     259 

enlargement  is  the  effect  of  the  pressure  of  the  arterial  distension  from 
behind  acting  on  a  tube,  which  has  lost  some  of  its  conti'actile  power" — 
P.  203.  Again,  "  One  patient  was  subject  to  attacks  of  determination 
of  blood,  which  caused  him  so  much  suffering  and  loss  of  moral  control, 
that  he  cut  his  throat  to  destroy  his  life.  When  recovering  from  the 
wound,  attacks  sometimes  came  on  ;  Jiist  with  beating  of  the  carotids, 
then  flushing  of  the  face  and  head,  suffusion  of  the  eyes,  and  sensations 
of  distraction  in  the  head."  "Fits  of  epilepsy  and  convulsive  hysteria 
are  immediately  jjreceded  hj  throbbing  of  the  carotids,  which  shows 
that  determination  of  blood  is  the  proximate  cause  of  the  paroxysm" — 
P.  201.  Now,  if  I  am  correct  in  supposing  that  the  meaning  of  these 
passages  is,  that  the  larger  arteries  assume  the  initiative,  take  upon 
themselves  the  action  of  a  forcing  pump,  and  send  or  determine  more 
blood  to  the  part,  then  it  appears  to  me  there  must  be  error  both  in  ob- 
servation and  reasoning.  So  far  from  the  enlargement  of  arteries  and 
increased  arterial  current  preceding  the  changes  going  on  in  the  capil- 
laries— so  far  from  being  connected  with  the  causes  of  inflammation — 
I  venture  to  affirm  that  they  are  the  results. 

In  all  cases  the  primary  stimulus  producing  inflammation  is  applied 
to  the  vessels  of  the  part,  either  directly  (as  from  injuries  or  irritants)  or 
indirectly,  that  is  by  reflex  action  (as  in  the  case  of  internal  inflamma- 
tions following  exposure  to  cold,  etc.),  and  in  consequence — that  is  to 
say,  as  a  result — of  the  local  change  in  the  part  thei'eby  occasioned, 
there  follows  the  throbbino-  of  the  neiu'hbourino-  arteries.  Let  us  attend 
to  what  takes  place  in  the  finger  from  a  thorn  entering  the  skin,  and 
remaining  unextracted  ;  the  irritating  borly  first  acts  upon  the  nerves 
and  blood-vessels  of  the  part,  then  comes  on  the  stoppage  of  blood  and 
exudation,  and  lastly  follows  the  throbbing  of  the  artery  in  the  finger. 
Surely  this  throbbing,  which  is  the  evidence  of  so-called  determination, 
is  a  resnlt  of  the  inflammation,  and  not  a  cause  of  it.  The  blood  in  this 
case,  instead  of  being  sent  by  a  vis  a  terc/o,  is  in  fact  drawn  by  a  vis  a 
fronte,  and,  as  we  shall  endeavour  subsequently  to  show,  for  the  luost 
important  purposes,  ^yhether  would  it  be  reasonable  to  treat  such  an 
inflammation  by  opening  the  artery — or  by  favouring  the  transformation 
of  the  exudation  thrown  out  into  pus,  w'hereby  the  irritating  cause  and 
its  results  are  both  got  rid  of?  All  experience  shows  that  the  latter  is 
the  proper  treatment,  and  that  wounding  the  artery  under  such  circum- 
stances would  be  highh"  injurious  and  perhaps  occasion  gangrene. 

But  why  should  nature,  in  cases  of  inflammation,  draw  an  increased 
amount  of  blood  towards  the  part  ?  She  does  so,  it  seems  to  me,  in 
obedience  to  one  of  her  wisest  laws,  but  one  which  has  been  too  much 
ignored  by  medical  practitioners.  It  must  be  obvious,  however,  that,  an 
inflammation  having  occurred,  the  great  work  now  to  be  accomplished 
is  an  increased  growth  by  cell  formation,  whereby  that  exudation  is  to 
be  broken  up,  the  pressure  it  exerts  on  the  nerves  and  blood-vessels 
removed,  and  the  whole  rendered  capable  of  being  eliminated  from  the 
economy,  either  directly  by  discharge  externally,  or  indirectly,  1st,  by 
passage  into  the  blood,  and  2d,  by  excretion  through  the  emunctories. 
To  perform  this  work  of  increased  growth,  an  augmented  flow  and  amount 
of  nourishing  fluid  is  necessary,  the  same  as  is  observable  at  the  period 
of  heat  in  animals,  to  ripen  the  Graafian  vesicles  ;  in  the  stag's  scalp 


260  PRINCIPLES  OF  MEDICINE. 

during  tte  growth  of  the  antlers ;  in  the  mamma  when  milk  is  first 
secreted  ;  in  the  gums  during  the  process  of  dentition  ;  in  the  ascent  of 
the  sap  during  spring  in  plants,  etc.  etc.  In  all  these  cases,  especially 
the  last,  the  fluid  is  not  sent  or  determined,  but  drawn  to  the  part,  in 
consequence  of  the  increased  growth  of  cells  imperatively  requiring  a 
greater  amount  of  blastema.  So  in  inflammation,  an  exudation  Laving 
been  poured  out,  which  lias  to  be  transformed  by  a  process  of  cell 
growth,  in  order  that  it  may  be  removed  or  rendered  subservient  to  the 
wants  of  the  economy,  it  is  absolutely  imperative  that  the  part  in  which 
these  nutritive  changes  go  on  should  receive  more  blood,  to  enable  it  to 
accomplish  them.  Hence  the  increased  current.  But  hitherto  medical 
practitioners  have  supposed  that  this  phenomenon  is  injurious,  and  ought 
to  be  checked  by  blood-letting  and  antiplilogistics.  The  rapid  flow  of 
blood,  which  is  so  necessary,  they  have  sought  to  diminish  ;  and  the 
increased  amount  in  the  neighbourhood  of  the  part,  which  is  so  essential 
for  the  restoration  to  health,  it  has  been  their  object  to  destroy.  In 
doing  so,  we  argue  they  act  in  opposition  to  sound  theory,  and,  as  we 
shall  afterwards  attempt  to  show,  to  good  practice  also. 

Sd.  Can  f/eneral  blood-letting  diminish  the  amount  of  blood  in  the 
infiamed  part  ?  It  is  vain  to  deny  that  the  notion  of  lessening  the 
amount  of  blood  in  the  inflamed  part  has  constituted  one  of  the  chief 
reasons  for  blood-letting,  and  given  rise  to  long  discussions  as  to  whether 
this  or  that  vein  shall  be  opened,  and  whether  leeches  shall  be  applied 
to  the  occiput  or  to  the  feet.  Now,  it  requires  to  be  shown  that  drain- 
ing the  body  of  blood  can  in  the  slightest  degree  influence  the  conges- 
tion in  the  inflamed  part.  There  the  vessels  are  enlarged,  the  current 
of  blood  is  arrested,  the  blood- corpuscles  are  closely  aggregated  together 
and  distend  the  vascular  tube,  and  are  in  no  way  aflfected  by  the  arterial 
current,  even  when  increased  in  its  neighbourhood.  That  opening  a 
vein  can  alter  this  state  of  matters  is  scarcely  to  be  conceived  ;  and  if 
it  could,  how  would  this  assist  in  removing  the  exudation,  which  has 
coagulated  outside  the  vessels  ? 

A  consideration  of  the  connection  and  distribution  of  the  large  vessels 
in  the  body  will  still  further  show  the  little  probability  there  is  of  either 
general  or  local  blood-letting,  as  usually  practised,  being  capable  of 
influencing  the  amount  of  blood  in  the  part  actually  inflamed.  How  is 
it  possible,  for  instance,  that  venesection  in  the  arm  can  directly  diminish 
the  amount  of  blood  sent  from  the  heart  by  the  great  pulmonary  artery 
to  the  lungs,  by  the  carotids  and  vertebrals  to  the  brain,  or  by  the  coro- 
naries  to  the  heart  itself?  In  inflammation  of  those  organs,  blood-let- 
tino-,  to  produce  any  effect,  must  be  large,  so  as  to  act  on  the  general 
system  indirectly  by  weakening  the  heart's  action  and  producing  syn- 
cope, and  this  at  a  time  when,  from  no  nourishment  being  taken  in  con- 
sequence of  fever,  great  prostration  of  the  vital  powers  is  to  be  expected. 
But  whilst  this  result  may  certainly  be  induced  by  large  bleedings,  the 
inflammation  in  the  part  is  altogether  unaflfected.  The  exudation,  under 
such  circumstances.,  which  requires  njore  blood  in  order  that  it  may 
undergo  the  necessary  transformations  previous  to  removal,  is  then 
arrested  in  its  development,  and,  so  far  from  being  rapidly  removed, 
remains  stationary,  or  dies  in  proportion  as  the  economy  is  exhausted. 


FORMER  REASONS  FOR  BLEEDING  ERRONEOUS. 

Fig.  3T6. 
3  3 


261 


Fig.  3V5.  Fig.  377. 

Fig.  375.  Longitudinal  plan  of  the  arteries  of  the  trunk.  The  left  side  shows  both 
the  longitudinal  and  transverse  anastomosing  arteries  of  the  wall ;  the  right  side  only 
the  longitudinal  and  diaphragmatic  anastomoses  belonging  to  the  wall,  and  the 
various  visceral  arteries  springing  from  the  aorta. 

Leftside. — 1,  Internal  mammary;  and  2,  deep  epigastric ;  connected  behind  to  the 
aorta  by  a  series  of  intercostal,  lumbar,  and  diaphragmatic  arteries.  3,  Superficial 
epigastric.     4,  Circumflex  iliac.     5,  Ilio-lumbar  from  internal  iliac. 

Eight  side. — Branches  of  abdominal  aorta,  from  above  downwards ;  diaphragmatic 
coeliac  axis,  superior  mesenteric,  right  supra-renal  and  renal,  right  spermatic  or 
ovarian  and  inferior  mesenteric. — {J.  Struthers.) 

Fig.  376.  Transverse  plan  of  the  arteries  of  the  abdomen  opposite  to  the  liver, 
spleen,  and  stomach.  1,  Aorta,  giving  off  from  its  back  part  the  arteries  (2,  2)  for 
the  wall,  which  unite  in  front  with  branches  of  the  internal  mammary  arteries  (3,  3). 
4.  Coeliac  axis,  coming  h'om  the  front  of  the  aorta,  and  supplying  the  spleen, 
stomach,  and  liver,  the  latter  also  receiving  the  vena  port;e. — {J.  Struthers.) 

Fig.  377.  The  same,  lower  down,  showing  a  portion  of  the  small  intestine  and 
sections  of  the  ascending  and  descending  colon  and  of  the  kidneys.  1,  Aorta,  giving 
off  behind  the  lumbar  arteries  (2,  2),  which  join  in  front  with  branches  of  the  deep 
epigastric  (3,  3).  In  front,  as  if  coming  from  the  aorta  at  the  same  part,  are  shown 
the  superior  and  inferior  mesenteric,  and  at  the  sides  the  renal  arteries.  Fig.  375 
shows  the  order  in  which  these  visceral  arteries  come  off  at  different  stages  of  the 
aorta,  and  their  relative  size. — {J.  Struthers.) 

The  anatomist  will  notice  that  it  is  chiefly  the  anastomosing  branches  of  the 
arteries  of  the  wall  which  are  shown,  and  also  that  tliese  are  represented 
proportionally  larger  than  natural. — {Struthers'  Anatom.  and  Physiol.  Observations. 
Edin.  8vo,  1854.) 


262  PRINCIPLES   OF   MEDICINE. 

If,  on  the  other  hand,  small  or  moderate  bleedings  are  practised,  how- 
can  they  operate  even  on  the  principles  of  those  who  advocate  them  ? 
These  do  not  affect  the  heart,  or  lower  the  force  of  the  circulation,  even 
in  the  neighbourhood  of  the  inflamed  part ;  how,  then,  can  they  operate 
on  the  stagnant  blood  in  the  inflamed  part  itself? 

As  to  local  bleeding,  its  supposed  effects  are  inexplicable  on  the 
supposition  of  drawing  blood  from  the  inflamed  internal  parts.  A  man 
has  pneumonia  or  nephi'itis,  resulting  from  changes  in  the  vessels  which 
are  supplied  direct  from  the  aorta,  and  leeches  are  applied  to  the 
integuments  supplied  by  vessels  derived  from  tlie  mammary  or  lumbar 
arteries.  Any  direct  anastomosis  between  the  vessels  on  the  surface  and 
those  in  the  parts  inflamed  is  not  to  be  thought  of,  as  has  been  shown 
anatomically  by  Dr.  J.  Struthers.  (See  Figs.  380  to  382,  with  the 
explanations  on  the  previous  page.)  How,  then,  does  the  loss  of  this 
small  amount  of  blood  operate  in  these  important  cases?  It  cannot  be 
by  any  conceivable  theory  of  diminishing  either  the  current  to,  or  the 
amount  of  blood  in,  the  part.  As  in  the  majority  of  cases,  therefore, 
the  loss  is  not  large  enough  to  affect  the  general  circulation,  and  as 
anatomy  prevents  our  belief  in  the  idea  that  it  can  influence  the 
inflammation  directly,  it  may  well  be  asked,  how  can  local  blood-letting 
be  of  any  benefit  at  all  ?  Is  it  not  more  probable  that  leeches  and 
cupping  do  no  good  by  drawing  blood,  but  that  the  relief  to  pain  which 
they  undoubtedly  occasion  is  owing  to  the  reflex  influence  of  counter- 
irritation,  and  in  the  vast  majority  of  cases  to  the  soothing  and  sedative 
influence  of  the  warm  fomentations  which  generally  follow  their  em- 
ployment?    Dry  cupping  is  often  as  effectual  as  local"  blood-letting. 

From  these  considerations,  it  follows  that  neither  general  nor  local 
blood-letting  can  possibly  be  supposed  to  diminish  the  amount  of  blood 
in  internal  parts  affected  with  inflammation. 

ith.  Should  the  character  of  the  pulse  indicate  the  propriety  of 
hleediiui  ?  That  an  accelerated  and  strong  pulse  in  inflammation  de- 
mands interference  on  the  part  of  the  medical  practitioner,  seems  to  be  a 
principle  which  has  been  very  generally  acted  on.  In  other  words, 
because  nature  accelerates  and  strengthens  the  pulse,  it  has  been  thought 
that  art  ought  to  interfere  to  diminish  its  force  and  frequency.  But 
here,  again,  as  it  appears  to  me,  the  result  has  been  mistaken  for  the 
cause ;  and  so  far  from  getting  rid  of  inflammation  by  weakening  the 
pulse,  we  not  only  do  not  check  it,  but  prolong  the  time,  as  previously 
explained,  for  the  transformation  of  the  exudation.  This,  indeed,  is 
proved  by  the  cases  of  Louis,  Chomel,  and  Grisolle,  Avhich  distinctly 
show  that  the  progress  of  a  pneumonia  is  never  shortened  by  bleeding. 
Dr.  Alison  also  admits  that  he  has  seen  the  dulness  and  crepitation  go 
on  increasing  after  bleeding.  But  the  inconsistency  of  the  therapeutical 
rules  on  this  head  will  become  more  manifest  when  we  remember  that  it 
is  necessary,  in  the  opinion  of  many  medical  practitioners,  not  only  to 
w^eaken  the  pulse  when  it  is  strong,  but  to  strengthen  it  wljen  it  lias 
been  made  weak.  Xow,  although  it  is  obviously  good  practice  to  sup- 
port the  strength  when  the  calls  upon  the  nutritive  functions  have 
exhausted  the  economy,  it  is  injurious  to  diminish,  by  bleeding,  the 
nutritive  processes  themselves,  when  they  are  busily  engaged  in  operating 


FORMER  REASONS  FOR  BLEEDING  ERRONEOUS,     263 

on  the  exudation  and  eliininatino;  the  morbid  products.  In  short,  the 
phenomena  of  fever  and  excitability  accompanying  inflammation  have 
been  wronglv  interpreted,  and  danger  is  to  be  apprehended  from  them 
not  directlv,  but  from  the  subsequent  exhaustion  wliich  all  great  exertions 
of  the  animal  economy  produce.  In  themselves,  these  exertions  are 
sanative,  and  indicate  the  struggle  which  the  economy  is  engaged  in 
when  attempting  to  get  rid  of  the  diseased  processes ;  and  whenever  we 
lessen  the  vital  powers  at  such  a  critical  juncture,  we  diminish  the 
chances  of  that  struggle  terminating  favourably.  This  proposition  seems 
to  be  universally  admitted  in  the  case  of  essential  and  eruptive  fevers ; 
and  its  truth  ought  to  be  accepted  equally  in  cases  of  inflammation. 

It  has  been  argued,  however,  that  the  immediate  beneficial  eflfects  of 
blood-letting  jnstify  the  practice.  This  is  a  therapeutic  question  of  the 
greatest  importance,  and  one  which,  I  venture  to  think,  has  not  been 
suflSciently  considered  by  medical  men.  No  doubt  pain  is  a  great  evil ; 
and  mankind  instinctively  seek  for  its  relief,  and  sometimes  at  any  cost. 
But  if  the  possession  of  life  be  an  advantage,  it  is  ofttimes  only  to  be 
maintained  at  the  price  of  more  or  less  privation  and  suflfering,  and  in 
this  point  of  view  disease  may  frequently  be  considered  as  a  benefit  and 
a  great  good,  mercifully  sent  by  a  wise  Pro\-idence  to  reconcile  man, 
under  a  variety  of  circumstances,  to  death  itself,  as  to  a  great  relief  from 
bodily  pain.  But  such  is  not  the  correct  way  of  considering  the  ques- 
tion in  a  therapeutic  or  curative  point  of  view;  the  great  object  of  the 
physician  is  first  to  cure,  and,  should  his  attempts  in  that  direction  fail, 
then  to  relieve  his  patient.  If  both  objects  can  be  accomplished,  so 
much  the  better ;  but  if  the  means  of  relieving  symptoms  are  opposed  to 
those  of  curing  the  disease,  then  to  obtain  the  latter,  the  former  must 
be  unhesitatingly  sacrificed.  I  have  pointed  out  in  another  place  how 
much  this  principle  has  been  overlooked  in  the  treatment  of  pulmonary 
tuberculosis  ;*  and  in  no  case  does  it  appear  to  have  been  more  disre- 
garded than  in  inflammation.  For  assuming  it  as  granted  that  in  some 
cases  the  pain  is  for  a  time  relieved  by  bleeding,  and  that  in  pneumonia 
the  respiration  temporarily  becomes  more  free,  at  what  a  cost  are  these 
advantages  obtained,  should  the  patient  be  so  weakened  as  to  be  unable 
to  rally.  Even  if  he  does  rally,  a  large  bleeding  almost  always  prolongs 
the  disease.  Of  course  I  am  now  speaking  of  a  true  pneumonia,  and 
not  of  that  combination  of  symptoms  which  was  called  pneumonia  by 
Cullen  and  Gregory.  I  do  not  consider  it  necessary  to  cite  cases  in 
proof  of  the  fact  that  in  many  instances  bleeding  has  done  great  mischief, 
because  this  will  be  readily  admitted  by  all  candid  medical  men. 

But  whilst  large  and  repeated  bleedings,  practised  with  a  view  of 
arresting  the  disease,  appear  to  me  opposed  to  a  correct  pathology,  small 
and  moderate  bleedings,  directed  to  palliate  certain  symptoms,  and  espe- 
cially excessive  pain  and  dyspnoea,  may  reasonably  be  had  recourse  to, 
and  unless  there  be  great  weakness,  without  any  fear  of  doing  injury. 
1  have  often  been  struck,  especially  in  cases  where  large  thoracic  aneu- 
risms cause  these  symptoms,  with  the  small  loss  of  blood  which  will 
occasion  marked  relief.  The  same  result  may  be  hoped  for  in  other 
cases  where  there  is  much  congestion,  either  with  or  without  exudation. 

*  The  Pathology  and  Treatment  of  Pulmonary  Tuberculosis,  by  the  Author. 
Edinburgh,  1853,  p.  84,  et  seq. 


264  PRIXCIPLES   OF   MEDICINE. 

But  I  need  scarcely  remark  that  this  mere  palliative  object  of  blood- 
letting is  not  the  ground  on  which  the  practice  has  hitherto  been  based, 
and  that  in  this  point  of  view  it  requires  to  be  very  differently  explained. 
To  this  subject  I  shall  again  allude.  (See  p.  275.)  In  the  meantime  it 
follows,  from  the  arguments  which  have  been  adduced  under  the  present 
head,  that  the  principles  which  have  heretofore  guided  the  practice  of 
bleeding  in  inflammations  are  erroneous.  It  now  remains  for  me  to  ad- 
vance and  endeavour  to  establish  to  the  satisfaction  of  my  readei-s  what 
appear  to  me  to  be  the  true  principles  of  treatment  in  inflammation. 


Proposition  4. —  That  an  ivfammation  once  established  cannot  he  C7it 
short,  and  that  the  object  of  judicious  medical  treatment  is  to  conduct 
it  to  a  favourable  termination. 

There  was  a  time  when  it  was  supposed  that  the  progress  of  typhus 
fever,  small-pox,  and  many  other  diseases,  which  arc  now  always  allowed 
to  run  their  natural  coui-se,  could  be  arrested  by  medical  interference. 
But  with  regard  to  them,  there  has  been  established  the  principle,  1st, 
of  prevention,  and  2d,  when  this  fails,  of  simply  conducting  them  to  a 
favourable  tennination.  It  appears  to  me  that  the  same  rule  ought  to 
hold  with  regard  to  internal  inflammations,  and  that  this  will  be  admitted 
when  it  is  made  apparent,  not  only  that  every  inflammation  once  formed 
runs  through  a  definite  course,  but  what  that  course  is.  This  I  now 
proceed  shortly  to  consider. 

If,  then,  we  watch  the  natural  progress  of  inflammation  in  any  of  the 
textures  of  the  body,  we  observe  that  it  terminates  in  two  ways,  viz.,  1st, 
bv  vital  changes  of  groAvth  of  different  kinds  in  the  exudation,  consti- 
tutino-  what  have  hitherto  been  called  suppuration,  adhesion,  granulation, 
cicatrization,  the  healing  processes,  etc.  etc.;  and,  2dly,  by  death  of  the 
exudation,  which,  if  rapid,  putrefies,  producing  gangrene,  or,  if  slow,  dis 
integrates,  causing  ulceration.  (See  p.  128,  et  seq.)  The  first  series  of 
chano-es  are  not  destructive,  but  formative  and  reparative.  Suppuration 
especially  should  be  looked  upon  as  a  kind  of  growth,  which  enables 
the  exuded  and  coagulated  blood-plasma  to  be  rapidly  broken  up,  and 
eliminated  from  the  economy.  If  so,  instead  of  being  checked,  it  should 
be  encouraged  as  much  as  possible — a  very  difi"erent  doctnne  fiom  what 
has  hitherto  prevailed.  Again,  every  thing  that  lowers  the  vital  strength 
and  weakens  the  economy  must  impede  the  nutritive  processes  of  growth, 
and  tend  more  or  less  to  a  slow  or  rapid  death  of  the  exudation.  Blood- 
letting especially  has  this  tendency,  and  must  therefore  be  wholly 
opposed  to  the  rapid  disappearance  of  inflammation  ;  for  example  : — 

If  a  bone  be  fractured,  inflammation  occurs  around  the  injured  part, 
and  exudation  is  poured  out,  which  undergoes  vital  changes,  whereby 
ultimately  it  is  transformed  into  bone.  If  soft  parts  are  destroyed  or 
removed,  the  exudation  poured  out  from  the  injured  vessels  undergoes 
other  vital  changes,  whereby  it  is  transformed  into  fibrous  tissue, 
constituting  first  granulations,  and  then  a  cicatrix.  After  subcutaneous 
section  of  tendon,  with  separation  of  its  extremities,  the  transformation 
is  more  perfect,  producing,  as  in  the  case  of  bone,  a  growth  exactly  simi- 
lar to  the  one  which  was  injured.     If  a  violent  blow  or  injury  has  beea 


NATURAL   PEOGRESS   OF  INFLAMMATION. 


265 


received,  a  greater  or  less  amount  of  exudation  is  infiltrated  among 
tlie  contused  and  torn  tissues,  which  is  transformed  by  cell  growth  into 
pus,  which,  if  it  can  be  evacuated  externally,  is  soon  got  rid  of,  but  if  not, 
is  on  the  disintegration  of  the  cells  absorbed  and  excreted  from  tiie  eco- 
nomv.  If,  under  other  circumstances,  the  pus  is  absorbed  as  rapidly  as  it 
is  foi-med,  the  inflammatory  swelling  is  said  to  be  resolved  or  Jiscussed  ; 
if  not,  it  collects  in  the  form  of  a  fluid,  and  constitutes  an  abscess.  Sure- 
ly it  cannot  be  maintained  that,  in  any  of  these  cases,  we  can  favour  these 
reparative  processes  by  blood-letting  and  lowering  the  strength  of  the 
economy  ?  On  the  contrary,  they  have  always  been  found  to  be  best 
perfected  in  individuals  of  vigorous  constitutions,  whilst  in  scrofulous  or 
broken-down  and  weak  persons,  they  proceed  slowly  or  not  at  all. 

But  in  internal  inflammations,  say  of  the  lungs  or  pericardium,  are  the 
processes  difterent  ?  Certainly  not.  In  the  one  case  the  exudation  is 
converted  into  pus  cells  and  absorbed,  and  in  the  other  into  fibrous  texture, 
causing  adhesions.  But  because  these  processes  have  been  hid  from 
view,  physicians  have  supposed  that,  instead  of  treating  the  inflamed 
parts  as  the  surgeon  does,  he  ought  to  attack  the  general  symptoms 
which  result  from  the  lesion.  In  cases  of  fracture  and  contusion,  there 
are  also  febrile  svmptoms,  increased  pulse,  and  so  on  ;  but  does  the  sur- 
geon imagine  that  callus  will  form  better,  or  an  abscess  be  resolved,  or 
reach  maturity  sooner  by  general  blood-letting  and  antiphlogistics  ? 
Experience  teaches  him  otherwise,  and  in  the  same  manner  it  may  be 
most  reasonably  argued  that  such  treatment  cannot  favour  the  natural 
termination  of  internal  inflammations. 

It  may  be  well,  as  illustrative  of  the  proposition  we  seek  to  establish, 
and  in  further  proof  of  this,  to  point  out  a  little  more  particularly  what 
are  the  changes  which  pneumonia  and  pericarditis  go  through. 

In  pneumonia  the  exudation  is  infiltrated  into  the  air  vesicles  and 
minute  bronchi,  and  between  the  fibres,  blood-vessels  and  nerves  of  the 
parenchyma,  imprisoning  the  whole  in  a  soft  mass,  which  coagulates  and 
renders  the  spongy  texture  of  the  lung  more  dense  and  heavy,  or  what 
is  called  hepatized.     This  accomplished,  no  air  can  enter,  the  nerves  are 


Fig.  378. 

compressed,  the  circulation  is  in  great  part  arrested  ;  and  the  object  of 


Fig.  378.  Three  air  vesicles  of  a  pneumonic  lung,  filled  with  exudation  in  difierent 
stages  of  development,  a,  Molecular  exudation  recently  poured  out ;  h,  cells  form- 
ing in  the  exudation ;  c,  cells  (pus  cells)  fully  formed.  See  case  of  Alexander 
Walker  among  Diseases  of  the  Nervous  System.  250  diam. 


266 


PRINCIPLES   OF   MEDICINE. 


nature  is  now  to  convert  the  solid  exudation  once  again  into  a  fluid, 
whereby  it  can  be  partly  evacuated  from  the  bronchi,  but  principally 
reabsorbed  into  the  blood  and  excreted  from  the  economy.  This  is 
accomplished  by  cell-growth.  In  the  amorphous  coagulated  exudation, 
granules  ai*e  formed;  around  groups  of  these  cell-walls  are  produced, 
and  gradually  the  solid  amorphous  mass  is  converted  into  a  fluid  with 
cells.  This  is  pus.  The  cells,  after  passing  through  their  natural  life, 
die  and  break  down,  and  thereby  the  exudation  is  again  reduced  to  a 
condition  susceptible  of  absorption  through  the  vascular  walls,  and  once 
more  mingles  with  the  blood,  but  in  an  altered  chemical  condition.  In 
the  blood  the  changed  exudation  (now  called  fibrin)  undergoes  further 
chemical  metamorphoses,  whereby,  according  to  Liebig,  it  is  converted 
by  means  of  oxygen  into  urate  of  ammonia,  choleic  acid,  sulphur,  phos- 
phorus, and  phosphate  of  lime.  The  urate  of  ammonia,  by  the  further 
action  of  oxygen,  is  converted  into  urea  and  carbonic  acid  ;  the  choleic 
acid  into  carbonic  acid  and  carbonate  of  ammonia  ;  the  sulphur  and  phos- 
phorus into  sulphuric  and  phosphoric  acids,  which,  combining  with  an 
alkali  or  earth,  form  sulphates  and  phosphates.  If  it  should  liappen 
that  the  quantity  of  oxygen  taken  is  not  sufficient  completely  to 
accomplish  this  cycle  of  changes,  then,  instead  of  urea,  either  urate  of 
ammonia  appears  in  the  urine,  or  if  the  ammonia  have  entered  into  any 
other  combinations,  pure  crystals  of  uric  acid.  In  yconsequence  of  these 
or  similar  changes,  the  exudation  is  finally  removed  from  the  economy. 

In  a  pleurisy  or  a  pericarditis,  the  ti'ansforniations  occurring  in  the 
exudation  are  different.     Let  us  follow  them  in  the  case  of  pericarditis. 


Fig.  3T9. 


When   a  severe  inflammation   of  the  pericardium   occurs,   the   liquor 


Fig.  3'79.  Layers  of  lymph  in  pericarditis,  presenting  tlie  form  of  large  villi. — 
(  Cruveilhier.) — Half  the  real  size. 


NATURAL   PROGRESS   OF  INFLAMMATION". 


267 


sanQ-uinis  is  exuded  in  considerable  qnantity,  separating  the  serous  layers 
to  a  greater  or  less  extent.  After  a  time  the  fibrin  coagulates  and  forms 
a  laver  which  attaches  itself  to  the  membrane,  whilst  the  serum  of  the 
blood  accumulates  in  the  centre.  The  coagulated  fibrin  at  first  assuines 
the  form  of  molecular  fibres,  plastic  or  pyoid  cells  are  formed  in  it  (Fig. 
101),  others  throw  out  prolongations,  so  as  by  their  union  to  form  a 
plexus,  which,  communicating  with  the  vessels  below  the  serous  mem- 
brane, renders  the  exudation  vascular  (Fig.  236).  Gradually  the  surface 
assumes  the  appearance  of  a  villous  membrane  (Fig.  3l9),  which 
possesses  also  the  absorbent  functions  of  one.  The  enlarged  villi 
frequently  contain  vacuoles  or  spaces,  reminding  me  strongly  of  the 
general  structure  of  the  placental  tufts,  than  which  nothing^  can  be 
imagined  more  perfectly  adapted  for  the  purposes  of  absorption  (Fig. 
380).  In  consequence, 'the  serum  now  disappears,  the  two  false  mem- 
branes are  brought  into  contact,  and  thus  the  absorption,  as  soon  as  it  is 
no  longer  required,  is  put  an  end  to,  and  adhesion  occurs.  The  matters 
absorbed  into  the  blood  pass  through  the  same  series  of   changes  as 


Fig.  330. 


those  in  pneumonia  do,  and   are   eliminated   from  the  economy  in  a 
similar  manner.     Such  is  the  natural  progress  of  pericarditis. 

The  two  kinds  of  processes  now  described    exhibit  the   same   Avise 
desio-n  in  pathological  as  we  everywhere  find  in  physiological  actions. 


Fig.  380.  Structure  of  the  villi  iu  pericarditis.  On  the  left  of  the  figure  are  some 
villi  treated  with  acetic  acid,  and  therebj-  rendered  very  transparent,  showing  the 
elongated  nuclei  of  the  fibre  cells  of  which  they  are  principally  composed.  «,  The 
vacuoles  or  spaces  common  in  these  villi ;  fe,  group  of  epithelial  cells  which  in  many 
places  covered  the  villi ;  c,  cells  of  various  shapes,  easily  squeezed  from  the  soft 
villous  structure,  undergoing  the  fibrous  and  vascular  transformations. — (See  Fig. 
2Z6.)  200  diam. 


268  PEINCIPLES   OF   MEDICINE. 

In  the  vascular  tissue  of  the  hino;,  new  blood-vessels  are  unnecessary. 
But  in  the  non-vascular  serous  membrane,  they  must  be  formed  to  bring 
about  removal  of  the  morbid  products.  In  the  one  case  the  entire 
exudation  is  transformed  into  cells,  to  produce  rapid  disintegration  and 
absorption,  which  latter  is  easily  accomplished  by  the  already  formed 
numerous  vessels  of  the  lung.  In  the  other  case  the  exuded  liquor 
sanguinis  is  separated  into  solid  and  fluid  parts,  and  as  there  are  no 
vessels  in  the  serous  membrane,  they  are  formed  in  one  portion  of  the 
exudation  to  cause  absorption  of  the  other. 

During  the  progress  of  these  essentially  vital  acts  and  modes  of 
growth  and  formation,  how  can  it  be  supposed  that  lowering  the  strength 
by  blood-letting  can  influence  them  in  any  way  except  for  the  worse ; 
that  is  to  say,  bv  weakening  that  power  on  which  the  transformations 
depend?  Dr.  Alison  admits  that  "it  is  not  merely  the  mechanical 
change  of  position  of  many  particles  of  the  blood,  but  a  strictly  vital 
action,  such  as  we  trace  up  only  to  principles  of  physiology  and 
pathology,  to  which  we  have  to  apply  a  remedy."  The  nature  of  this 
vital  action  he  has  not  sought  to  explain.  But  if,  as  we  have  pointed 
out,  it  is  essentially  a  formative  one,  and  in  kind  identical  with  growth 
in  voung  tissues,  it  ought  not  to  be  diminished  or  destroyed  by  depleting 
remedies. 

But,  says  Dr.  Alison,  if  we  abandon  blood-letting  as  recommended 
by  so  many  practical  authors  in  obedience  to  this  doctrine,  "  we  shall  be 
trusting  to  a  pathological  view  of  a  vital  process,  still  very  impertectly 
known,  in  opposition  to  a  therapeutical  principle,  founded  no  doubt  on 
empirical  observation  only  ;  requiring,  no  doubt,  as  all  powerful  remedies 
do,  an  exercise  of  judgment  of  the  practitioner  in  applying  it;  because  it 
may  easily  do  harm  by  enfeebling,  and  at  the  same  time  rendering  more 
irritable,  all  the  vital  actions  involved  in  the  disease,  more  than  good,  by 
restraining  the  amount  of  the  exudation ;  but,  nevertheless,  much  more 
to  be  depended  on,  as  f/uldlnr/  practice  in  these  circumstances,  than  any 
principle  in  pathology."  If,  however,  instead  of  being  imperfectly  known, 
as  he  supposed,  it  should  turn  out  that  the  pathological  view  I  am  con- 
tending for  is  true,  aud  is  extensively  known  among  the  younger  mem- 
bers of  the  profession,  then  the  admission  here  made  by  Dr.  Alison  of 
how  easily  bloodletting  may  do  harm  and  enfeeble,  may  be  expected  to 
produce  an  eft'ect  prejudicial  to  its  employment.  Besides,  the  moment  a 
pathological  law  can  be  successfully  established,  empirical  rules  are  over- 
thrown. Dr.  Alison,  who  has  done  so  much  in  attempting  to  establish 
the  supremacy  of  vital  laws,  is  too  good  a  logician  not  to  know  this. 
Hence  his  objection  is  directed  against  the  uncertainty  and  want  of 
general  inforniation  of  the  theoretical  view  as  a  guide  to  practice,  when 
compared  with  the  advantages  whicdi  he  considers  the  empirical  rule  has 
produced,  as  tested  by  past  experience.  This,  then,  leads  me  to  abandon 
pathological  research  and  deduction,  and  inquire  how  far  actual  facts 
indicate  which  is  the  best  practice — blood-letting  in  obedience  to  empi- 
rical rules,  or  abstaining  from  it,  in  accordance  with  the  pathological 
principles  now  brought  forward. 


NATURAL   PROGRESS   OF   IXFLAMMATIOX.  269 


Proposition  5. — That  all  positive  knoioledge  of  the  experience  of  the 
past,  as  ivell  as  the  more  exact  observation  of  the  present  day,  alike  esta- 
blish the  truth  of  the  preceding  principles  as  guides  for  the  future. 

In  endeavouring  to  determine  from  experience  what  is  the  vahie  of 
bleeding  in  acute  inflammations,  it  must  be  remembered  that,  whilst  past 
experience  has  declared  it  to  be  the  sine  qud  nan,  the  summuvi  reine- 
dium,  the  only  certain  means  of  cutting  short  the  disease,  and  so  on — 
present  experience  declares  by  almost  universal  consent  that  now-a-days 
individuals  labouring  under  them  recover  rapidly  without  bleeding  at  all. 
This  admission  constitutes  the  basis  of  the  theory  advanced  by  Dr, 
Alison,  viz.,  that  acute  inflammations  within  the  last  twenty  years  have 
changed  their  type.  So  that  the  question  now  is  not  whether  no 
bleeding  is  good  practice,  but  how  the  admission  of  this  fact  is  to  be 
reconciled  with  the  experience  of  twenty  years  ago.  Bnt  inasmuch  as 
for  the  reasons  previously  given  we  cannot  suppose  for  a  moment  that 
inflammation  has  ever  undergone  any  change  whatever  among  mankind, 
it  necessarilv  follows,  if  modern  practice  in  this  matter  be  correct,  that 
former  bleedings  must  have  been  inert  or  injurious. 

Before  it  is  possible,  however,  to  determine  with  exactitude  the  value 
of  any  practice,  it  is  essential  to  ascertain  the  natural  duration  of  the 
disease  we  propose  to  treat.  Fortunately  we  have  now  some  data  which 
will  enable  us  to  arrive  at  this  information  with  regard  to  one  of  the  most 
frequent  and  important  kinds  of  inflammation,  viz.,  pneumonia.  Very 
severe  cases  of  this  disease  were  observed  by  Dr.  George  Balfour,  in  the 
Homoeopathic  Hospital  of  Vienna,  under  a  treatment  that  no  reasonable 
medical  man  can  suppose  to  be  anything  else  than  inert.  Yet  most  of 
these  cases  got  well,  and  may  be  considered  as  excellent  studies  of  the 
disease  left  entirely  to  nature.*  We  have  also  the  accounts  of  the  expect- 
ant systems  of  treating  this  disease  in  Vienna  under  Skodaf  and  Dietl.]]] 

From  all  the  accounts  which  have  been  published  concerning  the 
natural  progress  of  a  pneumonia,  it  would  appear  that  very  slight  cases 
(that  is,  where  the  inflammation  has  been  limited)  may  be  convalescent 
on  the  seventh  day,  that  the  majority  of  eases  of  medium  intensity  recover 
between  the  seventh  and  fourteenth  davs,  and  ver\'  severe  ones  between 
the  fourteenth  and  twenty-first  days.  It  is  sometimes  difficult  to  judge 
from  the  accounts  of  different  authors  what  according  to  them  consti- 
tutes the  number  of  days  an  individual  is  aflPected.  Some  suppose  that 
disappearance  of  fever  or  cessation  of  pain  marks  recovery.  Others 
have  declared  convalescence  to  be  established  as  soon  as  the  patient  can 
take  a  little  beef  tea.  I  have  ventured,  however,  to  name  periods  between 
the  seventh,  fourteenth,  and  twenty-first  days,  trom  a  careful  examination 
of  the  cases  themselves,  and  from  applying  to  them  the  rules  which  have 
governed  the  records  of  my  own  practice.  These  are,  to  consider  the 
commencement  of  the  disease  as  indicated  by  the  rigor,  and  the  termina- 
tion as  indicated  by  marked  diminution  in  the  physical  signs  conjoined 

*  Brit,  and  For.  Medical  Review,  vols.  22  and  23. 

\  Dr.  G.  Balfour  in  Edin.  Medical  and  Surgical  Journal.  1847. 

j  Der  Aderlass  in  der  Lungenentzundung.  Wien.  1849. 


270  PRINCIPLES   OF   MEDICINE. 

with  disappearance  of  the  leading  symptoms, — I  say  marked  diminution, 
because  a  certain  amount  of  increased  vocal  resonance  and  even  crepita- 
tion, not  UTifrequently  continues  for  some  time  after  the  individual  has  left 
his  bed  and  has  to  all  intents  and  purposes  perfectly  recovered.  Such,  it 
appears  to  me,  is  the  average  duration  of  pneumonia,  and  I  believe  that 
if  an  individual  can  be  shown  to  have  recovered  from  an  attack  of  the 
disease  which  has  involved,  say  two-thirds  of  one  lung,  in  fourteen  days, 
it  is  a  good  recovery,  and  yet  only  consistent  with  the  natural  progress 
of  the  disease  in  sound  constitutions. 

Here  it  is  important  to  consider  that  the  violence  of  the  symptoms 
bears  no  necessary  relation  to  the  extent  or  intensity  of  the  disease. 
Some  persons  present  great  fever  and  constitutional  disturbance  when 
one  lung  is  only  slightly  involved,  and  recover  rapidly ;  whereas  others 
may  have  an  entire  lung  inflamed,  or  portions  of  both  lungs,  and  exhibit 
comparatively  trifling  fever  and  few  marked  symptoms,  until  impeded 
respiration  occurs,  ushering  in  death.  It  is  a  knowledge  of  this  impor- 
tant fact  which  serves  to  clear  up  much  of  the  discrepancy  existing  be- 
tween past  and  present  practice,  especially  when  conjoined  with  another, 
viz.,  that  however  bleeding  may  relieve  symptoms,  it  has  no  influence  in 
shortening  the  duration  or  diminishing  the  extent  of  the  disease.  Of 
this  fact  the  observations  of  Louis,  Grisolle,  and  Dr.  Alison  can  leave  us 
in  no  doubt ;  and  I  have  frequently  satisfied  myself  of  their  correctness. 
It  follows  that,  as  the  past  race  of  practitioners  considered  pneumonia 
only  demonstrable  by  symptoms,  which  furnished  the  sole  evidence  of 
the  advantage  of  bleeding,  as  soon  as  these  symptoms  were  diminished 
by  venesection,  they  thought  benefit  was  accomplished.  Whereas  now 
it  has  become  apparent  that  such  is  no  certain  evidence  of  recovery  from 
the  disease,  which  may  linger,  notwithstanding,  for  weeks,  give  rise  to  a 
tedious  convalescence,  and  even  induce  death  by  exhaustion  after  active 
functional  symptoms  have  for  the  most  part  disappeared. 

The  real  tests  of  successful  pi-actice,  therefore,  are  not  to  be  sought  for 
in  the  relief  of  symptoms,  but  in  the  removal  of  the  disease  ;  and  that 
treatment  will  be  best  which,  ccRteris  paribus^  causes  fewest  deaths,  and 
recovery  in  the  shortest  time.  Let  us  then  look  at  the  results,  1st,  of  the 
antiphlogistic  treatment  as  formerly  practised  by  bleedings,  and  tartar 
emetic  ;  2d,  of  the  expectant  system,  or  what  ought  to  be  called  a  diete- 
tic system;  3d,  of  the  treatment  directed  to  further  the  natural  progress 
of  the  disease  as  I  have  explained  it. 

Treatment  by  Bleeding. — It  appeal's  from  the  published  statistics  of 
the  Royal  Infirmary  of  Edinburgli,  that  upwards  of  one-third  of  all  the 
patients  affected  with  pneumonia,  who  entered  during  a  period  of  ten 
years,  died.  Xo  doubt  it  cannot  be  pretended  that  perfect  accuracy  as 
to  diagnosis  was  attained  in  all  the  cases.  It  is  certain  also,  that  nume- 
rous complications  and  the  debilitated  constitutions  so  frequently  met 
with  in  the  practice  of  a  large  hospital,  served  to  swell  the  mortality. 
It  is  remarkable,  however,  that  this  proportion  of  deaths  to  recoveries  is 
nearly  the  same  as  that  which  exists  in  the  total  number  treated  in  the 
Infirmary  since  the  commencement  of  the  present  century,  as  well  as 
what  resulted  in  the  cases  so  carefully  observed  by  M.  Louis,  in  the  hos- 
pital of  La  Chai'ite,  at  Paris. 


ANTIPHLOGISTIC  TREATMENT  OF   PXEUMOXIA, 


271 


Table  showing  the  number  of  patients  affected  with  pneumonia  treated 
in  the  Roral  Infirmary  of  Edinburgh,  and  the  resuhs,  from  July  1st 
1839  to  October  1st  1849  : 


Total  No.  of 

1 

Patients 
entering  the 

Tears. 

No.  Ad- 
mitted. 

Cured. 

Be- 
lieved 

Died.'     Statistician. 

Infirmary. 

7.969* 

1st  Julv  1839  to  1st  Oct 

1841 

139 

85 

5 

49  ,Dr.  JohnReid. 

3.537 

1st  Oct.  1841  to  1st  Julv  1842 

42 

23 

3 

16 

1  Dr.  T.  Pea- 
)        cock. 

2.760 

„       1842 

1843 

41 

26 

0 

15 

7,204 

„       1843 

1844 

31 

16 

4 

11 

) 

3,252 

,.       1844 

1845 

50 

33 

4 

13 

[Dr.  Hughes 

3,633 

„       1845 

1846 

61 

40 

6 

15 

7,435 

.,       1846 

1847 

93 

47 

5 

41 

7,446 

„       1847 

1848 

103 

52 

6 

45     J 

i     3,724+ 

.,       1848 

1849 

88 

66 

5 

17    Mr.M-Dougall. 

46,965 

1 

648 

3SS 

38 

222 

My  former  resident  clerk,  Dr.  Thorburn,  was  kind  enough,  at  my  re- 
quest, to  go  over  208  case-books  of  the  Infirmary,  dated  between  the 
years  1812  and  1837,  and  belonging  to  twelve  physicians,  all  of  whom 
practised  an  antiphlogistic  treatment.  He  found  that  of  103  cases  of 
pneumonia,  55  were  cured,  41  died,  and  7  were  relieved.  Dr.  Thorburn 
then  carefully  read  over  these  103  cases,  and  rejected  all  those  that  were 
incomplete,  or  which  presented  no  evidence  of  having  been  pneumonia. 
The  retuainder  were  tabulated,  and  it  may  safely  be  said  that  they  were 
all  cases  of  pneumonia,  or  of  acute  inflammations  of  the  chest  closely 
allied  to  that  disease,  and  the  result  was  : — Number  of  cases,  50  ;  died, 
19  ;  cured  or  relieved,  31. 

The  total  number  of  cases  recorded  by  M.  Louis,  was  107.J  Of  these 
32  died,  or  1  in  3^.  In  78  of  those  cases  which  occuiTed  at  La  Charite, 
bleeding  was  performed,  from  the  first  to  the  ninth  day,  and  the  deaths 
were  28,  or  1  in  3-^.  The  duration  of  the  disease  in  the  cases  which 
recovered,  was  15-J-days.  Of  the  remaining  29  cases,  which  occurred  at 
La  Pitie,  the  bleeding  was  performed  earlier,  that  is,  during  the  first 
four  days,  and  of  these  only  four  died,  that  is,  1  in  7^.  The  duration 
of  the  disease,  however,  in  the  cases  that  recovered,  was  18^  days. 
This  diminished  mortality,  but  greater  length  in  the  time  of  recovery, 
M.  Lonis  attributes  to  the  bleedings  not  having  been  so  large,  and  the 
greater  araoimt  of  tartar  emetic  employed.  Hence,  the  proposition  he 
sought  to  establish,  that  although  bleeding  has  a  very  limited  influence 
on  pneumonia,  it  should  be  practised  early.  With  regard  to  M.  Louis's 
results,  it  should  be  remembered,  that  all  these  patients  enjoyed  excel- 
lent health  when  they  were  attacked,  and  that  the  duration  of  the  disease 

*  At  these  periods  there  were  great  epidemics  of  fever. 

+  At  this  period  considerable  changes  took  place  among  the  medical  stafi"  of  the 
Intirmary. 

^  Recherches  sur  les  eflfets  de  la  Saignee.     Paris.     1835. 


272  PRINCIPLES  OF  MEDICINE. 

was  estimated  from  the  occurrence  of  febrile  symptoms,  up  to  the  time 
when  light  food  could  be  taken,  which  was  generally  three  days  after  the 
fever  had  ceased. 

That  the  result  of  an  active  antiphlogistic  treatment  was  the  pro- 
duction of  a  mortality  of  about  1  in  3  cases,  seems  to  me  further  esta- 
blished by  the  account  of  Rasori,*  who,  in  the  great  hospital  of  Milan, 
treated  648  cases  bv  large  doses  of  tartar  emetic,  of  which  555  were 
cured,  and  143  died,  that  is,  1  in  4A.  In  publishing  this  statement, 
Rasori  gives  the  result  as  one  more  favourable  than  the  practice  of  blood- 
letting, which  of  course  he  would  not  have  done  unless  the  latter  treat- 
mentwas  well  known  to  have  been  attended  with  a  greater  mortality 
than  that  by  tartar  emetic,  or  1  death  in  4i-  cases. 

M.  Grisollef  advocated  more  mo<;lerate  bleedings  than  those  so  fre- 
quently had  recourse  to,  his  conscience  preventing  the  abandonment  of 
venesection  altogether  (p.  561).  He  analyses  the  75  cases  of  Bouillaud, 
pointing  out  that  only  49  were  treated  by  the  coup  sur  couj)  mode  of 
bleeding,  of  whom  6  died,  or  1  in  8  cases,  a  favourable  result,  which  he 
attributes  to  the  youth  of  the  patients  treated.  Of  his  own  cases  one 
group  of  50  cases  were  bled  only  in  the  first  stage  of  the  disease  ;  of  these 
5  died,  or  1  in  10.  Those  cases  that  died  were  bled  most,  each  losing 
about  4  lb.  4  oz.  of  blood  in  successive  bleedings.  All  the  cases  in  this 
group  were  uncomplicated,  and  of  the  average  age  of  40  years.  Of  1 82 
cases  that  were  bled  in  the  second  stage,  32  died,  or  more  than  1  in  6. 
Here  also  those  who  died  were  bled  most.  Of  the  whole  232  cases,  37 
died,  that  is  about  1  in  6^,  as  the  general  result  of  M.  GrisoUe's  hospital 
practice,  a  mortality  only  one-half  that  of  M.  Louis's  cases,  although  the 
circumstances  under  which  they  occurred  were  the  same,  with  the  excep- 
tion of  not  being  so  heroically  treated.  Laennec  also,  who  only  bled 
moderately  at  the  commencement  of  the  disease,  regarded  the  mortality 
as  one  death  in  6  or  8  cases.J 

Dr.  Glen,  my  late  resident  clerk,  was  so  good  as  to  tabulate  for  me 
all  the  cases  of  pneumonia  given  in  the  army  returns,  and  reported  by 
Colonel  Tulloch.§  Xothingcan  be  more  unsatisfactory  than  the  nature 
of  these  returns,  as  we  have  no  information  as  to  the  exactitude  with 
which  they  were  made,  how  the  diagnosis  was  determined,  or  what  was 
the  treatment.  The  favourable  mortality,  as  it  has  been  supposed,  of  1 
death  in  13  cases,  which,  according  to  Dr.  Glen,  is  the  general  result,  is 
of  little  or  no  service  to  the  present  inquiry. 

Treatment  hj  Diet. — This  treatment  essentially  consists  in  allowing 
the  disease  to  go  through  its  natural  course.  During  the  stage  of  fever 
the  diet  is  light,  and  cold  water  allowed  for  drink ;  subsequently  more 
o-enerous  diet  is  allowed,  with  wine,  according  to  the  nature  of  the 
symptoms.  Sometimes  a  dietetic  is  converted  into  an  expectant  treat- 
ment, when  remedies  are  given  to  meet  occasional  symptoms,  as  in  the 
practice  of  Skoda,  in  the  Charity  Hospital  of  Vienna.     An  account  of 

*  From  an  Analysis  of  Rasori's  Practice — Annales  de  Therapeutique.  Janvier, 
1847. 

•j-  Traite  pratique  de  la  Pneumonie.     Paris.     1841. 

X  Forbes'  Translation.     Fourtli  Edition.     P   2.37. 

§  Government  Statistical  Reports  on  Mortality  among  the  Troops.     1853. 


THE   author's   treatment   OF   PNEUMONIA.  278 

this  has  been  given  to  us  by  Dr.  George  Balfour  of  Cramond,  who  found 
from  the  books  of  the  hospital,  that  during  a  period  of  three  years  and 
five  months,  commencing  1843,  392  patients  were  treated,  of  whom  45 
died,  or  1  in  1^.  Occasionally  opium  w"as  given  in  small  doses  if  there 
was  much  pain.  Venesection  was  also  practised  early  if  there  was  much 
dvspncea,  and  emetics  given  if  the  expectoration  consisted  of  tough  mucus. 

Dr.  Balfour  has  also  given  some  statistics  of  the  Homoeopathic  Hospi- 
tal of  Vienna,  accompanied,  however,  with  statements  which  render  it 
doubtful  whether  every  case  that  applied  was  admitted,  and  conse- 
quently not  fairly  comparable  with  other  hospital  statistics.  There  can 
be  no  doubt,  however,  that  many  severe  cases  of  pneumonia  recovered 
under  a  system  of  treatment,  which,  it  appears  to  me,  most  medical  men 
must  consider  to  be  essentially  a  dietetic  one. 

Dr.  Diet!  treated  380  cases  of  primary  pneumonia,  in  the  Charity 
Hospital  of  Vienna;  85  by  venesection,  106  by  large  doses  of  tartar 
emetic,  and  189  by  diet  only,  with  the  following  result : — 

Vene-  Tartar  Diet, 

section.  Emetic. 

Cured 68     84     175 

Died 17      22     14 


106     189 


Per  ceut 20.4 20.7     7.4 

Deaths 1  in  5 1  in  5.22 liu  13^ 

It  was  farther  observable  th.at  of  the  85  cases  treated  by  blood-letting, 
7  of  the  fatal  cases  were  uncomplicated;  whilst  of  the  189  cases  treated 
by  diet,  not  one  of  the  deaths  was  an  uncomplicated  one. 

Treatment  directed  to  farther  the  natural  progress  of  the  disease. — 
The  treatment  I  have  pursued  in  pneumonia  is  founded  on  the  patholo- 
gical principles  formerlv  given,  viz.,  never  to  attempt  cutting  the  disease 
short,  or  to  weaken  the  pulse  or  vital  powers,  but  on  the  contrary  to 
further  the  necessary  changes  which  the  exudation  must  undergo,  in  order 
to  be  fully  excreted  from  the  economy.  To  this  end,  during  the  period 
of  febrile  excitement,  I  content  myself  with  giving  salines  in  small  doses, 
with  a  view  of  diminishing  the  viscosity  of  the  blood.  As  soon  as  the 
pulse  becomes  soft,  I  order  good  beef  tea  and  nutrients  ;  and  if  there  be 
weakness,  from  4  to  8  ounces  of  wine  daily.  As  the  period  of  crisis 
approaches  I  give  a  diuretic,  generally  consisting  of  half  a  drachm  of 
nitric  aether,  sometimes  combined  with  ten  minims  of  colchicum  wine, 
three  times  daily,  to  favour  the  excretion  of  urates.  But  if  crisis  occurs 
by  sweat  or  stool,  I  take  care  not  to  check  it  in  any  wav. 

On  examining  into  the  results  of  this  practice,  which  has  been  publicly 
carried  on  by  me  in  the  clinical  wards  of  the  Royal  infirmary  during  the 
last  eight  years,  and  which  has  been  carefully  recorded  by  the  clinical 
clerks,  I  find  the  total  number  of  cases  to  be  78*;  the  average  age,  30|, 

Of  these,  75  were  dismissed  cured,  and  3  died,  that  is,  1  in  26. 

Of  the  75  cases  cured.  Go  were  uncomplicated,  and  10  complicated. 

*  In  the  former  edition  the  number  stated  was  65.  Since  then,  13  cases  of  pneu- 
monia have  been  treated  by  me  in  tlie  iutirmary. 

18 


274  PRINCIPLES  OF  MEDICINE. 

Of  the  65  uncomplicated  cases,  I  find  that  the  clerk  has  omitted  to  state 
either  the  exact  day  of  rigor,  or  of  convalescence,  in  5,  so  that  no  deduc- 
tioTi  can  be  derived  from  them  as  to  the  duration  of  the  disease.  Of  the  re- 
maining 60  uncomplicated  cases,  47  were  single  and  13  double  pneumonia. 
The  duration  of  the  47  cases  of  single  pneumonia  was  as  follows, 
viz. — 1  case  recovered  in  5  days ;  3  cases  in  7  days ;  2  cases  in  8  days ; 
4  cases  in  10  days ;  2  cases  in  11  days ;  3  cases  in  12  days;  2  cases  in 

13  davs;  12  cases  in  14  days;  2  cases  in  15  days;  3  cases  in  16  days; 
2  cases  in  17  days  ;  3  cases  In  18  days;  1  case  in  19  days;  2  cases  in  20 
days;  2  cases  in'21  days;  1  case  in  22  days;  1  case  in  23  days;  and  1 
case  in  26  days.  Average  duration  of  single  uncomplicated  pneumonia, 
14^^  days. 

The  duration  of  the  13  uncomplicated  cases  of  double  pneumonia  was 
as  follows: — 1  case  recovered  in  9  days  ;   1  case  in  13  days;  2  cases  in 

14  days ;  1  case  in  16  days ;  2  cases  in  18  days;  1  case  in  19  days  ;  1 
case  in  20  days  ;  3  cases  in  21  days;  and  1  case  in  55  days.  Average 
duration  of  double  uncomplicated  pneumonia,  20  days. 

Of  the  65  uncomplicated  cases,  7  were  bled,  and  were  subjected  to  an 
antiphlogistic  treatment  before  admission.  Of  these  1  case  recovered  in  7 
days;  2  cases  in  14  days;  1  case  in  16  days;  1  case  in  17  days;  1  case 
in  20  days;  and  1  case'(a  severe  double  one)  in  55  days.  Average  dura- 
tion of  cases  bled,  20  days. 

Of  the  10  complicated  cases  of  pneumonia  which  recovered,  the  1st 
case  supervened  on  chronic  asthma,  bronchitis,  and  emphysema,  and 
recovered  in  14  days;  the  2d  case  supervened  on  typhus  fever,  and  reco- 
vered in  16  davs;  the  3d  case  supervened  on  chronic  asthma,  bronchitis, 
and  pleurisv,  and  recovered  in 48  days;  the  4th  case  supervened  on  typhus 
fever,  and  recovered  in  18  days;  the  oth  case  supervened  on  pleurisy 
on  one  side,  with  pleural  exudation  existing  8  weeks  before  admission, 
and  recovered  in  19  days  ;  the  6th  case  supervened  on  rheumatism  with 
heart  disease,  and  recovered  in  19  days;  the  7th  case  supervened  on 
very  severe  rheumatism,  with  endocarditis  and  pericarditis,  but  recovered 
in  15  davs  ;  the  8th  case  was  complicated  with  pleurisy,  which  continued 
long  after  the  pneumonia  disappeared,  and  recovered  in  10  days;  the 
9th  case  was  complicated  w'ith  chronic  tubercular  condensation  at  the 
apex  of  the  right  hmg,  and  was  double,  but  recovered  in  9  days;  and  the 
10th  case  was^  complicated  with  bronchitis  and  phthisis,  but  recovered 
on  the  9th  dav.  The  average  duration  of  the  pneumonia  in  the  10  com- 
plicated cases  was  17|  days.  Of  these  7  were  single  and  3  double  pneu- 
monia, the  latter  recovering  respectively  in  18,  15,  and  9  days. 

Of  the  65  uncomplicated  cases  of  pneumonia,  including  the  13  double 
cases,  I  find  that  the  exact  day  of  dismission  is  omitted  from  the  register 
in  4  cases.  But  the  average  residence  in  the  hospital  of  the  remaining 
61  cases  was  24 J  days.  This  average  is  undoubtedly  too  high,  as  I  find 
that  several  cases  had  been  allowed  to  linger  in  the  house,  in  conse- 
quence of  supposed  chronic  pains,  or  trifling  skin' eruptions,  in  no  way 
connected  with  the  pneumonia. 

The  three  fatal  cases  were  all  complicated.  The  first  with  uncon- 
trollable diarrhoea,  and  on  dissection,  conjoined  with  pneumonia,  there 
was  found  extensive  follicular  disease  of  the  mucous  membrane  of  the 
duodenum,  jejuiuim,  but  chiefly  of  the  ileum.     The  second  case  was 


THE   AUTHORS   TREATMENT   OF   PXEUMOXIA.  275 

complicated  with  persistent  albuminuria  and  anasarca.  Xo  post  mortem 
examination  could  be  obtained.  The  third  case,  that  of  a  drunkard,  was 
complicated  with  delirium  tremens,  and  latterly  violent  convulsions.  On 
dissection,  in  addition  to  the  pneumonia,  there  was  found  universal  cere- 
bral meningitis,  with  exudation,  at  the  base,  as  well  as  over  both  hemi- 
spheres of  the  brain.     (See  Cerebral  Meningitis.  Case  of  David  Murrav.) 

In  addition  to  the  three  fatal  cases  here  recorded,  I  have  found  in 
the  pathological  registers  kept  by  Drs.  Gairdner  and  Ilaldane  seven  other 
cases,  in  which,  as  the  result  of  chronic  cerebral,  cardiac,  renal,  or 
other  pulmonary  disease  (such  as  phthisis),  pneumonia  appeared  before 
death,  adding  a  fatal  complication  to  previously  existing  maladies.  Xot 
one  of  these  can  properly  be  considered  as  a  case  of  acute  pneumonia, 
or  indeed  of  pneumonia  at  all.  They  have  all  been  entered  by  the  clerks 
in  the  ward  books  as  softening  of  the  brain,  morbus  cordis,  Bright's  disease, 
or  other  lesion  for  which  the  patients  entered  the  Infirmary  and  were  treat- 
ed.    In  most  of  them  it  was  the  jmeumonie  des  ar/oniza)is  of  the  French. 

These,  then,  are  positively  all  the  cases  of  acute  pneumonia  which 
have  entered  the  infirmary  under  my  care  during  the  last  ten  years,  so 
far  as  I  can  discover  them.  They  have  been  all  analysed  and  tabulated 
by  myself  and  by  my  clinical  resident  physicians,  to  whom  I  am  much 
indebted  for  the  great  care  and  pains  they  have  taken  in  confirming 
these  results.  Every  case  has  been  treated  publicly,  and  is  open  for 
inspection  in  the  ward  books,  and  the  result  is,  as  I  have  stated,  that  the 
mortality  of  acute  pneumonia,  in  the  practice  of  the  clinical  wards  while 
under  my  care,  is  1  in  26,  and  that  of  all  the  cases  of  uncomplicated  pneu- 
monia, 65  in  number,  not  one  has  died,  although  many  of  them  have 
been  very  severe,  involving  the  whole  of  one  lung,  and  in  13  cases  portions 
of  both  lungs. 

So  far,  I  think,  I  approach  very  near  correctness  bv  savino-  that  the 
result  of  a  vigorous  antiphlogistic  treatment  of  pneumonia  as  formerly 
practised  is  a  mortality  of  1  in  3  cases;  that  the  result  of  a  treatment  by 
tartar  emetic  in  large  doses,  according  to  Rasori,  and  more  recentlv  to 
Dietl,  is  a  mortality  of  1  in  5  cases — but  according  to  Laeunec,  1  in  10 
cases;  that  the  result  of  moderate  bleedings,  as  in  the  treatment  of 
Grisolle,  is  a  mortality  of  1  in  6^  cases;  and  that  the  result  of  a  dietetic 
treatment  with  occasional  bleedings  and  emetics  in  severe  cases,  as  with 
Skoda,  is  a  mortality  of  1  in  7,  and  if  pure,  as  under  Dietl,  a  mortality 
of  1  in  13  cases,  all  carried  on  in  large  public  hospitals.  Further,  that 
the  mortality  from  pneumonia  in  the  army  and  navv,  occurring  generally 
among  healthy  able-bodied  men,  has  been  also  a  mortalitvof  1  in  13 
cases.  Lastly,  that  the  result  of  a  treatment  directed  to  further  the 
natural  progress  of  the  disease  as  I  have  explained  it,  is,  in  the  clinical 
war<ls  of  the  Royal  Infirmary  of  E  linburgh,  when  under  my  care,  up 
to  this  time  (January  1849)  a  mortality  of  1  in  20  cases. 

From  these  facts  it  follows  that  uncomplicated  pneumonia,  especially 
in  young  and  vigorous  constitutions,  always  gets  well,  if  instead  of  being  ^ 
lowered,  the  vital  powers  are  supported,  and  the  excretion  of  eft'ete  pro- 
ducts assisted.  It  is  exactly  in  these  cases,  however,  that  we  were  for- 
merly enjoined  to  bleed  most  copiously,  and  that  our  systematic  works 
even  now  direct  us  to  draw  blood  largely  and  repeatedly  in  consequence 


276  PEIXCIPLES   OF   MEDICINE. 

of  the  supposed  imminent  danger  of  suppuration  destroying  the  texture 
of  the  King.  Such  danger  is  altogether  iUusory,  and  the  destruction  to 
lung  tissue,  so  far  from  being  prevented,  is  far  more  likely  to  be  produced 
by  the  practice.  In  fact,  the  only  cases  in  which  it  occurs  are  in  aged 
or  enfeebled  constitutions,  in  which  nutrients  and  not  antiphlogistics  are 
the  remedies  indicated.  We  can,  however,  readily  understand  how 
blood-letting,  practised  early  and  in  young  and  vigorous  constitutions,  does 
less  harm,  or,  to  use  a  common  expression,  "is  borne  better,"  than  when 
the  disease  is  advanced  or  tlie  patient  weak,  and  this,  because  then  the 
vital  powers  are  less  atfected  by  it.  Hence  the  diminished  mortality  in 
the  second  series  of  Louis's  cases,  and  probably  in  the  army  and  navy 
cases.  But  that  it  cures  the  greater  munber  of  persons  attacked,  or 
shortens  the  duration  of  the  disease,  is  disproved  by  every  fact  with 
which  we  are  acquainted. 

At  the  same  time  there  are  cases,  wliich  were  formerly  often  mistaken 
for  inliammation,  in  which  blood-letting  may  still  be  useful.  I  allude 
to  those  where  an  obstruction  to  the  circulation  exists  in  the  heart  and 
lung  dependent  on  over-distension  of  the  right  side  of  the  former  organ, 
or  on  venous  congestion,  engorgement,  and  perhaps  oedema  of  the  latter; 
also  certain  cases  of  bronchitis  preventing  aeration,  of  aneurisms  and  of 
asphyxia.  Although  even  here  the  true  value  of  the  remedy  has  yet  to 
be  positively  ascertained,  the  special  cases  demanding  it  more  carefully 
discriminated,  and  the  mechanical  principles  wliich  justify  the  practice 
determined.  The  temporary  benefit  occasioned  in  many  of  these  cases 
by  the  loss  of  a  trifling  amount  of  blood  is  often  very  remarkable,  and 
has  been  previously  referred  to  (p.  264).  I  have  seen  instances  where 
great  dyspnoea  and  pain,  caused  by  large  thoracic  aneurisms  in  vigorous 
men,  have  been  greatly  alleviated,  and  inexpressible  relief  produced  for 
from  twelve  to  twenty-four  liours,  by  a  bleeding  to  the  extent  of  only 
five  ounces.  It  seems  probable  that  this  may  arise  from  diminishing  for 
a  time  the  tension  of  the  whole  vascular  system.  But  whatever  be  the 
explanation  of  this  fact,  I  hold  that,  as  a  palliative,  and  practised  to  a 
limited  extent  in  cases  where  no  great  debilitv  exists,  blood-letting  may 
still  be  had  recourse  to.  So  with  regard  to  antimonials,  although  in  the 
large  doses,  which  weaken  the  heart  and  force  of  the  pulse,  they  are  not 
serviceable — in  smaller  doses,  together  with  other  neutral  salts,  they  may 
assist  in  diminishing  the  viscosity  of  the  blood,  and  in  favouring  the 
excretion  of  the  efi'ete  matters  by  the  skin  and  kidneys. 

As  to  mercurials,  the  confident  belief  in  their  power  of  causing  absorp- 
tion of  lymph,  by  operating  on  the  blood,  is  not  only  opposed  to  sound 
theoiy,  as  formerly  explained,  but,  like  blood-letting,  is  not  supported  by 
that  experience  which  has  been  so  confidently  appealed  to  in  their  favour. 
They  have  been  most  praised  in  the  treatment  of  serous  inflammations 
and  in  iritis.  But  recent  careful  observation  has  demonstrated  that  the 
moment  these  diseases  are  treated  without  mercury,  they  are  uninfluenced 
(except  in  certain  cases  for  the  worse)  by  this  drug.  Thus,  from  an 
analysis  of  40  cases  of  pericarditis,  treated  with  mercury,  and  recorded 
with  unusual  care  by  the  late  Dr.  John  Taylor,  only  4  appear  even  coin- 
cidentally  to  have  benefited  in  any  way.*     And  of  64  cases  of  iritis,  of 

*  British  and  Foreign  Medical  Review,  vol.  xxiv.  p.  565  ;  and  Lancet,  May  1845 
to  October  1846. 


THE  BLOODLETTING  CONTROVERSY  OF  1857-8.     277 

every  degree  of  severity,  including  its  idiopathic,  traumatic,  rheumatic, 
and  syphilitic  varieties,  treated  without  mercury,  by  Dr.  II.  W.  Williams 
of  Boston,  IT.  S.,  the  results — with  four  exceptions,  which  were  neo-lected 
at  the  commencement — were  perfectly  good.* 

I  cannot,  therefore,  resist  the  conclusion  that  the  principles  which  led 
to  an  antiphlogistic  practice  in  acute  inflammations  were  erroneous,  and 
are  no  longer  in  harmony  with  the  existing  state  of  pathology,  I  think 
it  has  been  further  shown  that  in  recent  times  our  success  ni  treatment 
has  been  great,  just  in  proportion  as  we  have  abandoned  heroic  remedies, 
and  directed  our  attention  to  fuithering  the  natural  progress  of  the 
disease.  Thus,  in  our  large  public  hospitals,  under  circumstances  prettv 
much  the  same,  it  has  been  shown  that  the  mortality  of  pneumonia  has 
been  diminished  from  1  in  3  to  1  in  7  cases,  then  to  1  in  13,  and  lastly, 
to  1  in  26  cases.  In  other  words,  death  from  this  disease  takes  place 
nearly  nine  times  less  frequently  now  than  it  did  twenty  years  ago.  I 
am  satisfied  also  that  deaths  from  acute  pericarditis  are  far  less  common 
now  than  formerly,  and  that  post-mortem  examinations  as  a  consequence 
demonstrate  adhesions  of  the  pericardium  much  more  frequently.  This 
great  improvement  in  practice,  it  appears  to  me,  is  attributable— Is^,  To 
the  greater  accuracy  with  which  we  can  now  detect  inflammations  of  the 
lung  and  heart;  and  2(7,  To  our  better  acquaintance  with  their  pathology 
— and  the  result  is  not  the  less  certain  -with  men  of  experience,  becaiise 
these  causes  operate  insensibly  to  themselves.  How  often,  durino-  the 
last  seventeen  years,  have  we  been  asked,  of  what  use  are  your  stetho- 
scopes, your  microscopes,  and  your  chemical  analyses  at  the  bed-side  ? 
In  reply,  w'e  point  to  the  revolution  now  going  on  in  the  practice  of 
medicine,  to  the  establishment  of  scientific  laws  instead  of  empirical 
rules,  and  to  the  abandonment  of  a  paUiative  in  favour  of  a  curative  plan 
of  treatment. 


Note. — Rephj  to  the  Objections  tohkh  have  been  urged  to  the  Author's 
Remarks  on  the  Treatment  of  Internal  Inflammations. 

So  much  has  been  published  in  reference  to  the  foregoing  observations  on  blood- 
letting, the  treatment  of  pneumonia,  and  the  supposed  change  of  tj^pe  in  inflamma- 
tions, that  it  will  be  impossible  for  me  to  allude  in  detail  to  all  that  has  been  said. 
It  is  evident  that  the  definition  of  the  word  inflammation,  the  ideas  to  be  attached 
to  the  pathological  condition  it  expresses,  as  well  as  all  that  refers  to  its  causes  and 
treatment,  require  to  be  re-systematised,  in  order  that  our  present  knowledge  of  the 
pathology  of  the  process  may  be  brought  into  harmony  with  modern  practice.  To 
this  task  I  shall  address  myself,  as  soon  as  my  avocations  will  permit.  In  the  mean- 
time, in  deference  to  the  distinguished  men  who  have  criticised  my  opinions  and 
facts,  I  propose  saying  a  few  words  in  reply  to  the  more  important  objections  which 
have  been  made  to  them. 

In  a  paper  published  in  the  Edinburgh  Medical  Journal  for  May  1857,  Dr.  Alison 
has  cited  some  cases,  and  one  especially  recorded  by  Dr.  Gregory,  where,  after 
large  bleedings,  recovery  took  place.  The  graphic  account  of  such  cases  is  well  cal- 
culated to  make  a  strong  impression  on  the  public,  and  even  on  the  minds  of  some 
professional  men,  although  it  is  difficult  to  see  how  isolated  cases  bear  on  the  ques- 

*  Boston  Medical  and  Surgical  Journal.     1856. 


278  PRINCIPLES   OF  MEDICINE. 

tion  at  all.  According  to  Dr.  Gregory,  a  j^oung  man  enters  the  clinical  wards  after 
several  days'  illness — neither  he  nor  his  pupils  had  any  doubt  as  to  the  nature  of  the 
disease  (pleurisy),  the  urgent  nature  of  it,  or  the  proper  remedy  for  it  (bleeding) ;  he 
was  bled  largely  and  repeatedly  in  consequence,  and  recovered,  in  Dr.  Gregory's 
opinion,  much  foster  than  such  patients  ordinarily  do.  Now,  this  case  differs  in  no 
particular  from  those  of  otlier  young  men  constantly  to  be  seen  in  the  wards  of  M. 
Bouillaud,  at  la  Charite,  Paris ;  and  there  is  no  proof  whatever  that  the  practice 
adopted  by  Gregory  in  past,  or  by  Bouillaud  in  modern  times,  cuts  short  the  progress 
of  the  disease  one  hour,  however  it  may  have  modified  the  symptoms.  Yet,  so 
important  does  this  case  appear  to  Dr.  Ahson,  that  he  observes  of  it,  "  if  we  were  to 
think  it  necessary  to  suppose  that  such  bleedings  as  those  described  by  Dr.  Gregory 
in  the  case  read,  were  only  injurious  to  the  lungs  of  the  man  who  left  the  hospital 
apparently  well  within  a  fortnight"  (this  does  not  appear  from  the  case)  "after  the 
violent  pleurisy,  and  all  these  bleedings  besides,  I  should  think  these  facts  alone 
quite  sufficient  to  stagger  my  belief  in  any  such  theory." 

But  I  have  never  maintained  such  a  theory.  On  the  contrary,  I  have  proved  that 
two  persons  out  of  every  three  treated  in  this  way  for  pneumonia,  in  public  hospitals, 
recovered ;  and  there  can  be  no  doubt  that  the  medical  men  who  practised  these 
bleedings  conscientiously  believed,  and  many  of  them  still  believe,  that  they  were 
beneficial,  and  saved  the  lives  of  their  patients.  But  I  have  a\so  p)-oved  that  recovery 
is  more  frequent  and  more  speedy  when  there  are  no  such  bleedings,  and,  if  so,  the 
conclusion  seems  irresistible,  that,  as  a  rule  of  practice,  they  are  inert  or  injurious. 
"What  is  required  to  show  the  excellence  of  Dr.  Gregory's  practice,  is  not  a  descrip- 
tion of  the  cases  which  recovered,  but  a  demonstration  that  a  greater  number  of 
persons  affected  were  saved  by  it  than  there  would  have  been  under  an  opposite 
treatment.  But  as  there  are  now  no  data  whereby  we  are  enabled  to  judge  of  this, 
it  stQl  appears  to  me  that  no  reliance  can  be  placed  on  the  experience  of  Cullen  and 
Gregory  as  to  the  general  effects  of  bleeding. 

Dr.  Alison,  however,  contends  that  blood-letting,  to  be  useful  in  pneumonia, 
should  be  practised  during  the  first  three  days,  and  that,  if  certain  characteristic 
symptoms  are  present,  it  is  not  safe  to  dispense  with  it.  On  this  point  I  have  only 
to  remark,  that  the  records  of  the  Royal  Infirmary,  during  the  period  when  blood- 
letting was  largely  practised,  prove  that  bleeding  was  seldom  had  recourse  to  there 
at  that  early  period,  even  by  Dr.  Alison  himself.  If  it  be  now  urged  that  that 
explains  the  great  mortality,  I  reply,  it  may  have  assisted,  inasmuch  as  the  earlier  a 
bleeding  is  practised,  the  less  dangerous  it  is.  With  regard  to  its  not  being  safe  to 
dispense  with  it,  I  have  also  proved  that  in  all  places  where  pneumonia  has  been 
largely  treated  without  blood-letting,  the  mortality,  so  far  from  being  increased,  has 
invariably  diminished.  In  confirmation  of  this  important  result  of  modern  expe- 
lience,  I  may  cite  a  passage  from  a  letter  I  received  from  Dr.  Arthur  Mitchell,  dated 
Yienna,  April  2d,  1857,  in  answer  to  one  of  mine,  requesting  him  to  furnish  me  with 
the  conclusions  of  tlie  Yiennese  physicians.  He  says — "  I  have  met  no  man  here 
who  will  entertain  for  a  moment  the  idea  that  the  change  in  the  treatment  of  pneu- 
monia has  resulted  from  any  change  in  its  type.  They  say  that  when  physicians 
became  more  expert  in  the  physical  examination  of  pulmonary  disease,  they  found 
that  bleeding  did  not  affect,  in  a  favourable  manner,  tlie  real  progress  of  the  disease, 
and  therefore  they  were  led  to  discontinue  it.  They  all  seem  to  be  of  opinion,  how- 
ever, that  although  there  is,  as  the  resnlt  of  this  change,  a  dimiimtion  of  the  mortality, 
it  is  not  very  great,  but  that  the  recoveries  are  quicker,  and  much  more  satisfactory." 
— (See  also  Dr.  Mitchell's  paper  on  tlie  Statistics  of  Pneumonia  in  Yienna,  Edinburgh 
Medical  Journal,  November,  1857.)  No  better  proof  could  be  given  of  the  influence 
of  modern  diagnosis  on  the  treatment  of  disease. 


THE  BLOODLETTING  CONTROVERSY  OF  1857-8.     279 

I  beg,  therefore,  again  to  repeat,  that  'Hhe  real  tests  of  successful  practice  are  not 
to  be  sought  for  in  the  relief  of  symptoms,  but  in  the  removal  of  the  disease ;  and 
that  that  treatment  will  be  best  which,  cateris  paribus,  is  followed  by  fewest  deaths, 
and  leads  to  recovery  in  the  shortest  time."     See  p.  270. 

Dr.  Alison  seems  to  suppose  tliat  my  observations  were  made  principally  on  the 
dead  body.  But,  in  fact,  they  have  been  made  on  the  transparent  parts  of  livuig 
animals,  as  well  as  on  patients  labouring  under  inflammation ;  and  all  the  phenomena 
observed  in  them  I  have  foond  perfectly  consistent  with  what  was  discoverable 
after  death.  Neither  have  I  "ever  asserted  that  exudation  of  liquor  sanguinis,  in 
order  to  constitute  inflanunation,  must  be  visible  to  the  naked  eye.  On  the  contrary, 
I  have  always  maintained  that  those  who  have  not  studied  this  morbid  process  with 
the  aid  of  high  magnifying  powers,  can  know  very  little  of  it,  inasmuch  as  all  the 
primary  changes  are  invisible  to  unassisted  sight. 

But  the  question  is  not  hotv  a  doctrine  is  arrived  at,  but  whether  that  doctrine  be 
true  and  consistent  with  all  known  facts?  On  this  point  Dr.  Alison  argues  that 
inflammation  is  not,  as  I  have  defined  it,  viz.,  "  a  change  in  a  part  characterised  by  the 
exudation  of  lymph  through  the  walls  of  the  minute  vessels,  resulting  from  changes 
more  or  less  well  marked  in  tlie  nervous,  vascular,  sanguineous,  and  parenchymatous 
elements  of  that  part,"  p.  253.  He  adheres  to  his  former  statement,  viz.,  that  it  is 
"the  tendency  always  observed,  even  when  these  changes  have  been  of  short  dura- 
tion, to  eftusion  from  the  blood-vessels  of  some  new  products,  speedily  assuming,  in 
most  instances,  the  form  either  of  coagulable  lymph  or  pus,"  etc.  The  difference 
between  us,  then,  is  this,  that  whilst  I  call  active  congestion  plus  exudation— inflam- 
mation, he  says  it  is  active  congestion  _^Zm.!.- a  tendency  or  nisus  to  exudation.  But 
how,  in  any  given  case  or  group  of  cases,  this  '•  tendency  "  to  a  certain  act  can  be 
separated  from  the  act  itself,  or  how,  if  it  can,  it  is  to  be  recognised  in  the  living 
bod}^  so  as  to  constitute  a  foundation  for  practice.  Dr.  Alison  has  not  informed  us. 
It  is  evidently  an  assumption  which,  even  were  it  true,  could  never  lead  to  any  ad- 
vancement in  our  knowledge,  or  improve  our  treatment.  For,  if  it  be  affirmed  that 
congestion,  in  any  given  case,  presents  a  tendency  to  exudation ;  and  if  on  bleeding 
no' exudation  follows,  how  is  it  possible  to  know  whether  the  tendency  was  pre- 
sent ?  But  when,  as  most  frequently  happens,  exudation  occurs,  and  continues  to 
spread  notwithstanding  bleeding,  it  is  then  only  we  have  any  proof  that  such  ten- 
dency existed,  together  with  the  certamty  that  in  all  such  cases  the  remedy  has 
failed  to  fulfil  its  supposed  function. 

This  assumption  of  what  is  the  tendency  of  morbid  lesions  prevails  largely  in  the 
writings  of  medical  men,  who  assert  that  a  certain  disease,  of  tiie  nature  of  which 
they  often  know  nothing,  has  a  tendency  to  destroy  texture,  and  kill ;  and  that  in 
some  cases  (as  phthisis)  remedies  are  useless  in  arresting  it,  whilst  in  others  (as 
pneumonia)  their  application  cuts  it  short.  I  have  long  maintained,  and  this  seems 
now  to  be  generally  admitted,  that  the  notion  of  the  necessary  fatal  character  of 
phthisis  was  erroneous,  and  that  it  can  be  arrested  by  art,*  while,  in  the  present 
work,  I  contend  that  pneumonia  is  by  no  means  a  fatal  disease  in  sound  constitu- 
tions, and  cannot  be  cut  short.  This  last  proposition  I  endeavour  to  prove  by  esta- 
blishing three  series  of  facts,  viz. — 1st,  That  when  the  tendency  to  inflammation 
was  generally  attempted  to  be  checked  by  antiphlogistics,  there  was  a  great  mor- 
tality (1  case  in  3) ;  2d,  That  a  pneumonia,  when  established  in  sound  constitutions, 
runs  through  its  whole  course,  including  exudation  of  lymph  and  suppuration,  with- 
out any  destruction  of  tissue  at  aU ;  and  3d,  That  when  a  treatment  is  adopted  to 
favour  these  processes  instead  of  trying  to  check  them  or  cut  them  short,  the  former 

♦  On  "  Pulmonary  Tuberculosis,"  8vo,  1S53. 


280  PRINCIPLES   OF   MEDICINE. 

great  mortality  of  1  case  in  3  is  diminished  to  1  case  in  26.  These  facts  appear  to 
me  irreconcileable  with  the  opinions  and  statements  put  forth  by  Dr.  Ahson. 

With  regard  to  what  Dr.  Alison  calls  the  ''  ingenious  speculation  "  contained  in 
my  third  proposition ;  it  is  satisfactory  to  me  to  observe  that  he  agrees  with  it. 
But  this  so-called  speculation  is,  in  fact,  an  attempt  to  show  that  the  mechanical 
principles  which  have  hitherto  guided  practitioners  in  their  attempts  to  cut  short 
internal  inflammations  by  bleeding,  are  erroneous,  and  not  in  harmony  with  the 
present  advanced  state  of  pathology.  In  other  words,  my  third  proposition  (p.  259, 
tt  seq.)  points  out  that  the  preliminary,  essential,  and  resulting  changes  of  this 
nrorbid  process,  are  essentially  vital  in  their  nature,  and  require,  for  their  perfect 
and  healthful  performance,  that  the  vital  force  of  the  economy,  so  far  from  being 
depressed,  ought  to  be  maintained,  and,  if  necessary,  supported.  If!  then,  so  acute 
a  thinker  as  Dr.  Alison  has  detected  no  fallacy  in  my  reasoning,  I  may  be  pardoned 
for  considering  this  proposition  as  having  been  clearly  demonstrated. 

In  a  discu-ssion  of  this  kind,  it  would  be  easy  to  meet  opinion  with  opinioni 
assertion  with  assertion,  and  case  with  case  ;  but  I  decline  to  do  so,  because  such  a 
mode  of  procedure  cannot,  under  existing  circumstances,  lead  to  a  solution  of  the 
questions  at  issue.  My  object  has  been  to  furnish  a  contribution  towards  the  settle- 
ment of  an  important  point  for  practice.  This  I  have  done,  1st,  By  showing  how 
the  modern  views  of  physiology  and  pathology  have  superseded  the  doctrines  which 
formerly  prevailed;  and  2d,  How  an  improved  practice  has  of  late  years  taken  place, 
and  brought  about  diminished  mortality,  and  more  rapid  convalescence  in  pneumonia. 

If  what  has  previously  been  stated  fails  to  convince,  a  mere  repetition  of  the  facts 
and  arguments  advanced  will  not  do  so,  and  we  must  w^ait  for  further  results. 
Hence,  it  is  not  my  purpose  to  follow  Dr.  Alison  into  what  may  be  the  proper 
practice  in  many  diseases  he  has  alluded  to.  Neither  is  it  necessary  to  enter  mto 
a  lengthened  refutation  of  the  idea,  that  the  natural  progress  of  an  inflammation  is 
like  the  burning  of  a  house,  nor  of  the  application  of  Archbishop  Whately's  remarks 
on  the  action  of  fire-engines,  to  the  modus  operandi  of  blood-letting.  I  would 
only  remark  how  curious  it  is  that  now,  as  in  ancient  times,  analogies  should  be 
drawn  between  blazing  buildings,  and  that  morbid  process  unfortunately  named  from 
the  Latin  word  injiammo.  To  suppose  that  inflammation  has  any  relation  to  burn- 
ing with  fire,  is  about  as  reasonable  as  to  imagine  that  a  growing  tree  or  animal  is 
being  consumed. 

In  a  subsequent  communication  inserted  in  the  same  Journal  for  October,  1857, 
Dr.  Alison  says : — "  I  believe  it  to  be  a  matter  of  real  practical  importance,  that 
practitioners  in  all  parts  of  the  world  should  make  up  their  minds  without  delay  as 
to  the  question  whether  or  not  there  is  sufficient  evidence  of  such  changes  of  type  in 
inflammatory  diseases,  as  are  described  in  several  of  the  inclo.sed  extracts  of  letters 
with  which  I  have  lately  been  honoured — being  part  of  the  general  dispensations  of 
Providence  as  to  those  diseases,  and,  as  far  as  we  yet  know,  an  ultimate  fact  in  their 
history."  But  on  careful  perusal  of  the  letters  from  various  practitioners,  published 
with  that  paper,  I  find,  it  is  true,  strong  opinions  stating  that  the  iyge  of  inflamma- 
tions has  changed,  together  with  some  cases  which  have  recovered  after  large  bleed- 
ings, but  not  one  fact  or  argument  to  support  the  doctrine  now  advanced  by  Dr.  Ali- 
son, that  such  change  of  type  is  an  ultimate  fact  or  law  in  the  history  of  inflamma- 
tions. Surely  a  conclusion  of  such  importance  ought  to  be  based  on  something  more 
positive  than  the  fluctuating  opinions  of  medical  practitioners,  however  eminent 
they  may  be.  Experience  alone  is  exceedingly  fallacious,  for  there  is  such  a  thing  as 
experience  in  wrong  as  well  as  in  right ;  and  notwithstanding  my  great  respect  for 
the  originator  of  this  doctrine,  I  think  it  would  not  be  becoming  in  us,  with  due  re- 


THE  BLOODLETTING  CONTROVERSY  OF  1857-8.     281 

gard  to  the  interests  of  science,  to  yield  to  tlie  authority  of  distinguished  practition- 
ers of  the  art,  unless  they  can  show  that  their  theory,  like  every  other  that  is  really 
correct,  is  consistent  with  all  known  facts.  To  this  test  every  theory  must  be  put, 
from  whatever  high  authority  it  may  originate. 

Now,  at  p.  255,  et  seq.,  in  Proposition  2,  I  have  pointed  out  that  we  have  no  facts 
to  show  that  the  pulse  and  general  vigour  of  the  constitution  have  undergone  any 
change  for  the  worse  among  mankind.  It  so  happens  that  there  is  no  subject  in  all 
physiology  with  regard  to  which  we  possess  more  elaborate  and  more  exact  infor- 
mation than  we  do  concerning  the  pulse.  Hales  published  a  remarkable  series  of 
experiments,  in  reference  to  the  static  force  of  the  pulse,  in  1731,  and  similar  obser- 
vations made  by  Poiseulle  in  1828,  by  Valentin  in  1844,  by  Ludwig  in  1847,  and  by 
Vierrordt  .so  late  as  1855,  show  that  no  great  variation  has  taken  place  during  127 
years.  "What  proof  has  been  advanced  by  the  supporters  of  change  of  type  to  show 
that  it  has  ?     Certainly  none  whatever. 

As  to  the  vigour  of  the  human  constitution,  the  theor}',  if  it  means  anything, 
proceeds  upon  the  supposition,  that  when  a  man  of  average  strength  now-a-days  is 
seized  with  mflammation,  he  presents  all  the  symptoms  that  used  to  be  observed  in 
a  weak  one.  This  is  asserting  that  the  human  race  has  so  degenerated  within  the 
last  twenty  years,  that  the  lowering  treatment  which  formerly  was  beneficial  is  now 
injurious.  But  so  far  is  this  notion  from  being  supported  by  facts,  that  it  might 
easily  be  shown  that  men  in  these  countries  are  now  more  vigorous,  better  fed, 
clothed,  and  housed,  and  that  human  life  is  more  valuable  than  it  was  formerly. 
Mere  opinion,  however,  could  never  establish  one  doctrine  or  the  other.  Some  have 
even  gone  so  far  as  to  attempt  an  explanation  of  the  supposititious  fact,  thinking 
that  the  use  of  potatoes,  of  tea,  or  the  introduction  of  railways,  has  something  to  do 
with  it.  Dr.  Watson  is  of  opinion  that  it  is  attributable  to  the  epidemics  of  cholera, 
which  "  leave  traces  of  their  operation  on  the  health  and  vitality  of  a  community, 
long  after  they  have  ceased  to  prevail  as  epidemics."  (Practice  of  Physic,  4th 
edition,  p.  97.)  Mr.  Robertson  of  Manchester  is  satisfied,  from  experience,  that  it  is 
since  the  boil  epidemic  appeared  that  the  change  has  taken  place  (Edin.  Med.  Jour- 
nal, Oct.  1857,  p.  299).  Surely  it  would  be  weU,  before  speculating  as  to  causes, 
to  determine,  in  the  first  place,  whether  the  alleged  change  in  pulse  and  type  has 
taken  place  at  all.  How  often  do  our  senses  deceive  us,  when  objects  are  at  hand ! 
how  little  can  they  be  depended  on  when  it  is  simply  a.«serted  by  this  or  that  prac- 
titioner, that  a  pulse  was  stronger  twenty  years  ago  than  it  is  now !  Yet  we  have 
no  further  evidence  tlian  this  advanced  by  the  supporters  of  a  theon,%  which  claims 
for  its  fundamental  fact  a  diniiui.shed  vital  force  in  the  heart  and  pulse  of  man  and 
animals,  to  explain  a  change  of  medical  practice. 

Indeed,  it  should  not  be  forgotten  that  veterinary  surgeons  have  also  ceased  to 
bleed  in  inflammation.  Have  anunals  then  also  degenerated,  and  is  the  type  of 
organic  diseases  changed  in  them  ?     This  question  was  answered  by  a  farmer,  in 

the  Scotsman  newspaper  for  October  22d,  1857,  as  follows: — "Dr. ,  in  his 

communication  of  the  15th  ultimo,  makes  the  startling  announcement  that  physical 
and  moral  decay  are  undermining  the  vigour  and  energy  which  formerly  charac- 
terised the  inhabitants  of  this  country;  and,  as  a  proof  of  the  assertion  that  physical 
decay  was  at  work,  states  that  the  free  blood-lettings  in  the  case  of  inflammatory 
diseases,  which  formerly  was  the  practice,  cannot  now  be  resorted  to  with  benefit. 
I  am  neither  a  medical  man  nor  a  veterinary  surgeon,  but  I  own  a  few  horses,  and 
other  animals  of  the  cattle  and  sheep  tribes.  How  comes  it,  then,  that  some  tliirty 
years  ago,  when  any  of  these  animals  were  seized  with  any  inflammatory  aflection, 
however  slight,  that  profuse  bleeding  was  resorted  to,  and  with  advantage  ?  Now, 
however,  the  veterinary  surgeon  never  bleeds  save  on  very  rare  occasions ;  at  the 


^ 


282  PRINCIPLES   OF   MEDICINE. 

same  time  telling  me  that  the  animal  cannot  afford  to  lose  any  blood,  and  this  treat- 
ment is  equalh-  successful  as  the  former  was.     On  Dr. 's  principle,  then,  our 

horses  should  be  physicall)-  inferior  to  what  they  were  thirty  j-ears  ago.  Is  this  the 
fact  ?  My  experience  says  they  are  at  least  equal  in  physical  power,  energy,  and 
vigour  to  what  they  were  then.  Do  the  horses  of  Glasgow  or  Edinburgh  draw 
lighter  loads ;  do  our  carts  convey  less  grain  to  market ;  do  we  plough  with  a 
shallower  furrow ;  do  our  race-horses  run  at  a  slower  pace  ?  The  general  answer 
win  be.  they  do  not.  For  instance,  the  last  Derby  was  one  of  the  quickest-run  races 
on  record.  How  does  the  doctor  account  for  this  on  his  theory  ?"'  I  need  scarcely 
say  that  the  doctor  has  made  no  rejoinder. 

If  it  had  been  contended  that  the  greater  vigour  of  the  population  had  so  influ- 
enced the  symptoms  as  to  have  rendered  dyspnoea,  quick  pulse,  and  other  pheno- 
mena of  weakness  less  apparent,  it  would  have  been  more  accordant  with  pathology. 
But  as  the  former  therapeutical  rule  was,  that  bleeding  was  demanded  only  in  ca.ses 
of  robust  and  strong  constitutions,  such  a  doctrine  would  have  been  inconsistent. 
In  the  meantime  it  seems  to  me  apparent  that  there  are  no  facts  upon  which  the 
theory  of  change  of  type  in  inflammations  can  be  based,  as  in  any  way  explanatory 
of  the  change  in  our  treatment. 

Dr.  Watson  of  London,  in  a  recent  edition  of  his  work  on  The  Principles  and 
Practice  of  Physic,  has  added  to  the  chapter  on  inflammation  a  note,  in  which  he 
alludes  to  my  remarks.  He  argues  that  Cullen  and  Gregory  not  being  certain  as  to 
the  exact  seat  of  the  inflammation,  is  nothing  to  the  purpose,  if  they  were  compe- 
tent to  ascertain  that  inflammation  was  going  on  somewhere  in  the  chest.  But  that 
they  could  even  do  this  with  certainty,  is  very  doubtful.  Besides,  I  argue  against 
the  general  opinions  of  Cullen  and  Gregory  as  to  large  bleedings  in  internal  inflam- 
mations, not  only  because  they  were  incapable  of  separating  pneumonia  from  other 
inflammations  of  the  chest,  but  because,  so  far  as  we  are  now  capable  of  determining, 
their  practice  was  a  fatal  one ;  because  those  wlio  have  imitated  it,  and  carefully 
examined  the  results,  have  found  it  to  be  so  (Louis,  Dietl) ;  and  because  all  those 
who  have  abandoned  it  declare,  that  not  only  do  their  cases  get  well  as  soon,  but 
sooner,  when  blood  letting  is  not  practised.  Now,  I  can  find  no  facts  or  arguments 
to  controvert  this  position  among  the  statements  of  my  opponents. 

Again :  "  Who,"  says  Dr.  Watson,  "  treats  knowingly  the  extravasated  products 
of  inflammation  by  general  bleeding  ?"'  The  word  "  knowingly"  here  is  all- 
important,  because  the  fact  is,  Cullen,  Gregory,  and  all  those  who  followed  them, 
did  bleed  largely  after  exudation  had  occurred.  Hence,  very  probably,  the  large 
mortahtj',  and  hence  the  difference  between  the  first  and  second  series  of  Louis' 
cases.  But  our  improved  knowledge  of  diagnosis  having  taught  us  how  to  detect 
such  exudation,  we  now  do  not  bleed  under  circumstances  where  our  predecessors 
did.  This  is  why  I  contend  that  the  change  of  treatment  is  owing  to  an  improved 
diagnosis  rather  than  to  a  change  of  type.  Then,  as  to  pathology.  Dr.  Watson  is 
of  opinion  that  our  knowledge,  arrived  at  by  chemical  and  microscopical  investiga- 
tion, is  not  yet  complete  or  ripe  enough  to  warrant  any  exclusive  reliance  upon  it 
as  a  guide  to  treatment.  But  no  one  has  ever  contended  for  the  exclusiveness  of 
this  or  any  other  mode  of  investigation.  That  pathology,  as  a  science,  has  of  late 
years  made  rapid  strides  in  advance,  cannot  be  denied ;  and  if  so,  why  should  it 
not  do  in  modern  times  what  it  has  done  in  all  times  past,  viz.,  suggest  to -our  minds 
the  reasonableness  or  unreasonableness  of  particular  modes  of  practice  ?  It  is  in 
vain  telling  us  to  adhere  to  the  routine  of  our  forefathers  when  the  principles  which 
guided  them  are  proved  to  be  erroneous.  But  when,  in  addition  to  change  in 
theory,  actual  experience  demonstrates  that  we  are  right,  when  modem  pathology 


THE  BLOODLETTING  CONTROVEESY  OF  1857-8.     283 

and  modern  practice  harmonize  with  and  support  one  another,  then  it  appears  to  me 
that  the  time  has  arrived  for  demonstrating  tlie  errors  of  former  teaching,  as  well  as 
of  past  empirical  observations. 

Dr.  Watson  also  objects  to  statistics,  as  being  inconclusive  and  liable  to  mislead, 
when  applied  to  the  treatment  of  separate  cases  of  disease.  Now,  no  one  is  more 
thoroughly  persuaded  of  the  tallacies  inherent  in  medical  statistics  than  I  am,  and 
no  one  has  more  constantly  pointed  these  out  to  others.  (See  Monthly  Journal  of 
Medical  Science,  October,  18-47.)  But  the  error  of  some  statistics  resides  more  m 
the  jumbling  together  of  difterent  experiences,  and  of  the  cases  of  various  practi- 
tioners, than  in  an  endeavour  by  a  better  method  to  arrive  at  the  results  of  a  par- 
ticular practice  in  the  hands  of  any  one  well-qualified  observer.  Surely  the  statistics 
of  Louis  on  phthisis,  and  on  the  effects  of  bleeding  in  pneumonia,  are  trustworthy, 
as  are  also  those  of  Grisolle  and  Dietl.  And  I  venture  to  affirm  that  my  own  sta- 
tistics of  78  cases  of  pneumonia  may  challenge  the  strictest  inquiry  into  their 
accuracy.  Then,  no  one,  so  far  as  I  am  aware,  uses  or  withholds  any  given  remedy 
merely  because  of  numerical  calculations,  but,  having  seen  occasion  to  try  this  or 
that  practice,  he  determines  its  good  or  bad  effects  by  counting  as  well  as  watching. 
Above  all,  he  should  watch  and  report  on  those  who  die,  as  well  as  on  those  who 
recover  under  a  particular  treatment,  if  he  wish  to  ascertain  its  real  value ;  and 
what  is  this  but  counting  cases  ?  Is  such  observation  not  better  than  arraying 
opinion  against  opinion,  placing  the  vague  statements  of  senior  in  opposition  to  those 
of  junior  practitioner,  or  contrasting  the  scholastic  views  of  London  and  Edinburgh 
with  those  of  Paris  and  Vienna  ?  Thus,  when  it  is  shown  that  of  78  cases  of  pneu- 
monia which  entered  my  clinical  wards,  only  1  in  26  died,  but  that  of  75  similar 
cases  which  entered  the  wards  of  La  Charite  under  M.  Louis,  1  m  3|  died ;  then  I 
think  it  reasonable  to  conclude,  that,  as  in  my  cases  the  vital  processes  were  fur- 
thered and  supported,  whereas  in  those  of  M.  Louis  they  were  diminished  or  sub- 
dued, the  great  mortality  of  1  in  3  was  owing  to  the  treatment,  and  that  such  is  a 
legitimate  apphcation  of  statistics.  When,  moreover,  I  ascertain  that  this  conclusion 
is  borne  out  by  the  experience  of  other  hospital  physicians,  then  the  conviction  is 
forced  on  my  mind,  that  the  number  of  deaths  from  pneumonia  is  lessened  in  modern 
times  in  consequence  of  our  change  of  practice,  rather  than  of  a  change  of  type  in 
the  disease. 

I  cannot  agree  with  Dr.  Watson  that  the  whole  matter  in  dispute  is  virtually  con- 
ceded, because  I  admit  that  symptoms  are  relieved  by  blood-letting.  A  rigorous  anti- 
phlogistic treatment  was  formerly  put  in  force  with  a  view  of  cutting  short  the  disease. 
Now,  this  object  I  contend  is  not  attauied ;  but,  on  the  contrary,  the  real  disorder 
is  prolonged,  and  rendered  proportionally  more  fatal  by  that  practice.  On  the  other 
hand,  small  bleedings,  which  do  not  lower  the  vital  strength,  are  sufficient  to  relieve 
urgent  symptoms ;  it  being  recognised  that  the  lesion  otherwise  is  to  be  assisted  in 
its  natural  progress.  Surely  this  is  a  complete  revolution  in  the  principles,  as  well 
as  in  the  practice,  referable  to  internal  inflammations.  But  that  we  should  "  so  bleed 
as  to  secure  the  advantages  of  the  remedy,  and  avoid  its  disadvantages,"  is  a  happy 
practical  conclusion  of  Dr.  Watson's,  in  which  all  parties  must  concur. 

Dr.  Bell  of  Glasgow,  in  the  Glasijoiv  Medical  Journal,  July  1857,  has  done  me  the 
honour  of  criticising  my  opinions  and  facts  at  great  length,  and  has  endeavoured  to 
show  that  not  only  is  my  theory  erroneous,  and  practice  bad,  but  that  even  my 
phraseology  is  illogical  and  unmeaning.  And  yet  a  careful  perusal  of  Dr.  Bell's  paper 
will  only  serve,  I  think,  to  establish  that  he  confessedly  does  not  comprehend  modern 
pathology;  that  his  cases  support  all  I  have  stated  as  to  treatment;  and  that  he 
seems  to  understand  my  meaning  tolerably  well.     Of  27  cases  of  acute  pneumonia 


284  PRINCIPLES    OF   MEDICINE. 

under  his  care  in  the  Glasgow  Roj^al  Infirmary,  admitted  in  the  early  stage,  he 
says,  23  were  sthenic  and  only  4  asthenic.  These  were  bled,  mercurialized,  purged, 
and  blistered,  according  to  ancient  usage,  except  that  the  amount  of  blood  taken 
never  exceeded  20  oz,,  the  average  quantity  benig  14  oz.  All  these  cases  got  well. 
The  duration  of  the  treatment  was  eighteen  days.  Now,  if  these  cases  were  really 
sthenic  in  character,  and  if  they  were  cured  by  the  means  employed,  then  Dr.  Bell 
is  the  strongest  opponent  of  Dr.  Alison's  views  that  has  j^et  appeared.  But  the 
fact  is,  all  these  cases  entered  the  infirmarj'  very  early  in  the  disease,  before 
hepatization  was  far  advanced,  and  would,  I  am  satisfied,  have  got  well  nnich  sooner 
than  in  eighteen  days,  had  a  lowering  treatment  not  been  employed.  Besides,  the 
very  moderate  bleedings  practised  at  tlie  commencement  of  the  disease,  cannot  be 
considered  as  an  antiphlogistic,  but  rather  as  a  palliative  remedy.  They  did  not 
diminish  to  any  serious  extent  the  vital  power  of  the  econom}^,  hence  the  patients 
ultimately  recovered. 

The  mischief  of  Dr.  Bell's  practice,  however,  will  be  best  understood  by  quoting 
his  general  results,  which  are,  out  of  71  cases,  4  deaths,  although  the  complicated 
cases,  with  phthisis  and  albuminuria,  are  not  included.  Of  the  cases  in  which 
hepatization  existed  on  admission,  he  tells  us  that  the  average  time  they  were  in 
the  hospital  was  47  days,  and  the  average  time  they  were  under  treatment  was  22 
days.  "  This  lengtliened  duration,"  he  observes,  "  affords  a  startling  commentary  on 
the  bad  effects  which  may  he  expected  to  follow  the  natural  plan  of  treatment  recom- 
mended by  Dr.  Bennett."  Startling  indeed.  An  average  treatment  of  22  days,  and 
a  lingering  convalescence  of  47  days,  with  a  mortality  of  four,  after  the  exclusion 
of  complicated  cases,  will  not  well  contrast  with  my  average  duration  of  14^  days, 
and  with  the  fact  that  the  only  three  fatal  cases  I  have  had  were  just  of  that  kind 
that  Dr.  Bell  carefully  excludes  from  his  list.  Had  I  followed  Dr.  Bell's  plan,  there 
would  have  been  ncf  mortality  among  my  cases  at  all.  I  have  also  calculated  the 
average  number  of  daj's  my  uncomplicated  cases  were  in  the  hospital,  and  find  it  to 
be  24|  days,  including  the  cases  of  double  pneumonia. 

Dr.  Bell  has  also  endeavoured  to  throw  doubts  upon  the  accuracy  of  my  state- 
ments, and  has  demanded  an  explanation  of  his  own  erroneous  conclusions  with 
regard  to  them.  This  I  shall  give.  On  looking  over  some  former  cases  on  pneumonia 
published  by  me.  Dr.  Bell  thinks  he  has  discovered  three  fatal  cases  which  are  in- 
cluded in  my  series,  but  not  counted.  But  he  overlooks  the  obvious  fact,  that  the 
first  case  was  not  treated  by  me  at  the  commencement ;  that  it  was  probably  one  of 
phthisis,  a  point,  however,  I  could  not  determine,  because,  as  stated  in  the  commen- 
tary, "  I  had  only  just  then  taken  charge  of  the  wards."  The  second  case  Avas  one 
of  organic  lesion  of  the  heart,  with  Bright's  disease,  and  the  pneumonia  after  death 
was  recent  and  vesicular — that  is,  confined  to  isolated  air  vesicles.  Surely  such  a  case 
is  not  one  to  be  included  among  ordinary  cases  of  acute  pneumonia.  The  third 
was  a  case  of  either  phthisis  or  chronic  pneumonia  of  the  apex,  and  of  course,  there- 
fore, was  not  placed  in  the  list  of  acute  pneumonias.  Hence,  then,  these  three  caseg 
are  not  included  among  my  78  cases.  Again,  Dr.  Bell  fancies  that  the  same  cases 
prove  that  I  have  not  invariably  treated  every  case  of  pneumonia  by  furthering  the 
natural  progress  of  the  disease.  He  is  again  mistaken.  It  is  true  that  in  1849  I  was 
not  so  certain  of  the  uselessness  of  bleeding  as  I  am  now,  and  did  say  of  a  case  bled 
hefore  admission,  early  in  the  disease,  that  the  practice  was  judicious.  I  confess,  also, 
to  having  thought  then,  and  to  having  said,  that  a  large  bleeding  before  exudation 
comes  on,  may  cut  short  its  progress,  etc.  But  I  can  see  nothing  so  contradictory  in 
all  this  as  Dr.  Bell  does.  Neither  has  my  ordering  antiraonials,  and  applying  a  blister 
in  a  few  cases,  ever  amounted  to  an  antiphlogistic  practice,  or  vitiated  the  general 
plan  I  have  described. 


THE   BLOODLETTING   CONTROVERSY   OF    1857-8.  285 

All  the  facts  contained  in  Dr.  Bell's  paper,  therefore,  it  appears  to  me.  fully  bear 
ont  the  correctness  of  the  principles  and  practice  which  I  have  so  long  recommended 
in  the  treatment  of  internal  intiaramations. 

Dr.  Christison,  in  the  Edinhurgh  Mtdical  Journal  for  January  1858,  thinks  that  Dr. 
Alison's  view  is  supported  by  the  changes  which  have  taken  place  in  the  treatment 
of  fevers.  But  I  cannot  see  any  analogy  between  inflammation  of  a  part  which 
gives  rise  to  constitutional  disturbance,  and  an  essential  fever  originating  in  the  blood 
from  some  morbid  poison.  I  agree  with  Dr.  Christison  in  thinking  that  we  know 
little  more  of  the  pathology  of  fever  now  than  we  did  forty  years  ago.  But  it  is  very 
different  with  regard  to  inflammation.  The  unknown  and  varying  causes  producing 
epidemics  are  well  illustrated  in  the  case  of  cholera,  which  visits  us  at  uncertain 
periods,  for  reasons  of  which  we  are  profoundly  ignorant.  The  causes  producing 
inflammation  in  a  part  have  always  been  the  same,  and  are  unchangeable.  Unless, 
therefore,  the  non-bleeding  in  fevers  should  have  shaken  the  confidence  of  practi- 
tioners in  the  use  of  blood-letting  as  an  empirical  remedy  in  all  cases,  I  do  not  see 
how  the  treatment  of  constitutional  fever  under  such  different  circumstances  can  cor- 
rectly be  compared  with  that  of  inflammation.  Dr.  Christison,  like  Dr.  Watson, 
points  out  that  I  have  advanced  no  argument  to  show  that  the  febrile  phenomena 
must  always  be  the  same.  But  I  humbly  think  it  is  not  for  me  to  show  that  the 
human  constitution  is  incapable  of  undergoing  alterations.  The  onus  prohandi  must 
be  laid  on  those,  who  assert  that  any  such  change  is  sufficient  to  account  for  the 
remarkable  modifications  which  have  taken  place  in  medical  practice  during  the  last 
twenty  years. 

In  a  continuation  of  his  paper  in  the  July  No.  of  the  same  Journal,  1858,  Dr. 
Christison  strongly  affirms  tiiat  the  change  in  the  amount  of  fever,  and  tlie  strength 
of  the  pulse  accompanying  inflammations,  sufficiently  explains  the  abandonment  of 
bleeding  in  recent  times,  and  that  what  he  misses  in  the  present  character  of  the 
pulse  is  its  incompressibility.  He  contends  that  as  soon  as  the  pulse  acquired  the 
comparatively  soft  and  easily  compressible  character,  medical  men  practised  blood- 
letting with  great  caution.  "But,"  says  Dr.  Christison,  referring  to  his  general 
opinion  of  change  of  type,  "  unfortunately  I  am  not  able  to  refer  to  any  recorded 
facts  in  support  of  this  proposition."  Such  an  admission  appears  to  me  alone  fatal 
to  all  Dr.  Christison's  theories  on  the  subject,  because  numerous  facts  prove  that 
twenty  or  thirty  years  ago  antiphlogistic  remedies  and  blood-letting  were  practised  as 
a  matter  of  course  in  pneumonia,  altogether  independent  of  the  state  of  the  pulse. 
The  question  at  that  time  regulated  by  the  pulse  was  not  the  practice  itself,  but  only 
the  extent  to  which  it  sliould  be  carried.  Besides,  if  Dr.  Christison  could  have  de- 
monstrated that  the  practice  of  which  he  speaks  had  been  a  good  one,  his  memory 
might  have  been  depended  on  as  furnishing  evidence  to  a  certain  extent  of  what  he 
asserts.  But  as  I  have  shown  that  all  authentic  records  of  the  past  prove  blood- 
letting and  antiphlogistics  to  have  been  a  most  fatal  practice,  the  probability  is  that 
the  pulse  was  of  just  the  same  character  then  as  it  is  now. 

Dr.  Easton  of  Glasgow,  in  a  clinical  lecture  published  in  the  Edinhurgh  Medical 
Journal  for  February  1858,  agrees  with  me  as  to  the  impossibility  of  inflammations 
undergoing  any  change  of  type,  and  believes  that  there  is  no  analogy  between  the 
morbid  actions  of  fever  and  inflammation.  At  the  same  time  he  thinks  with  Dr. 
Watson,  "that  there  are  waves  of  time,"  which  influence  organic  diseases.  This 
seems  to  me  rather  contradictory,  because  if  such  waves  of  time  exist,  and  if  they 
modify  inflammations,  this  is  what  Dr.  Alison  understands  by  change  of  type.  He 
impresses  upon  his  pupils  "  the  fad  {?)  that  in  large  towns,  and  more  particularly  in 


286  PRINCIPLES   OF   MEDICINE. 

hospitals,  blood-letting  exercises  an  injurious  effect  on  the  vast  majority  of  the 
cases  of  pneumonia  Avhich  are  now  met  with  in  these  situations ;  while,  on  the  other 
hand,  it  would  be  exceedinglj-  improper  not  to  admit,  that  in  country  districts,  and 
more  particularly  if  the  disease  be  seen  at  the  very  outset,  or  shortlj^  thereafter,  not 
otherwise,  cases  may  be  found  in  which  a  single  blood-letting  will  arrest  the  further 
progress  of  the  disease."  But  where  are  these  cases?  Dr.  Bell  teUs  us  that  even 
in  the  Glasgow  Infirmary,  when  patients  enter  at  an  early  stage,  they  present  a 
sthenic  type,  but  he  has  not  shown  that  one  of  his  cases  was  arrested  by  blood-letting, 
and  admits  that,  although  treated  earlj-,  their  duration  on  an  average  was  eighteen 
days.  I  fear  I  must  be  guilty  of  the  impropriety  (as  Dr.  Easton  seems  to  consider 
it)  of  not  admitting  the  probability  of  finding  such  cases,  as  well  as  of  believing 
that  the  so-called  fact  is  no  fact  at  all.  Dr.  Easton  also  reminds  me  that  exudation 
of  liquor  sanguinis  is  not  necessary  to  constitute  inflammation  of  the  lungs,  and  con- 
tinues :  "  Many  cases  of  that  disease  are  met  with,  while  yet  in  the  primary  stage  of 
engorgement ;  and  it  ought  to  be  our  duty,  by  appropriate  treatment — including  even 
blood-letting  if  necessary — to  prevent  that  very  exudation  which,  without  reason, 
withovit  proof,  and  in  defiance  of  all  experience,  he  (Dr.  B  )  assumes  to  be  the  sine 
qud  non  of  the  malady."  This  is  only  a  repetition  of  the  argument  of  Dr.  Alison, 
and  is  only  adding  assertion  to  assertion,  and  opinion  to  opinion  Admitting  that 
cases  in  the  stage  of  primary  engorgement  are  met  with,  I  ask  both  physicians,  how 
are  these  to  be  recognised  as  cases  of  pneumonia?  how  are  the  constitutional  symp- 
toms to  be  separated  from  those  of  fever  ?  and  how,  without  exudation,  are  we  to 
be  satisfied  that  a  blood-letting  has  cut  short  an  inflammation  ?  When  these  ques- 
tions are  answered,  it  will  be  time  enough  to  say  that  my  attempt  to  render  the 
meaning  of  inflammation  definite  instead  of  vague,  and  to  distinguish  it  from  mere 
congestion  or  engorgement  of  the  blood-vessels,  is  without  reason,  without  proof,  and 
in  defiance  of  all  experience. 

Dr.  Henry  Kennedj'  of  Dublin  has  inserted  a  paper  in  the  Edinburgh  Medical 
Journal  for  January  1859,  in  which  I  have  failed  to  detect  any  facts  bearing  on  the 
subject,  or  any  arguments  which  have  not  been  previously  answered.  He  saj's  that 
changes  in  the  "epidemic  constitution"  of  animal  and  vegetable  life  hav^e  existed 
from  the  earliest  periods  of  recorded  time  (p.  625).  If  so,  they  must  have  influenced 
the  phenomena  of  inflammation  formerly  as  they  do  now,  and  cannot,  therefore,  ex- 
plain the  present  unanimity  of  opinion  with  regard  to  the  inutility  of  antiphlogistics. 
Dr.  Kennedy  accuses  me  of  being  desirous  to  reduce  inflammation  to  a  uniform  stand- 
ard, and  of  adhering  to  a  routine  of  treatment ;  whereas  he  says  inflammation  may 
vary  in  six  persons  affected  with  it  and  each  case  may  require  a  different  treatment. 
Here  also  I  can  discover  no  argument  bearing  on  the  question  at  issue,  for  the  same 
circumstances  which  induce  the  variations  in  six  persons  now,  were  in  operation  when 
Cullen  and  Gregory  flourished;  and  if  their  treatment  was  successful  then,  why  is  it 
not  so  now?  Dr.  Kennedy  deals  largely  in  a.?sertion;  but  his  paper  is  destitute  of 
all  proofj  and  what  he  saj-s  only  amounts  to  his  agreeing  in  opinion  with  Dr.s.  Alison, 
Watson,  and  others.  He  indeed  enters  into  an  argument  (p.  632)  to  show  that  na- 
ture does  not  alwa3-s  cure  a  pneumonia.  But  I  have  never  said  that  it  did.  On  the 
contrary,  while  my  Proposition  4  maintains  that  medical  art  cannot  cut  short  an 
inflammation,  it  maintains  that  our  efforts  are  most  valuable  in  conducting  it  to  a 
favourable  termination.  In  this  and  many  other  points  of  his  essay  Dr.  Kennedy  has 
apparently  so  completely  misunderstood  my  remarks,  that  it  will  be  sufficient  for  me, 
I  hope,  to  call  his  attention  to  the  further  observations  contained  in  this  lengthy 
note  to  the  original  paper.  In  replj^  to  what  Dr.  Kennedy  says  concerning  statistics, 
routine,    mercur}-,  etc.  (p.  G37,  ei  seq.),  I  would  refer  him  to  the   cases   publicly 


THE   BLOODLETTING   CONTROVERSY   OF    1857-8.  287 

treated  by  me  in  the  Royal  Infirmary,  of  which  he  has  taken  no  notice,  and  several 
of  which  are  recorded  in  this  work.  (See  Pneumonia.)  His  confident  conviction 
that  my  treatment  "  will  be  found  inert,  and  fail  in  everything  but  loss  of  time,"  is 
sufficiently  answered  by  the  amount  of  success  and  rapidity  of  cure  which  tliat  treat- 
ment has  been  proved  to  occasion,  as  described  p.  274. 

But  whilst  several  eminent  men  have  thus  opposed  the  principles  of  practice 
contained  in  this  work,  I  am  happy  to  know  that  many  able  and  distinguished  physi- 
cians agree  with  me  essentially  in  the  views  I  have  taken  on  this  important  practical 
subject.  Among  these,  Dr.  Todd  of  London  has  long  successfully  practised  on 
principles  which,  if  not  identical,  are  closely  allied  to  them. 

In  a  recent  paper  of  his,  inserted  in  the  1st  and  2nd  Nos.  of  Beak's  Archives  of 
Medicine,  1857-8,  there  occur  the  following  passages: — "Internal  inflammations  are 
cured  not  by  the  ingesta  administered,  nor  by  the  egesta  promoted  by  the  drugs  of 
the  physician,  but  by  a  natural  process  as  distinct  and  definite  as  that  process  itself 
of  abnormal  nutrition  to  which  we  give  the  name  of  inflammation.  What  we  may 
do  by  our  interference  may  either  aid,  promote,  and  even  accelerate,  this  natural 
tendency  to  get  well :  or  it  may  very  seriously  impair  and  retard,  and  even  altogether 
stop,  that  salutary  process. 

"  It:  then,  this  view  of  the  nature  of  the  means  by  which  inflammation  is  resolved 
in  internal  organs  be  correct,  it  is  not  imreasonable  to  assume  that  a  very  depressed 
state  of  vital  power  is  unfavourable  to  the  healing  process.  Indeed,  if  you  watch 
those  cases  in  which  nothing  at  all  has  been  done,  or  in  which  nothing  has  been 
done  to  lower  the  vital  powers,  you  will  find  that  the  mere  inflammatory  process 
itself,  especially  in  an  organ  so  important  as  the  lung,  depresses  the  strength  of  the 
patient  each  day  more  and  more. 

"  You  will  perceive,  then,  that  according  to  these  views,  there  are  strong  d  j>riori 
reasons  in  favour  of  the  policy  of  upholding  our  patients,  even  in  the  earliest  stages 
of  acute  disease,  by  such  food  as  may  be  best  suited  to  their  digestive  organs,  such 
as  is  most  readily  assimilated,  and  calls  for  the  least  effort,  the  smallest  expenditure 
of  vital  force,  for  its  primary  digestion.  Nutritive  matter  in  a  state  of  solution — 
broths,  soups,  farinaceous  matters — answers  this  pui-pose  best,  and  also  alcohol, 
which  is  directly  absorbed  without  any  previous  change,  and  tends  to  feed  the  calo- 
rifacient  process,  and  to  diminish  the  waste  of  tissues  which  would  necessarily 
follow  in  order  to  maintain  it. 

"Inflammation  is  a  deranged  nutrition.  Like  the  normal  nutrition,  it  involves 
supply  and  waste,  and  as  the  latter  is  considerable,  the  former  will  be  proportionably 
so.  The  tendency  in  inflammation  is  to  the  more  or  less  rapid  formation  of  abnormal 
products,  such  as  lymph  and  pus;  and  the  supplies  for  these  formations  must  be 
drawn  from  the  blood,  or  from  the  tissues,  in  both  cases  with  the  eSect  of  more  or 
less  exhaustion  of  the  vital  force,  with  more  or  less  extensive  organic  disintegration. 
The  active  chemical  process  which  accompanies  all  these  changes,  engenders  the 
great  heat  of  the  inflamed  part. 

"  The  more  this  process  of  inflammation  draws  upon  the  blood  the  greater  will  be 
the  exhaustion  of  vital  force,  and  the  more  the  whole  frame  will  suffer ;  the  more  it 
feeds  on  the  tissues,  the  greater  wiU  be  the  difficulty  of  the  reparative  process.  Is 
it  not.  then,  important  that  adequate  supplies  should  be  conveyed  to  this  proces.=, 
abnormal  though  it  be?  And  is  it  not  likely  that  the  most  appropriate  supplies  may 
be  conveyed  to  it  through  the  blood,  so  that  the  waste  of  tissue  may  be  stopped,  and 
the  tendency  to  abnormal  formations  be  checked,  at  least  from  that  direction  ? 

"  And  thi.s.  in  truth,  seems  to  me  to  be  but  the  plain  and  simple  fact ; — you  must 
feed  inflammations  as  vou  would  other  active  vital  processes.     You  must,  that  is, 


1 


288  PRIXCIPLES   OF   MEDICINE. 

feed  them  to  prevent  them  from  extending  to,  and  preying  on,  healthy  organic  struc- 
tures, and  committing  great  destruction.  Bear  in  mind,  too,  that  you  cannot  stop 
an  inflammation  so  long  as  the  exciting  cause  of  irritation  is  inherent  in  the  inflamed 
part ;  you  cannot  cure  an  inflamed  eye  so  long  as  the  irritating  particle  of  dust 
remains  adherent  to  it.  It  is  wise  policy,  then,  to  try  and  gain  time,  until  by  anti- 
dotal means,  or  by  elimination,  you  can  get  rid  of  the  local  irritation,  whatever  that 
may  be." 

Dr.  ilarkham,  in  an  able  series  of  communications  in  the  Lancet  for  November  and 
December  1857,  and  in  the  Edinhurgh  Medical  Journal  for  1857-8,  pp.  886,  1058,  not 
only  upholds  them,  but  advances  new  and,  it  seems  to  me,  unanswerable  arguments 
in  their  support. 

The  following  is  a  summary  of  the  more  important  points  insisted  on  by  him: — 

The  hj-pothesis  that  venesection  was  a  right  remedy  in  inflammations  in  former 
days  is  entirely  founded  on  the  supposition  that  the  practice  of  physicians  in  those  ' 
days  was  a  proper  practice ;  but  it  is  impossible  for  us  now  to  arrive  at  any  just 
conclusions  on  this  point ;  they  have  left  us  nothing  but  their  assertions  and  convic- 
tions whereby  to  try  the  value  of  theu-  practice.  This  we  know,  that  their  expe- 
rience quite  differs  from  oiu-s  in  this  particular  of  practice ;  herein  all  ar6  agreed,  and 
those  who  have  faith  in  the  infallible  clear-sightedness  of  our  forefathers,  in  order  to 
reconcile  the  apparent  discrepancy  which  thus  arises  between  the  practice  of  past 
and  present  days,  call  in  the  agency  of  a  change-of-type  theory.  Thus,  theory  is 
called  in  to  support  hypothesis ;  and  as  may  be  readily  anticipated,  the  whole  fabric 
melts  away  under  the  touch  of  modern  medical  argumentation. 

Clinical  medicine  (as  now  understood)  is  entirely  a  modern  invention.  Our  fore- 
fathers bled  in  pneumonia,  that  is,  for  everything  that  occurred  wrong  and  produced 
inflammatory  symptoms  within  the  thorax :  they  bled  in  tubercular  disease,  m  pneu- 
monia, in  heart  diseases  of  all  sorts,  in  rheumatism  of  the  thoracic  muscles,  etc.,  etc , 
and  from  thence  they  concluded  that  venesection  was  good  in  pneumonia,  and  we 
are  called  upon  to  endorse  and  accept  their  sentiments.  Now,  it  is  a  fact  beyond 
all  cavil,  and  worthy  of  note,  that  the  whole  profession  (for  individuals  have  diflered 
in  all  ages  about  bleeding)  began  to  change  their  opinions  about  venesection,  at  the 
very  time  that  they  began  to  study  medicme  by  the  lights  of  modern  investigation, 
viz.  modern  pathology  and  diagnosis.  The  reason  is  plain.  Every  well-kept  record 
of  diseases  showed  the  injury  done  by  large  bleedings  in  inflammations ;  and,  doubt- 
less, the  accumulated  facts,  duly  reasoned  on,  at  length  brought  physicians  to  hesitate 
in  the  practice,  and  at  last  to  denounce  it. 

The  change  of  type  theory  rests  wholly  on  a  belief  m  the  testimony  of  the  expe- 
rience of  skilled  physicians  in  past  days.  These  men  were  strong-minded  men,  full 
of  sense,  and  their  well-educated  senses,  we  are  told,  were  little  likely  to  have  their 
judgment  misled;  they  bled,  saw  the  excellent  results  of  bleeding,  and  justly  con- 
cluded that  no  remedy  was  so  admirable  m  inflammation ;  theref(/re  the  diseases  for 
which  they  bled  undoubtedly  demanded  bleeding.  We  bleed  not  as  they,  tlierefore 
disease  has  changed  its  tj-pe.  True,  they  lauded  venesection  to  the  skies,  but  they 
have  left  us  no  records,  whereby  we  may  judge  of  the  correctness  of  then:  opinions. 
Others,  however,  who  loved  and  admired  bleeding  equally  as  they  did,  and  whose 
authority,  none  will  deny,  equals  the  best  of  theirs,  have  put  on  record  the  data 
whereon  their  love  of  the  practice  was  based,  and  we  can  judge  them.  Had  Andral, 
like  Cullen  and  Gregory,  left  nothing  recorded  but  his  unbounded  eulogy  of  venesec- 
tion in  pneumonia,  he  also,  like  them,  would  have  been  quoted  as  an  authoritative 
proof  of  the  efficacy  of  it ;  but  he  has  given  us  the  data,  whereby  we  may  test  the 
value  of  his  assertions,  and  we  find  them  utterly  condemnatory  of  his  practice.     Can 


THE   BLOODLETTIXG   COXTEOVEEST   OF   1857-8.  289 

any  one  doubt,  that  the  practice  of  those  other  worthies  would  stand  equally  con- 
demned, could  it  he  brought  in  a  like  manner  to  the  bar  of  modern  criticism  ?  If 
Andral  was  deceived,  why  not  they?  Andral  teUs  us,  that  the  experience  of  ages 
has  taught  us  to  be  more  prodigal  in  the  taking  of  blood  in  pneumonia  than  in  any 
other  disease ;  that  there  is  no  period  of  the  disease,  no  condition  of  the  pulse,  no 
apparent  debUity  of  system,  no  age,  which  forbids  its  practice.  Let  us  see  how  his 
conclusions  are  justified.  He  records  65  cases  of  pneumonia;  of  these  36,  more 
than  one-half,  are  fotal.  Of  the  uncomplicated  cases,  there  are  9,  which  reach  only 
the  stage  of  engorgement,  and  two  of  tliem — about  1  in  4 — die.  Thirteen  reach  the 
second  stage,  and  of  these  5  die — 1  in  2^.  Seven  cases  reach  the  thira  stage,  and 
they  all  die.     Of  complicated  cases  he  gives  36  ;  of  these  22  die ! 

Another  fatal  argument  against  the  change-of-tyjje  tlieory  is  this  telling  fact,  that 
wise  men  have,  in  all  ages,  and  still  do  in  this  age  with  equal  fervour,  differ  as  to 
the  value  of  remedies.  From  the  days  of  Celsus  down  to  our  own.  men  have  fought 
for  and  against  bleeding,  just  as  some  do  now.  In  France  and  England,  mercury  is 
a  specific  in  syphilis ;  in  Scotland,  mercury  is  a  poison  in  syphilis.  In  the  w^ards 
of  the  same  hospital,  physicians  with  European  reputations,  on  the  same  day,  treat 
fever,  one  by  copious  bleedings,  the  other  by  copious  draughts  of  wine,  both  honestly 
convinced,  fi-om  the  results  of  their  treatment,  of  the  propriety  of  their  practice. 
That  which  alone  gives  undoubted  value  to  a  remedy  is  the  consentaneous  opinion  of 
experienced  men,  which  is  universally  accepted  as  true,  and  is  not  contradicted  iy  the 
opinion  of  equally  experienced  men. 

Then,  again,  if  we  look  at  the  treatment  by  venesection  of  other  acute  diseases  in 
past  days,  we  must  admit,  from  the  very  nature  of  them  as  taught  us  by  modern 
pathology,  that  bleeding  never  could  have  been  the  remedy  for  them.  Could  it  ever 
have  been  the  right  remedy  for  tubercular  disease  ?  yet  it  doubtless  was  the  remedy, 
for  in  those  times  phtliisis  was  "  pneumonia."  Could  it  ever  have  been  needed  in 
rheumatic  fever  ?  and  yet  has  there  been  any  disease  to  overcome  ^hich  more  blood 
has  been  shed  ?  From  Sydenham  down  to  Bouillaud,  the  practice  has  been  sus- 
tained as  steadily  as  an  infallible  dogma ;  to  this  moment  authoritative  text-books 
impress  its  use  upon  the  rising  generation  of  phlebotomists.  The  idea  was,  that  the 
maieries  morhi  could  be  "  evacuated  at  the  mouth  of  the  vein,"  and  of  course  the 
practice  was  logically  followed.  But  modern  pathology  has  taught  us  this :  that 
there  is  a  poisonous  matter  in  the  body  producing  those  peculiar  symptoms,  and 
empirical  treatment  has  demonstrated  to  us  through  manifest  results,  constantly 
ensuing,  and  not  contradicted  by  opposing  opinions,  that  we  possess  an  agent,  which 
will  neutralise  that  poisoniug  element.  But  rheumatism  must  surely  have  ever  been 
the  same  disease ;  consequently,  the  wisdom  of  the  ancients  notwithstanding,  bleed- 
ing never  could  have  been  the  remedy  for  acute  rheumatism.  The  injury  done  by  it 
in  such  disease,  physicians  of  all  late  ages  have  not  failed  to  mention.  If  our  fore- 
fathers were  wrong  here,  why  not  in  other  inflammations  ? 

Dr.  Markham,  in  a  paper  lately  read  before  the  Medico-Chirurgical  Society  of  Lon- 
don, has  endeavoured  to  show  what  is  the  manner  in  which  venesection  does  act 
when  it  acts  beneficially  in  inflammation.  He  therein  argues  that  bleeding  is  use- 
less, as  regards  the  inflammation :  but  that  it  is  frequently  of  service  by  relieving 
certain  of  the  secondary  consequences  which  result  from  the  inflammation,  viz.,  con- 
gestion of  the  heart.  (See  pp.  295-6.)  He  beheves  that  it  is  never  of  service  in 
any  case,  except  when  this  congestion  of  the  heart  exists.  He  quotes  cases  of  dis- 
eased conditions  of  the  brain,  of  the  abdomen,  of  the  heart,  and  of  the  lungs,  in  all 
of  which  congestion  of  the  heart  secondarily  arose,  and  in  which  venesection  gave 
relie£  He  argues  for  the  inefScacy  of  bleeding  over  internal  inflammations,  from 
what  we  see  of  its  inefificacy  in  external  inflammations.     Venesection  has  no  visible 

19 


290  PRINCIPLES   OF   MEDICINE. 

influence  over  oiDhthalmia  or  rheumatism,  or  any  other  external  inflammation,  except 
when  very  large,  and  then  only  temporarily.  "Why  should  it  have  any  influence 
over  internal  inflammations  ?  Surgeons  have  long  since  given  it  up,  because  they 
saw  its  inutility  ;  but  physicians  could  not  see  their  way  so  clearly  to  a  like  conclu- 
sion, until  modern  pathology  enlarged  their  powers  of  vision.  He  considers  that 
practice  clearly  demonstrates  the  fact,  that  bleeding  is  not  required  except  when 
congestion  of  the  heart  exists,  and  that  the  beneficial  influence  of  bleeding  is  more 
marked  in  proportion  as  this  condition  of  the  heart  exists  in  a  more  marked  manner. 
Of  course,  however,  there  are  congestions  of  the  heart,  and  periods  in  the  course  of 
all  congestions,  in  which  the  remedy  can  give  no  relief.  When,  indeed,  is  bleeding 
now-a-days  resorted  to  except  in  those  cases  in  which  this  congestion  exists  ?  If 
the  position  maintained  by  him  be  correct,  then  he  thinks  it  follows  that  the  objects 
of,  and  indications  for,  bleeding  become  clear  and  definite. 

Dr.  Markham  also  draws  attention  strongly  to  the  distinction  wliich  is  to  be  drawn 
between  venesection  and  the  direct  abstraction  of  blood  from  an  inflamed  part.  We 
have,  he  says,  the  positive  ocular  demonstration  of  the  benefits  of  local  bleeding  in 
external  inflammations.  A  few  leeches  applied  to  an  inflamed  rheumatic  joint  or 
around  an  eye  rarely  ever  fail  to  reduce  the  chief  characteristics  of  the  inflammation — 
the  pain,  heat,  redness,  and  swelling.  Twenty  ounces  of  blood  taken  from  the  arm 
produce  no  such  eftect.  Arguing  from  what  we  see  in  external  inflammations,  he 
concludes  that  local  abstraction  of  blood  must  be  also  beneficial  in  all  those  internal 
inflammations  in  which  there  is  a  direct  vascular  communication  between  the  inflamed 
part  and  the  skin  from  whence  the  blood  is  drawn.  Practice,  he  affirms,  entirely 
corroborates  this  view.  Leeches  on  the  thorax  are  of  use  in  pneumonia,  because 
they  relieve  the  pain  of  the  inflamed  parietal  pleura;  they  manifestly  draw  no  drop 
of  blood  from  the  lungs.  They  are  of  service  in  pericarditis  applied  over  the  cardiac 
region,  because  they  also  relieve  the  local  pleuritic  inflammation,  which  he  believes 
to  be  the  cause  of  the  pain.  Acute  pain  does  not  always  accompany  pericarditis,  he 
says ;  neither  does  local  pleurisy,  and  we  may  legitimately  account  for  the  absence 
of  the  one  by  the  absence  of  the  other.  Leeches  are  useless  as  regards  liepatic 
affections,  but  they  sometimes  relieve  the  pain  of  the  peritoneal  inflammation,  which 
is  sometimes,  excited  by  those  affections,  and  of  whose  existence  we  find  frequent 
proof  in  the  dead-house,  in  the  shape  of  old  organised  adhesions  of  liver  to  abdominal 
walls.  In  peritonitis  he  thinks  tliem  of  service ;  but  in  kidney  aff'ections  useless ; 
the  relief  so  often  apparently  given  by  them  being  caused  by  those  still  more  powerful 
remedies — the  warmth  and  repose  in  bed,  which  their  application  necessarily  occa- 
sions or  indicates.  In  fine,  he  says  the  absence  or  presence  of  this  vascular  con- 
nexion gives  us  an  explanation  of  the  fact,  that  leeches  often  do  no  good  in  internal 
inflammations,  and  that  they  often  are  of  no  service.  Of  the  mode  of  action  of  the 
leeches  on  local  inflammations  he  has  nothing  to  offer ;  he  accepts  the  fact  as  cer- 
tain. He  does  not  deujr  the  benefits  of  local  irritation ;  he  believes  that  it  may  act 
in  a  reflex  manner  through  the  vaso-motor  nerves  on  the  vessels  of  the  inflamed 
part ;  but  the  pathological  history  of  this  wonderful  nervous  agency  has  yet  all  to 
be  written.  It  is  possible  that  leeches  may  thus  sometimes,  by  irritation,  influence 
the  vascular  states  of  inflamed  or  healthy  organs  within  the  body,  in  cases  where  no 
vascular  communication  exists  between  the  parts  whence  they  di'aw  blood  and  the 
organs  within. 

Dr.  George  Balfour,  in  a  paper  published  in  the  Edinlurgh  Medical  Journal  for 
September  1858,  shews  that  from  the  earliest  times  certain  medical  men  have  suc- 
cessfully treated  inflammations  without  blood-letting.  But  his  notion  that  this  has 
resulted  from  blind  empiricism,  rather  than  from  theory,  I  think  disproved  by  his 


THE   BLOODLETTING   CONTROVERSY   OF   1857-8.  291 

own  observations.  The  following  quotation  contains  his  views'  on  the  subject : — 
"  Brought  up  in  the  professional  tenets  of  one  so  respected  and  loved  as  Dr.  Alison, 
I  can  never  forget  the  horror  with  which  I  at  first  regarded  the  practice  of  Skoda, 
the  incredulity  with  which  I  listened  to  his  explanations,  or  my  astonishment  when 
extended  observation  had  convinced  me  of  the  correctness  of  his  conclusions,  the 
truth  of  which  eleven  years  of  private  practice  in  this  country  have  but  tended  to 
confirm.  True  pneumonia  has  been,  in  my  experience,  a  comparatively  rare  disease, 
and  I  have  had  under  my  care  only  seventeen  cases,  all  of  which  recovered.  AU 
bore  a  strong  resemblance  to  Cullen's  type,  and  would,  I  believe,  have  borne  blood- 
letting well ;  that  they  would  have  therefore  recovered  better  is  impossible ;  that 
they  would  have  recovered  quicker  is  unlikely,  as,  'after  full  or  repeated  blood- 
letting, convalescence  is  generally  slow'  (Alison),  forming  a  striking  contrast 
to  the  rapid  recovery  of  those  who  have  never  been  bled.  I  may  say,  then ;  that 
my  own  personal  experience  has  not  led  me  to  suppose  that  the  practice  of  not 
bleeding  in  pneumonia  has  been  brought  about  by  any  change  of  type ;  neither  has 
my  reading  given  me  any  reason  to  think  that  there  has  been  any  wave  or  waves 
of  changing  type,  but  rather  to  agree  with  Dr.  Duncan  that,  as  far  as  regards  inflam- 
mation at  least,  such  'changes  exist  only  in  the  imagination  of  physicians,'  and  that 
from  the  time  of  Pythagoras  downwards  to  the  present,  the  non-bleeding  treatment 
of  pneumonia  has  been  in  all  ages  at  least  as  successful  as  its  opposite ;  has  seldom, 
if  ever,  wanted  an  exponent,  and  has  been  practised  by  quite  as  many  of  the  '  cla- 
riores  rtiedicV  Modern  pathology  has  no  doubt  rectified  many  mistakes  into  which 
a  refined  physical  diagnosis  had  led  physicians,  and  by  clearly  explaining  the  modus 
operandi  of  the  treatment,  has  rendered  it  more  easily  adopted  by  a  certain  class  of 
minds :  just  as  the  spread  of  civilisation,  its  vices,  its  malaria,  and  overwork  of  both 
body  and  mind,  has  rendered  a  proportion,  at  least,  of  our  population  less  tolerant 
of  blood-letting  in  disease  than  our  less  refined  forefathers,  and  so  enabled  another 
class  of  minds  more  easily  to  adopt  the  non-bleeding  system.  Yet  the  whole  course 
of  medical  history  tends  to  teach  us,  that  though  blood-letting  has  been  practised  in 
all  ages,  it  has  been  necessary  in  none.  Its  opponents  have  clearly  shown  that  it 
can  correct  no  humours,  evacuate  no  materies  morbi,  and  has  no  influence  over 
exudation ;  while  those  of  its  advocates  who  have  most  ably  investigated  its  use, 
have  distinctly  proved  that  it  cannot  cut  short  the  disease  (Chomel,  Andral,  Louis), 
prevent  exudation,  or  jugulate  any  symptom  (Grisolle).  So  little  influence  has  it 
over  those  phenomena  which  may  be  supposed  to  precede  inflammation,  that  it  is 
precisely  in  the  case  of  those  who  have  lost  much  blood  previous  to  the  occurrence 
of  inflammation  that  we  have  most  to  dread  a  fatal  termination  ;  and  in  commenting 
on  a  fatal  case  of  this  character,  one  of  the  greatest  clinical  teachers  of  this  or  any 
other  age  commences  by  the  strong  assertion,  that  the  first  consideration  suggested 
by  it  is,  'the  tendency  which  excessive  depletion  produces  to  the  formation  of 
inflammation.' "  (Graves.) 

Such  is  an  account  of  the  blood-letting  controversy  excited  by  my  remarks,  and 
which  has  been  carried  on  during  the  years  1857-58.  That  the  extraorduiary  acti- 
vity which,  during  the  last  fifteen  years,  has  been  communicated  to  the  natural 
sciences,  should  fail  to  produce  any  change  in  medical  practice,  was  scarcely  to  be 
expected,  any  more  than  that  such  change  could  be  efiected  without  great  opposi- 
tion and  much  discussion.  Yet,  singular  to  say,  the  discussion  in  this  case,  instead 
of  preceding,  has  followed  the  change,  inasmuch  as  many  of  those  who  are  now  con- 
tending for  the  advantages  of  blood-letting  and  antiphlogistics  in  inflammation,  are 
the  very  parties  who  acknowledge  that  they  no  longer  employ  them.  But,  though 
tardy,  the  discussion  may  still  be  useful,  should  it  serve  to  direct  men's  minds  to 


292  PRINCIPLES   OF   MEDICINE. 

what  I  conceive  to  be  the  true  principles  which  should  guide  our  endeavours  to 
advance  medicine.  These  are — 1st,  That  an  empirical  treatment,  derived  from  blind 
authority,  and  an  expectant  treatment,  originating  in  an  equally  blind  faith  in  uaturei 
are  both  wrong :  2dly,  That  a  knowledge  of  physiology,  pathology,  and  therapeutics, 
and  not  experience  alone,  is  the  real  foundation  for  the  practice  of  the  medical  art ; 
and,  3dly,  That  a  true  experience  can  only  have  for  its  proper  aim  the  determmation 
of  how  far  the  laws  evolved  during  the  advance  of  these  sciences  can  be  efficiently 
made  available  for  the  cure  of  disease. 


THE  INFLUENCE  OF  PREDOMINANT  IDEAS  ON  THE 
HEALTHY  AND  DISORDERED  FUNCTIONS  OF  THE 
BODY. 

Dr.  Henry  Monro,*  speaking  of  monomania,  says  that  "  in  these  cases 
neither  the  controlling  agency  of  the  will  nor  the  reason  is  suspended 
on  most  subjects,  though  it  is  so  on  certain  points;  these  people  can 
guide  their  thoughts  well  enough  on  most  questions,  can  see  the  full 
relations  that  cause  bears  to  effect,  and  that  mental  impressions  bear  to 
external  things,  but  they  cannot  properly  control  those  impressions 
which  are  most  strongly  fixed  on  the  mind.  This  state  has  very  fre- 
quently a  stage  of  contest  and  conscious  difficulty  at  fii'st,  when  the 
struo-gle  between  the  morbid  impressions  and  the  faculties  by  which  to 
control  them  is  great ;  indeed,  we  may  say  that  all  morbid  and  excessive 
impressions  which  exclude  all  other  considerations  bear  the  rudimentary 
form  of  this  aftection,  though  insanity  cannot  be  said  strictly  to  be  fully 
developed  until  the  contest  is  decided  by  such  a  victory  on  the  part  of 
the  morbid  impressions  that  the  moral  liberty  to  exercise  their  reasoning 
faculties  on  these  subjects  is  gone. 

Now,  the  first  stage  of  the  process  here  so  accurately  described,  viz., 
that  in  which  persons  cannot  control  those  impressions  which  are  most 
strongly  fixed  on  the  mind, — may  be  produced  artificially  in  about  one 
out  of  twenty  individuals  of  the  entire  population.  Thus,  if  that  number 
be  chosen  indiscriminately,  and  directed  to  gaze  steadily  at  any  object  for 
about  ten  minutes,  a  peculiar  condition  of  the  cerebral  functions  will  be 
produced  in  one  or  more  of  them  (especially  if  they  be  young) ;  and 
under  this  condition  those  aff"ected  may  be  made  to  act  in  accordance 
with  any  train  of  ideas  which  may  be  suggested  to  them,  their  motion  and 
sensation  being  influenced  in  a  variety  of  ways.f  It  seems  as  if  their 
mental  faculties  become  fatigued,  in  consequence  of  which  they  lose  the 
25ower  of  controlling  any  idea  that  becomes  predominant. 

The  peculiar  mental  condition  thus  produced  manifests  itself  while 

*  Remarks  on  Insanity,  etc. 

\  The  mode  of  producing  this  condition  may  be  varied,  but  it  is  in  all  cases  essen- 
tially the  same.  Tims  Mesmer  caused  individuals  to  sit  in  a  kind  of  trough,  and  they 
were  directed  to  look  at  a  wire  placed  in  their  hand.  The  Fakirs  of  India  throw  them- 
selves into  a  trance  by  looking  at  the  extremity  of  their  own  noses.  Mr.  Braid  of 
Manchester  holds  an  object  a  little  above  the  ej-es,  so  as  to  fatigue  them  sooner.  Dr. 
Darling  causes  them  to  look  at  a  small  coin  placed  in  the  palms  of  their  hands,  whilst 
others  fix  the  attention  of  persons  on  themselves,  on  the  tips  of  their  fingers  extended 
towards  their  eyes,  and  make  motions  or  so-caUed  passes  which  arrest  the  attention. 


INFLUENCE  OF  PREDOMIN^iNT  IDEAS  ON  THE  BODY.   293 

the  individual  is  gazing  upon  the  object,  in  the  first  instance,  by  a  misti- 
ness of  vision,  succeeded  in  some  by  a  feeling  of  lassitude  and  desire  to 
sleep,  in  others  only  by  a  stiffness  of  the  eyelids,  and  in  a  third  class 
by  deep-drawn  sighs,  hurried  respiration,  heaving  of  the  chest,  or  other 
si*<Tns  of  general  excitement.  If  now  such  persons  are  repeatedly  told, 
in°a  confident  manner,  tliat  they  cannot  open  their  eyes,  it  will  be  found 
that  they  cannot  do  so,  especially  if  the  operator  directs  particular  attention 
to  the  eyelids  by  touching  or  pointing  to  them.  But  on  receiving  per- 
mission, or  on  being  commanded  to  open  them,  they  will  do  so  at  once. 

In  the  same  manner,  an  individual  so  affected  may  be  made  to  make 
every  conceivable  kind  of  motion  against  his  will,  or,  on  the  other  hand, 
such  movements  as  he  may  wish  "to  make  can  be  impeded,  arrested, 
or  perverted.  Thus  I  have  seen  a  person  unable  to  speak,  from  inability 
to  open  the  jaws;  not  able  to  bend  an  arm  or  a  leg;  fixed  to  a  chair,  or 
prevented  from  sitting  down ;  unable  to  approach  a  particular  object,  or 
irresistibly  impelled  towards  it;  unable  to  cross  a  real  or  imaginary  line 
on  the  floor;  the  arm  suspended  and  fixed  in  the  act  of  drinking,  or  the 
body  arrested  in  the  act  of  dancing;  the  individual  made  to  walk,  dance, 
or  run,  as  directed ;  to  imitate  riding  on  horseback,  when  seated  on  a 
chair;  or  to  stagger  about  the  room  in  a  supposed  state  of  intoxication, 
etc.  Many  of  the  lower  animals  also  appear  to  be  susceptible  of  being 
impressed  by  what  strongly  arrests  their  attention,  in  such  a  way  that 
they  are  rendered  incapable  of  voluntary  motion,  or  iri-csistibly  impel- 
led "towards  the  object.  Hence  the  long  glittering  bodies  of  serpents, 
or  the  glaring  eyes  of  other  ammals^  fascinate  birds  and  small  quadrupeds, 
and  render  them  an  easy  prey  to  their  enemies.  Hares  and  all  sorts  of 
animals,  also,  are  often  run  over  by  railway  trains.  Similar  eftects  are 
produced  in  individuals  who  look  from  heights  and  precipices,  and 
experience  an  uncontrollable  desire  to  leap  down,  although  they  know 
it  will  be  to  certain  destruction. 

In  like  manner,  during  this  condition,  all  the  sensations  may  he  in- 
creased, perverted,  or  destroyed,  through  the  medium  of  suggestive  ideas 
communicated  to  the  mind.  By  fixing  attention  on  any  part  of  the  skin 
it  may  be  made  to  feel  hot  or  cold,  tingling  and  painful,  or  benumbed 
and  destitute  of  sensibility,  according  to  the  ideas  communicated.  Sight 
may  be  lost  or  rendered  painful,  spectral  images  may  be  presented  to 
the  vision,  or  various  objects  made  to  resemble  others  to  which  they 
bear  no  analogy.  Smell  also  may  be  perverted,  and  any  kind  of  odour 
given  to  inodoi'ous  substances.  A  rose,  in  the  mind  of  such  an  individual, 
may  have  the  smell  of  an  onion,  and  plain  water  the  fragrance  oi^  can 
de  Color/ne.  Various  noises,  in  like  manner,  may  be  heard;  hearing  is 
frequently  very  acute,  at  other  times  it  is  apparently  abolished.  Lastly, 
the  taste  may  be  affected,  and  plain  water  made  to  present  to  such  a 
person  the  sweetness  of  honey,  the  bitterness  of  wormwood,  or  the 
acidity  of  vinegar. 

Then,  as  regards  the  mental  faculties,  memory  may  be  lost,  whilst 
judgment  and  comparison  for  the  time  being  cannot  be  exercised.  The 
imaginative  faculties,  on  the  other  hand,  may  be  very  vivid,  so  that  the  indi- 
vidual readily  assumes  the  manners  of  other  persons  in  various  walks  of 
life — goes  through  the  operations  of  different  mechanical  trades,  conceiv- 
ing himself  to  be  an  artisan — endeavours  to  escape  from  imaginary  dangers 


294  PRINCIPLES   OF   MEDICINE. 

or  tries  to  repel  them — and  acts  as  Le  himself  or  others  might  be  natu- 
rally supposed  to  do  under  any  given  circumstances  or  conditions.  Thus 
he  may  be  made  to  fight,  to  swim,  to  run,  to  stagger  as  if  intoxicated, 
and  so  on.  Even  the  sex  may  in  this  manner  be  mentally  changed, 
and  a  lady  may  assume  the  manners,  tone  of  voice,  and  language  of  her 
husband.  Such  persons  also  may  readily  be  conducted  in  imagination 
to  various  distant  countries  or  cities,  when  they  "will  act  and  talk  as  if 
they  were  really  there ;  or  they  may  be  led  tlirough  a  very  complicated 
series  of  actions,  such  as  a  quarrel  terminating  in  a  duel ;  a  fishing  or 
shooting  excursion  in  which  they  catch  numerous  fish,  or  bag  a  quantity 
of  game,  etc.  etc. 

In  the  same  war  sleep  may  be  most  readily  induced,  and  become  so 
sound  that  all  ordinary  stimuli  Avill  not  awake  the  sleepers;  sensation 
even  being  occasionally  annihilated  for  the  time.  Yet  it  often  happens, 
that  at  the  command  of  him  who  has  conmmnicated  the  suggestive  ideas, 
they  immediately  awake  from  a  condition  of  sopor  out  of  which  local 
painful  applications  failed  to  arouse  them.  Susceptible  persons  may  be 
even  commanded  to  sleep  at  a  particular  hour  on  a  certain  day,  and 
awake  at  a  particular  time,  and  this  they  will  do  under  the  idea  that  at 
the  hour  named  some  peculiar  influence  is  exerted  on  them.  This  condi- 
tion is  analogous  to  that  of  somnambulism,  trance,  or  ecstasy,  and  presents 
all  the  intermediate  gradations  between  these  states  and  ordinary 
dreaming  and  reverie. 

AVhat  is  very  curious  in  connection  with  many  of  these  nervous 
aberrations  is,  that  a  person  may  be  perfectly  conscious  during  the  v»hole 
time  of  what  he  is  doing,  and  even  of  the  absurdity  of  his  actions.  He 
may  know  that  the  water  he  drinks  is  not  milk  or  syrup,  and  yet  he 
declares  it  to  have  the  taste  of  those  liquids.  Frequently,  when  his  move- 
ments are  influenced,  he  evidently  resists,  but  seems  to  be  controlled  by 
a  will  stronger  than  his  own.  He  even  laughs  at  his  own  ridiculous 
actions,  but  acknowledges  his  helplessness.  The  efibrts  at  resistance 
only  induce  fatiguCy  and  tend  to  render  him  more  certainly  the  victim  of 
the  influence  by  which  he  is  governed.  This  condition  is  certainly  closely 
allied  to  the  incipient  stage  of  monomania.  It  should  also  be  noticed 
that,  although  young  and  nervous  persons  are  undoubtedly  those  who 
are  most  commonly  aff"ected,  such  is  by  no  means  always  the  case,  as 
many  individuals,  apparently  in  good  health  and  robust,  have  been 
made  to  exhibit  all  the  phenomena  described. 

Such  are  only  some  of  the  phenomena  which  may  be  produced  in  those 
aftected  with  the  peculiar  nervous  condition  which  I  am  describing. 
They  admit  of  infinite  modifications,  but  the  symptoms  are  all  referable 
to  increase,  diminution,  or  perversion  of  intelligence,  sensation,  or  volun- 
tary motion,  variously  combined,  according  to  the  endless  train  of  sug- 
gestive ideas  that  may  be  communicated  to  the  individual. 

Similar  phenomena  have  occurred  in  all  ages,  produced  in  certain 
persons  by  predominant  ideas,  and  variously  modified  according  to  the 
education,  politics,  or  religion  of  the  period.  Thus  the  effects  produced 
on  many  votaries  during  their  initiation  into  the  ancient  mysteries ;  the 
ecstasies  of  the  Pythian  and  other  priestesses ;  the  influence  of  religious 
entliusiasm  ;  the  dancing  epidemics  of  St.  Vitus,  or  of  Tarantism,  in  the 
middle  ages ;  the  hallucinations  of  the  Convulsionaires  at  the  tomb  of 


INFLUENCE  OF  PREDOMINANT  IDEAS  ON  THE  BODY.   295 

St.  Medard,  in  Paris,  etc.  etc.,  are  of  a  like  character.*  Numerous  per- 
versions of  the  nervous  functions,  identical  in  their  nature  with  those 
described,  consisting  of  sensory  illusions,  muscular  convulsions  or  rigid- 
ity, and  peculiar  trains  of  thought  influencing  acts  and  conversation, 
may  be  found  in  the  histories  of  witchcraft  or  demonology,  in  the 
legends  of  the  saints,  the  Journal  of  Mr.  Wesley,  and  in  the  accounts 
given  by  travellers  of  the  religious  camp  meetings  in  the  woods  of 
America.  They  are  perhaps  more  common  now  than  previously,  and 
excite  even  more  astonishment  among  the  ignorant,  the  onlj^  difference 
being  that  the  same  phenomena  which  in  a  dark  age  were  attributed  to 
divination  or  incantation  now  assume  the  garb  of  science,  and  are 
ascribed  to  Magnetism  or  Electricity. 

1  consider  it  unnecessary  to  enter  into  any  lengthened  argument  to 
refute  the  numerous  hypotheses  which  ascribe  these  effects  to  external 
influences.  I  know  of  no  series  of  well-ascertained  facts  capable  of 
supporting  such  a  doctrine.  Lately,  I  have  tried  numerous  experiments 
with  the  aid  of  those  who  believe  in  Animal  Magnetism,  all  of  which 
have  onl)'^  convinced  me  that  no  such  principle  exists,  and  that  all  the 
phenomena  really  occasioned  depend  on  suggestive  ideas  communicated 
to  the  person  affected.  But  while  these  theories  scarcely  merit  atten- 
tion, the  facts  themselves  are  highly  important,  and  demand  the  careful 
consideration  of  the  physiologist  and  medical  practitioner.  Let  us,  then, 
examine  into  what  can  reasonably  be  advanced  in  explanation  of  these 
nervous  phenomena. 

We  have  seen  that  sensation  may  be  defined  to  be  the  consciousness 
of  an  impression,  and  we  know  that  the  mind  strongly  intent  upon  an 
object  is  unconscious  of  those  impressions  which  are  going  on  around — 
so  that  no  sensation  results  from  these.  Every  physiologist  is  aware 
that  the  body  of  a  decapitated  animal  may  be  thrown  into  violent  con- 
vulsions, and  cases  have  occurred  even  in  man  of  the  limbs  having  been 
thrown  about,  as  if  in  the  greatest  agony,  although  in  reality  no  pain 
whatever  has  been  experienced.  All-absorbing  mental  ideas  prevent 
sensation  of  local  impressions  unconnected  with  them  ;  hence  wounds 
are  not  felt  in  battle,  blows  and  falls  are  unheeded  during  the  excitement 
of  intoxication  or  of  nitrous  oxide  gas,  and  Indian  warriors  and  religious 
enthusiasts,  intent  on  particular  trains  of  thought,  have  not  suft'ered  from 
any  of  the  supposed  torments  which  were  inflicted  on  their  bodies. 
These  facts,  then,  ofter  a  sufiicient  explanation  to  the  physiologist  of  the 
occasional  insensibility  of  somnambulists,  or  others  labouring  under  some 
predominant  idea. 

Whilst,  however,  an  individual  may  be  unconscious  of  impressions 
unconnected  with  his  particular  train  of  ideas,  everything  in  relation  to 
these  is  often  perceived  with  extraordinary  readiness.  The  abolition  of 
sensation  with  regard  to  general  impressions  seems  to  be  counter- 
balanced by  an  exquisite  sensitiveness  relative  to  the  one  impression 
either  actually  made  or  suggested.  Dr.  EloUand  has  very  ably  pointed 
out  the  effects  of  mental  attention  on  the  bodily  organs,  showing  that 
there  are  few  persons  who  do  not  experience  irritation  or  some  imaginary 
feeling  in  parts  to  which  their  attention  is  much  directed.f     If  at  night, 

*  Hecker's  Epidemics  of  the  Middle  Ages. 
f  Medical  Notes  and  Reflectious,  chap.  5. 


296  PKINCIPLES   OF   MEDICINE. 

owino-  to  some  unusual  position,  -we  feel  a  beating  at  the  heart  or  at  the 
temples,  we  easily  imagine  there  is  something  alarming  ;  the  respirations 
are  altered,  if  we  think  about  them  ;  if  we  suppose  the  mouth  is  dry,  we 
immediately  swallow  the  saliva,  and  render  it  so ;  if  we  fancy  we  have 
a  cough,  we  cough  immediately,  and  clear  the  air  passages ;  and  if  we 
suppose  any  source  of  irritation  exists  on  the  skin,  we  involuntarily  apply 
our  hand  to  and  rub  the  part.  Nothing  is  moi'e  common  for  medical 
students,  Avhen  first  studying  individual  diseases,  than  to  imagine  them- 
!<elves  to  be  the  victims  of  each  in  succession.  Then,  in  certain  condi- 
tions of  the  system,  it  is  well  known  that  actual  pain  may  be  produced 
in  a  part  by  fixing  our  attention  upon  it.  Hypochondriacs  are  martyrs 
to  these  erroneous  impressions.  Supposed  pains  in  the  limbs  or  stomach 
prevent  their  walking  or  eating,  and  their  health  suffers  from  want  of 
exercise  or  want  of  food.  Sir  lienjamin  Brodie  has  given  some  singular 
cases  where  so-called  nervous  pains  of  this  description  have  actually  led 
to  tenderness  and  swelling  of  the  integuments  covering  the  part.  It  may 
easily  be  understood  how  facts  of  this  kind  may  be  made  to  assume  the 
appearance  of  prophecy,  and  how  informing  a  valetudinarian  that  he  will 
certainly  have  a  rheumatic  or  neuralgic  pain  on  any  given  dav,  is  likely 
to  produce  it. 

As  illustrative  of  the  strong  influence  of  predominant  ideas  even  in 
healthy  persons,  I  may  mention  the  following  circumstances  : — Mr.  Mac- 
farlan,  druggist.  North  Bridge,  Edinburgh,  informed  me,  that  on  one 
occasion  a  butcher  was  brought  into  his  shop,  from  the  market-place 
opposite,  labouring  under  a  terrible  accident.  The  man,  on  trying  to 
hook  up  a  heavy  piece  of  meat  above  his  head,  slipped,  and  the  sharp 
hook  penetrated  his  arm,  so  that  he  himself  was  suspended.  On  being 
examined,  he  was  pale,  almost  pulseless,  and  expressed  himself  as  suffering 
acute  agony.  The  arm  could  not  be  moved  without  causing  excessive 
pain,  and  in  cutting  off  the  sleeve  he  frequently  cried  out,  yet  when  the 
arm  was  exposed  it  was  found  to  be  quite  uninjured,  the  hook  having 
only  traversed  the  sleeve  of  his  coat.  A  clergyman  told  me,  that  some 
time  ago  suspicions  were  entei'tained  in  his  parish  of  a  woman,  who  was 
supposed  to  have  poisoned  her  newly-born  infant.  The  cofhn  was 
exhumed,  and  the  procurator-fiscal,  who  attended  with  the  medical  men 
to  examine  the  body,  declaimed  that  he  already  perceived  the  odour  of 
decomposition,  which  made  him  feel  faint,  and  in  consequence  he  with- 
drew^  But,  on  opening  the  coffin,  it  was  found  to  be  empt}',  and  it  Avas 
afterwards  ascertained  that  no  child  had  been  born,  and  consequently  no 
murder  committed.  Numerous  instances  might  be  given  of  individuals 
engaged  in  duels,  or  on  other  occasions,  who  have  supposed  themselves 
to  be  wounded,  and  have  fallen  down  as  if  dead,  without  having  received 
the  slightest  injury. 

Then,  as  regards  irregular  movements  in  connection  with  predominant 
ideas,  the  phenomena  of  hysteria  and  chorea  will  at  once  suggest  them- 
selves to  you.  In  the  latter  disease,  peculiar  movements  are  always 
occasioned  by  the  exercise  of  volition,  or  by  certain  impulses  which  can- 
not be  controlled.  In  hydrophobia  there  is  a  remarkable  susceptibility 
to  the  most  minute  circumstances,  which  give  rise  in  any  way  to  the 
idea  of  drink,  and  invariably  excite  the  most  fearful  spasms.  Numerous 
singular  instances  of  occasional  and  partial  perversion  of  the  voluntary 


INFLUENCE  OF  PREDOMINANT  IDEAS  ON  THE  BODY.   297 

movements  might  be  quoted,  either  arising  spontaneously,  or  acquired 
by  habit,  or  produced  in  animals  by  injuring  certain  parts  of  the  nervous 
system,  or  by  giving  particular  drugs ;  but  I  shall  content  myself  with 
relating  two  cases,  formerly  under  the  care  of  Dr.  Christison,  which  he 
was  so  good  as  to  communicate  to  me.    The  first  was  that  of  a  gentleman 
who  frequently  could  not  carry  out  what  he  willed  to  perform.     Often 
on  endeavouring  to  undress,  he  was  two  hours  before  he  could  get  off 
his  coat,  all  his  other  mental  faculties  being  perfect.     On  one  occasion, 
having  ordered  a  glass  of  water,  it  was  presented  to  him  on  a  tray,  but 
he  could  not  take  it,  though  anxious  to  do  so,  and  he  kept  the  servant 
standing  before  him  for  half  an  hour,  when  the  obstruction  was  over- 
come.    In  the  other  case  the  peculiarity  was  limited.     If,  when  walking 
in  the  street,  he  came  to  a  gap  in  the  line  of  houses,  his  will  suddenly 
became  inoperative,  and  he  could  not  proceed.     An  unbuilt-on  space  in 
the  street  was  sure  to  stop  him.     Crossing  a  street  also  was  very  diffi- 
cult, and  on  going  in  or  out  of  a  door  he  was  always  arrested  for  some 
minutes.     Both  these  gentlemen  graphically  described  their  feelings  to 
be  "  as  if  another  person  had  taken  possession  of  their  will."     These  and 
similar  perversions  of  motion,  whether  of  excess  or  diminution,  however 
produced,  cannot  always  be  governed  by  predominant  ideas,  but  that 
they  frequently  are  so  is  proved  by  a  multitude  of  facts.     The  old  story 
of  Bocrhaave  is  as  apposite  as  any  other,  who  is  said  to  have  inmiediately 
cured  several  girls  at  school  of  chorea,  by  threatening,  in  a  loud  voice, 
that  the  next  who  was  attacked  should  have  the  actual  cautery  applied. 
The  power  of  imitation,  which  must  operate  through  the  mind  of  the 
individual,  is  known  by  medical  men  to  be  very  strong,  however  inex- 
plicable.    Immoderate  laughter  is  very  catching ;  few  can  resist  even  a 
well-imitated  yawn,  and  on  board  ship  nothing  more  certainly  brings  on 
sea-sickness  than  seeing  others  ill.     Habits,  modes  of  expression,  dialect, 
carriage  of  the  body,  and  peculiar  movements,  are  also  readily  acquired 
from  those  around  us.     On  visiting  the  Bosjesmen,  who  were  exhibited 
here  some  years  ago,  the  effect  of  their  dance  on  the  audience  was  strik- 
ing.    Beginning  slow,  to  the  rhythmical  beatings  of  their  clubs,  the  noise 
became  gradually  louder,  more  and  more  exciting,  every  step  and  ges- 
ture keeping  exact  time.     I  myself,  and  some  friends  with  me,  at  length 
felt  a  peculiar  jar  all  through  our  systems,  our  own  feet  involuntarily 
kept  time  with  the  dancers,  and  from  the  feelings  then  experienced,  we 
could  at  all  events  comprehend  the  nature  of  those  impulses  which  have 
caused  multitudes  to  join  in  the  dance  of  St.  Vitus  or  of  Tarantism. 

In  all  these,  and  various  other  cases  which  might  be  cited,  it  must  be 
evident  that  the  effect  is  produced  by  operating  on  the  mind  of  the  indi- 
vidual, and  through  that  on  his  bodily  powers.  In  short,  predominant 
ideas,  whether  originating  spontaneously  or  suggested  by  the  words  and 
actions  of  others,  seem  to  be  the  exciting  cause  in  individuals  affected 
with  a  peculiar  condition  of  the  cerebral  functions.  As  regards  the 
nature  of  this  condition,  it  seems  analogous  to  that  of  sleep  or  dreaming, 
in  which  certain  faculties  of  the  mind  are  active,  and  may  be  even  stimu- 
lated into  excessive  action,  Avhilst  others  are  suspended.  Hence  it  has 
been  called  Hypnotism  by  Mr.  Braid.*     All  the  phenomena  produced 

*  Nemypnologj,  or  the  Rationale  of  Nervous  Sleep.     1843. 


298  PRINCIPLES   OF   MEDICINE. 

are  strictly  analogous  to  what  medical  men  are  acquainted  with  in  vari- 
ous morbid  states;  and  it  must  now  be  considered  as  well  established, 
that  in  certain  conditions  of  the  nervous  system  they  may  be  induced 
at  will.  This  conclusion,  however,  is  something  new,  for  it  has  but 
recently  been  admitted  m  physiology  or  pathology,  that  a  condition  of 
the  cerebral  functions  may  be  occasioned  in  apparentl}*  healthy  persons, 
during  which  suggestive  ideas  are  capable  of  producing  those  phenomena 
we  have  described,  and  which  render  them,  for  the  time,  as  irresponsible 
as  monomaniacs.  Yet  such  is  really  the  fact,  which,  once  admitted  into 
physiology,  must  have  an  important  influence  on  the  theory  and  practice 
of  medicine.  This  condition  may  probably  be  accounted  for  physiologi- 
callv  in  the  following  manner : — 

"vV'e  have  previously  seen  that  the  cerebral  lobes  contain  white  fibres, 
which  run  in  three  directions.  1st,  Those  which  pass  from  below 
upwards,  and  connect  the  hemispherical  ganglion  with  the  spinal  cord. 
2d,  Those  which  pass  transversely,  forming  the  commissures,  and  which 
unite  the  two  hemispheres.  And  .3d,  Those  which  run  from  before 
backwards,  uniting  the  anterior  with  the  posterior  lobes  on  each  side 
(p.  Ill) ;  these  fibres  being  also  probably  subservient  to  that  combina- 
tion of  the  mental  faculties  which  characterises  thought  (p.  112).  Now 
all  metaphysicians  and  physiologists  are  agreed  that  the  mind  is  com- 
posed of  various  faculties,  and  that  different  portions  of  the  nervous  mass 
are  necessary  for  their  manifestation.  True,  it  is  by  no  means  deter- 
mined of  how  many  faculties  the  mind  is  made  up,  and  still  less  is  it 
known  which  parts  of  the  brain  are  necessary  for  the  manifestation  of 
each  individual  faculty.  But  let  the  first  proposition  be  granted,  then 
there  is  no  difticulty  in  supposing  that  one  or  more  of  these  may  be 
paralysed  or  suspended,  whilst  others  are  entire,  any  more  than  there  is 
in  knowing  that  sensation  may  be  lost  whilst  motion  remains  intact, 
although  the  nerve  fibres  of  both  run  side  by  side.  I  presume,  then,  that 
certain  mental  faculties  are,  as  the  result  of  exhausted  attention,  tempo- 
rarily paralysed  or  suspended,  whilst  others  are  rendered  active  in  conse- 
quence of  being  stimulated  by  suggestive  ideas  ;  that  the  psychical  stimuli 
of  the  former  make  no  impressions  on  the  cerebral  conducting  fibres, 
whilst  those  of  the  latter  ai'e  increased  in  intensity  ;  that  the  proper 
balance  of  the  mind  is  thereby  disturbed,  and  thus  the  individual  for  the 
time  being  acts  and  talks  as  if  the  predominant  idea  was  a  reality.  The 
condition  is  analogous  so  far  with  ordinary  somnambulism,  certain  forms 
of  hypochondriasis  and  monomania,  but  admits  of  infinite  changes 
accoi'ding  to  the  nature  of  the  idea  suggested. 

x\ccording  to  this  theory,  therefore,  we  suppose  that  a  psychical  sti- 
mulus is  generated,  which,  uncontrolled  by  the  other  mental  operations 
acting  under  ordinary  circumstances,  induces  impressions  on  the  peri- 
pheral extremities  of  the  cerebral  fibres,  the  influence  of  which  only  is 
conveyed  outwards  to  the  muscles  moved.  In  the  same  manner  the 
remembrance  of  sensations  can  always  be  called  up  by  the  mind  ;  but 
under  ordinary  circumstances  we  know  they  are  onli/  remembrances, 
from  the  exercise  of  judgment,  comparison,  and  other  mental  faculties ; 
but  these  being  exhausted,  in  the  condition  under  consideration,  while 
the  suggested  idea  is  predominant,  leave  the  individual  a  believer  in  its 
reality. 


INFLUENCE   OF  PREDOMINAJSTT   IDEAS   ON  THE   BODY.      299 

In  tins  manner  we  attribute  to  the  faculties  of  the  mind  a  certain 
power  of  correcting  the  falhicies  which  each  is  liable  to  fall  into,  in  the 
same  way  that  the  illusions  of  one  sense  are  capable  of  being  detected  by 
the  healthy  use  of  the  other  senses.  We  further  believe  that  the  appa- 
ratus necessary  for  the  former  operations  consists- of  the  nerve  fibres 
which  unite  different  parts  of  the  hemispherical  ganglion,  whilst  that 
necessary  for  the  latter  are  the  nerve  fibres  connecting  together  the  organs 
of  sense  and  the  ganglia  at  the  base  of  the  encephalon.  A  healthy  and 
sound  mind  is  characterised  by  the  proper  balance  of  all  the  mental 
faculties,  in  the  same  manner  that  a  healthy  body  is  dependent  on  the 
proper  action  of  all  the  nerves.  There  are  mental  illusions  and  sensorial 
illusions,  one  caused  by  predominant  ideas,  and  corrected  by  proper 
reasoning ;  the  other  caused  by  perversion  of  one  sense,  and  corrected 
by  the  right  application  of  the  others.  Both  these  conditions  are 
intimately  united,  and  operate  on  each  other,  inasmuch  as  voluntary  and 
emotional  movements  and  sensations  are  mental  operations. 

This  theory,  if  further  elaborated,  appears  to  me  consistent  with  the 
facts  described  at  the  commencement  of  this  lecture,  and  capable  of 
explaining  them  on  physiological  principles.* 

We  may  now  ask  ourselves  whether  the  facts  which  have  been  ascer- 
tained, and  the  generalisations  which  flow  from  them,  are  capable  of  being 
rendered  useful  in  the  practice  of  medicine  ?  The  beneficial  inflaence 
of  hope  and  confidence  over  disease  is  as  well  known  to  medical  men  as 
the  injurious  tendency  of  fear  and  despondency.  This  effect  of  mind  on 
the  bodv  has  from  the  earliest  periods  been  seized  upon  by  individuals  as 
a  ground  for  veneration  or  astonishment.  In  ancient  times  the  heathen 
priests  were  the  physicians,  and  the  temples  were  converted  into  so  many 
dispensaries,  at  which  the  sick  applied  for  relief.  In  catholic  countries, 
during  the  middle  ages,  the  offices  of  priests  and  physicians  were 
frequently  united  in  one  person,  so  that  the  powerful  effects  of  certain 
shrines,  and  the  benefits  of  pilgrimages  in  cases  not  ailmitting  of  simple 
cure,  met  with  every  encouragement.  From  what  has  preceded,  it  must 
be  allowed,  that,  so  far  from  its  being  improbable  tiuit  real  cures  Avere  so 
effected,  all  that  we  know  of  the  effects  of  confident  promises  on  the  one 
hand,  and  belief  on  the  other,  renders  it  very  likely  that  many  such 
occurred.  The  legends  of  the  saints,  the  history  of  witchcraft,  the  jour- 
nal of  Mr.  Wesley,  the  accounts  of  celebrated  pilgrimages,  and  of  the 
virtues  of  particular  shrines,  and  the  writings  of  religious  enthusiasts 
generally,  abound  in  wonderful  cures.  Charms,  amulets,  and  relics,  are 
stated  to  have  at  once  banished  all  kinds  of  agony,  and  removed  nume- 
rous nervous  diseases.  Many  of  these  tales  are  certainly  incredible,  whilst 
others  are  perfectly  conceivable.  The  benefits  of  the  royal  touch  are 
confirmed  by  the  observations  of  Richard  Wiseman,  and  the  cures  per- 
formed by  Greatrakes  are  warranted  by  Robert  Boyle.  In  all  these  cases, 
there  can  be  little  doubt  that  any  benefit  which  did  occur  may  be  attri- 

*  It  has  lately  been  proposed  by  Mr.  Braid  to  call  the  condition  of  which  we  have 
been  speaking,  and  which  results  from  a  dominant  idea — monoideism.  The  term 
monokleology  would  indicate  the  doctrine  of  the  influence  of  dominant  ideas  in  control- 
ling mental  and  physical  action.  To  monoideise  might  express  the  act  of  performing 
processes  for  inducing  monoideism,  and  monoideiser  designate  the  person  who  monoi- 
deises.  Then  moiioideised  will  indicate  the  condition  of  the  person,  and  monoideody- 
namics  the  mental  and  physical  changes  which  result  from  the  process. 


800  PRINCIPLES   OF   MEDICINE. 

buted  to  a  strong  belief,  on  the  part  of  the  patient,  in  the  efficacy  of  the 
means  employed  * 

In  recent  times  more  systematic  attempts  Lave  been  made  in  tliis  v,av 
to  relieve  pain,  control  nervous  excitement,  lessen  muscular  debility,  and 
stimulate  certain  secretions.  If  it  be  considered,  that  the  power  of  pro- 
ducing profound  sleep,  and  acting  on  the  nervous  functions,  may  be  mani- 
fested in  so  many  individuals  as  one  in  twenty  of  the  whole  population, 
it  must  be  evident  that  in  a  class  of  persons  particularly  predisposed,  the 
number  capable  of  being  affected  would  be  much  greater.  This  subject, 
liow-ever,  is  yet  in  its  infancy,  and  has  to  be  separated  from  the  charla- 
tanism ^vllich  has  hitherto  been  mingled  with  it.  The  labours  of  Dr. 
Eisdale  among  the  natives  of  India,  and  of  Mr.  Braid  in  Manchester,  exlii- 
bit  a  worthy  commencement  to  the  rational  treatment  of  disordeis  by 
the  means  now  alluded  to ;  and  there  can  be  little  doubt  that  in  no  long 
time  its  influence,  when  further  studied,  will  be  acknowledged.  But  how 
far  this  influence  is  dependent  on  the  confidence  of  the  patient ;  on  the 
belief  in  some  mysterious  circumstance,  which  is  presumed  to  produce 
the  effect,  or  on  some  unknown  law-regulating  function  through  the 
mind,  further  observation  alone  can  determine. 

In  the  meantime,  it  seems  to  me  that  we  are  indebted  to  Mr.  Braid 
not  only  for  having  first  clearly  demonstrated  that  the  phenomena  de- 
scribed are  wholly  occasioned  by  predominant  ideas  in  the  individual, 
but  for  the  first  contribution  of  any  value  to  the  mode  of  applying  this 
theory  to  the  cure  of  disease.  By  suggesting  thoughts  to  the  patients 
in  various  ways,  sometimes  by  speaking  so  that  they  may  hear  what  is 
said,  at  others  by  directing  their  thoughts  to  certain  subjects,  and  occa- 
sionally rendering  these  more  vivid  by  repetition  or  by  definite  physical 
impressions,  we  can  fix  certain  ideas  strongly  in  their  minds.  These 
ideas  act  as  stimulants  or  sedatives  according  to  their  purport,  and  the 
current  of  thought  directed  to  or  withdrawn  from  particular  organs  or 
functions.  Remarkable  cases  have  been  met  with,  where  a  judicious 
application  of  this  doctrine  has  removed  insomnolence  or  various  kinds 
of  pain,  spasms,  and  other  evidences  of  excitement ;  where  hysterical 
paralyses  of  the  limbs  or  special  organs  of  sense  have  been  relieved  or 
cured,  and  where  the  torpid  functions  of  lactation,  perspiration,  defisca- 
tion,  menstruation,  etc.,  have  been  rendered  more  active.f     That  such 

*  The  wonderful  cures  performed  by  Mesmer,  and  all  those  who  have  convinced 
themselves  and  others  of  the  advantages  of  the  ephemeral  systems  which  are  continu- 
ally springing  up  around  us,  are  much  indebted  to  belief  in  their  efficacy  on  the  part 
of  the  patient.  Dr.  Haygarth,  of  Bath,  performed  all  the  cures  of  Mesmer  and  Perkins 
with  two  bits  of  wood  made  to  resemble  the  metallic  tractors  of  the  latter. — that  is, 
so  long  as  he  kept  the  secret, — for  the  moment  he  published  his  book,  and  the  impo- 
sition was  known,  no  more  cures  were  accomplished.  In  the  same  manner,  there  is 
every  reason  to  believe  that  the  eflQcacy  of  many  public  nostrums  resides  in  the  repu- 
tation which  surrounds  them.  Miss  Harriet  Martineau,  in  publi-shing  her  own  case, 
naively  remarks: — "If  at  any  time  during  my  illness  I  had  been  asked,  with  serious 
purpose,  whether  I  believed  there  was  no  resource  for  me  ?  I  should  have  replied 
that  Mesmerism  might  perhaps  give  me  partial  relief " — {Letters  on  Mesmerism,  1845, 
p.  4.)  No  wonder,  therefore,  that  when  at  length  it  icas  tried,  it  produced  the  desired 
effect ;  and  the  medical  attendant,  seeing  the  delusion  that  existed,  perhaps  acted 
judiciously  in  bringing  the  lady  en  rapimrt  with  the  fir.st  magnetiser  he  could  procure. 

f  See  Braid  ou  Hypnotic  Therapeutics — Monthly  Journal  of  Medical  Science, 
July,  1S53. 


INFLUENCE  OF  PREDOMINANT  IDEAS  ON  THE  BODY,   SOI 

results  may  be  induced  must  be  admitted  by  all  who  reflect — 1st,  On 
the  undoubted  fact  that  certain  persons  are  and  can  be  made  slaves  of 
dominant  ideas;  and  2d,  On  the  equally  undoubted  fact  that  such  mental 
ideas  are  known  by  universal  experience  to  exercise  a  stimulating  or 
depressing  eft'ect  on  all  the  bodily  functions.  Hence  the  beneticial 
effects  of  many  drugs  and  systems  of  treatment,  which  are  really  inert 
or  uncertain  in  their  action,  and  whicb  are  supposed  to  act  through  the 
blood  or  on  the  tissues  directly,  operate  by  exciting  expectant  ideas,  and 
through  these  ideas,  indirectly  on  the  parts  disordered. 

On  the  other  hand,  the  indiscriminate  performance  of  experiments  on 
nervous  individuals  may  be  injurious.  During  the  session  of  1850-51, 
society  in  Edinburgh  was  greatly  agitated  by  this  subject.  Fashionable 
parties  were  converted  into  scenes  of  experiments  on  the  cerebral  func- 
tions. Noblemen,  members  of  the  learned  professions,  and  respectable 
citizens,  amused  themselves  in  private,  whilst  public  discourses  and 
exhibitions  to  an  unusual  extent  were  got  up  for  the  entertainment  of 
the  public.  On  one  occasion  the  Ro^'al  Medical  Society  was  operated 
on ;  and  if  a  proof  of  the  correctness  of  the  facts  described  be  required, 
it  would  be  found  in  the  circumstance,  that  the  nervous  aberrations 
noticed  were  readily  exhibited  in  some  of  its  most  sceptical  members. 
The  result  of  this  excitement  was  an  increased  degree  of  nervousness  in 
many  individuals.  In  some  educational  establishments,  girls  and  boys 
threw  themselves  into  states  of  trance  and  ecstasy,  or  showed  their  fixed 
eyeballs  and  rigid  limbs,  for  the  amusement  of  their  companions.  Sensi- 
tive ladies  did  not  object  to  indulge  in  the  emotions  so  occasioned,  and 
exhibited  themselves  in  a  like  way  for  the  entertainment  of  evening 
parties.  Several  instances  were  known  to  me  where  intelligent  young 
men — students  in  this  University — were,  for  a  longer  or  shorter  time, 
incapacitated  from  following  their  ordinary  occupations,  and  obliged, 
from  want  of  attention  and  mental  power,  to  stay  away  from  their 
classes.  Some  of  these,  from  a  feeling  of  the  injury  they  have  sustained, 
very  properly  refused  to  allow  any  experiments  to  be  tried  on  them ; 
and  the  parents  of  very  sensitive  young  persons,  from  the  obvious  detri- 
ment their  health  has  sustained,  also  forbade  a  repetition  of  these  scenes. 
One  young  man  of  great  promise,  who  was  at  that  time  fi-equently 
operated  on,  is  at  this  moment  in  a  lunatic  asylum.  I  thought  myself 
w'arranted  in  calling  such  a  state  of  things  "  The  Edinburgh  Mesmeric 
Mania  of  1851." 

Such  experiments  cannot  be  considered  as  free  from  danger.  The 
great  object  of  all  who  seek  proper  self-education  is  to  control  the  emo- 
tions and  passions,  and  regulate  the  imagination  by  the  severer  faculties 
of  judgment,  comparison,  and  attention.  Hitherto  medical  men,  so  far 
from  exciting,  have  done  all  in  their  power  to  prevent  such  phenomena 
as  have  been  described ;  but  now,  that  it  has  been  clearly  shown  that 
they  may  be  produced  in  numbers  of  people  by  the  ignorant  and  mer- 
cenary, every  effort  should  be  made  to  discourage  them.  It  is  well 
known  that  cases  are  on  record  of  individuals  who,  commencing  by  the 
imitation  of  hysterical  or  epileptic  convulsions,  have  at  length  found 
themselves  really  labouring  under  those  diseases  ;  nor  is  it  unreasonable 
to  suppose,  that  the  mental  faculties  will  be  greatly  injured  in  persons 
who  frequently  surrender  up  their  own  wills,  and  act  in  accordance  with 


302  PRINCIPLES   OF  MEDICINE. 

the  extravagant  ideas  suggested  to  them.  After  all,  the  pleasure  of 
excitement  principally  consists  in  feeling  that  it  can  be  regulated,  and  is 
under  command.  The  moment  it  ceases  to  be  so,  a  sense  of  the  imper- 
fection becomes  most  agonizing  to  the  mind,  and  gives  rise  to  that 
despondency  so  common  among  the  insane.  Hence  those  only  who 
have  studied  this  subject,  and  are  prepared  as  medical  men  to  exercise 
judiciouslv  the  influence  they  may  possess  on  the  minds  of  their  pa- 
tients, ought  to  attempt  the  cure  of  nervous  diseases  in  the  manner  now 
referred  to. 

If,  then,  it  has  been  satisfactorily  shown,  in  consequence  of  our  ad- 
vanced knowledge  of  diagnosis  and  pathology,  that  an  antiphlogistic 
practice  is  opposed  to  the  cure  of  diseases  of  nutrition,  whilst  predomi- 
nant mental  ideas  may  be  made  to  influence  diseases  of  innervation,  it 
follows  that  many  of  the  principles  which  have  hitherto  guided  us  in 
their  treatment  must  be  considerably  modified.  That  medical  practice 
has  undergone  a  great  revolution  during  the  last  fifteen  years,  is  a  fact 
already  so  well  established,  that  it  can  be  no  longer  denied.  Firmly 
believing  that  many  of  the  changes  which  have  been  eff"ected  are  per- 
manent improvements  in  our  art,  and  may  be  traced  to  the  advance  in 
the  sciences  on  which  that  art  is  based,  it  will  be  our  especial  object  in 
the  succeeding  pages  to  point  out  in  what  way  more  perfect  principles 
have  led  to  a  better  practice.  Amid  the  multiplicity  of  conflicting  state- 
ments, and  the  clashing  of  opposing  systems,  it  will  be  our  honest  desire 
to  separate  what  is  known  from  what  is  unknown,  and  lay  down  such 
rules  for  treatment  as  both  science  and  experience  may  alike  confirm. 


SECTION  IV. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  diagnosis  of  nervous  disorders  is  dependent  on  a  kind  of  knowledge 
altogether  different  from  that  appertaining  to  the  consideration  of  cuta- 
neous, pulmonary,  or  cardiac  affections.     In  these  last,  as  we  shall  see,  a 
direct  appeal  to  the  senses  enables  us  to  arrive  at  conclusions  with 
tolerable  accuracy.     An  arbitrary   classification  of  skin  diseases   once 
established,  with  clear  definitions,  we  have  only  to  apply  these  to  the 
appearances  observed  to  ascertain  the  disorder.     Once  master  the  prac- 
tical difficulty  of  distinguishing  with  exactitude  moist  from  dry  rales — 
whether  a  murmur  replace  the  first  or  second  sound  of  the  heart,  and 
what  is  its  position,  and  we  possess  a  key  which,  with  the  aid  of  per- 
cussion, will  frequently  enable  us  to  arrive  at  the  certain  diagnosis  of 
pulmonary  and  cardiac  affections.     But,  with  regard  to  nervous  diseases, 
no  such  exactitude  is  attainable  in  the  present  state  of  the  science  or  art 
of  medicine.     The  encephalon  is  an  aggregation  of  various  parts,  more 
or  less  connected  together,  the  functions  of  Avhich  are  by  no  means 
determined.     In  health  these  act  in  liarmony,  but  in  disease  they  are  so 
irregularly  disordered  that,  while  the  action  of  one  is  excited,  that  of 
another  may  be  perverted  or  annihilated.     Then,  again,  we  frequently 
observe  that  some  of  the  most  fatal  nervous  diseases,  such  as  hydro- 
phobia,  leave  after   death    no   lesion    detectable   by  the  most  careful 
histological  examination,  whilst  on  other  occasions  tumours  and  extensive 
destruction  of  the  cerebral  mass  may    exist,    without   producing   any 
symptoms  whatever.     And  yet,  notwithstanding  the  obvious  difficulties 
which  oppose  themselves  to  exactitude  of  diagnosis  of  nervous  diseases, 
careful   observation,  conjoined  with    a  knowledge    of  physiology    and 
pathology,  will  enable  us  to  approximate  closely  towards,  if  not  actually 
to  reach,  a  correct  opinion  in  the  great  majority  of  cases. 

The  same  circumstances  render  a  pathological  classification  of  nervous 
diseases  impossible.  Thus  any  one  special  lesion  may  produce  the  most 
remarkably  difterent  effects,  according  as  it  occurs  rapidly  or  slowly ;  as 
it  is  single  or  multiple  ;  as  it  is  small  or  great  in  amount ;  as  its  nature 
is  simple  or  compound  ;  or  as  it  aftects  difterent  parts  of  the  nervous 


804  PRINCIPLES   OF   MEDICINE. 

mass.  Thus  tlie  compound  functional  character  of  the  brain  alone,  if 
disordered,  may  give  rise  to  increase,  perversion,  or  loss  of  three  func- 
tions, viz.,  intelligence,  sensation,  and  motion,  each  as  difterent  in  its 
modes  of  manifestation  and  effects,  as  are  the  important  func- 
tions of  digestion,  respiration,  and  secretion.  Neither  can  we  satis- 
factorily arrange  nervous  diseases  in  accordance  with  the  symptoms 
which  may  be  present,  as  these  are  so  various  and  so  complicated  in 
different  cases.  This,  however,  is  the  method  which  has  stamped  its 
features  on  medical  literature  since  the  days  of  Hippocrates,  and  from 
which,  in  consequence,  without  anything  more  certain  to  offer,  it  is  in 
the  present  state  of  medical  science  impossible  to  escape.  What  we, 
however,  strenuously  contend  for,  is  the  inconsistency  in  our  nomen- 
clature of  applying  to  morbid  lesions  the  same  names  as  have  long  been 
recoo-nised  in  a  difterent  sense  as  indicating  groups  of  symptoms. 
Apoplexy,  for  instance,  is  not  necessarily  hemorrhage  into  the  brain,  nor 
does  every  hemorrhage  produce  apoplexy.  If,  then,  we  use  a  mixed 
classification  which  seems  to  be  the  best  now  open  to  us,  that  is,  one 
partly  anatomical,  founded  on  altered  structures,  and  partly  physiological, 
founded  on  altered  functions  (that  is,  symptoms) — let  us  define  accu- 
rately in  all  instances,  what  we  mean  by  the  names  employed.  Thus 
w^e  can  use  the  terms  congestion,  softening,  and  suppuration  of,  or 
exudation,  effusion,  and  hemorrhage  into  the  brain  and  spinal  cord,  as 
w^e  do  when  these  lesions  affect  any  other  organs.  But  we  should 
understand  by  ajjoplexy,  loss  of  consciousness  and  voluntary  motion, 
beginning  at  the  brain ;  by  epilcjisy^  paroxysmal  loss  of  consciousness 
with  convulsion ;  by  spasm,  increased  tonic ;  and  by  convulsion, 
increased  clonic  contractions  of  the  muscles;  and  by  jxiralf/sis,  loss  of 
motor,  or  sensitive  power  of  a  part,  etc.  If  we  employ  morbid  lesions 
to  designate  the  disease,  we  regard  groups  of  symptoms  as  their  effects. 
But  if  we  use  groups  of  symptoms  to  denominate  the  disease,  then, 
how^ever  well  we  may  observe  these,  we  are  often  incapable  of  deter- 
mining what  are  the  structural  changes  on  which  they  immediately 
depend. 

The  key  to  the  diagnosis  of  nervous  diseases  will  be  found  in  the 
general  sketch  we  have  given  of  the  function  of  innervation  (p.  Ill), 
and  especially  in  the  pathological  laws  which  regulate  diseased  action  of 
the  nervous  system ;  and  to  these  we  refer  the  reader  (p.  115).  The 
morbid  anatomy  of  the  nervous  system  will  be  found  treated  of  in  various 
parts  of  the  work.*  But  there  is  one  predominant  lesion,  which  has 
lately  had  much  light  thrown  upon  it  histologically,  and  which  is  so 
important  in  a  diagnostic  point  of  view,  that  we  propose  alluding  to  it, 
before  entering  on  the  consideration  of  individual  nervous  diseases. 

*  Congestion  of  the  cerebral  vessels,  pp.  115  to  11 S.  Exudative  softenings,  pp. 
131,  132.  Albuminous  degeneration,  pp.  213,  214.  Pigmentary  degeneration, 
p.  227.     Mineral  degeneration,  p.  235. 


CEREBRAL   AND   SPINAL   SOFTENINGS. 


305 


ON  THE  PATHOLOGY  OF  CEREBRAL  AND  SPINAL  SOFT- 
ENINGS, AND  ON  THE  NECESSITY  OF  EMPLOYING  THE 
MICROSCOPE  TO  ASCERTAIN  THEIR  NATURE. 

The  nature  of  cerebral  and  spinal  softening  has  been  much  disputed. 
Some  attribute  it  entirely  to  chronic  or  acute  inflammation  ;  others, 
while  they  acknowledge  that  softening  is  undoubtedly  thus  produced, 
are  also  of  opinion,  that  it  may  occasionally  depend  upon  other  causes. 
Thus  softening  has  been  considered  a  lesion  sui  generis^  similar  to  what 
occurs  in  ata'xic  fever  (Recamier),  to  gangrena  senilis  (Rostan,  Aber- 
cromby),  to  obliteration  of  the  arteries  (Bright,  Carswell),  or  to  a 
diminution  of  nutrition  (Delaberge,  Monnevet).  It  has  also  been  referred 
to  post  mortem  maceration  (Carswell,  Paterson  of  Leith),  and  is 
undoubtedly  often  produced  by  mechanical  violence  after  death.  The 
difficulty  hitherto  has  been  how  to  distinguish  with  precision  one  kind 
of  softening  from  another. 

From  a  "careful  analysis  of  numerous  cases  of  cerebral  softenings,  I 
have  arrived  at  the  conclusion  that  they  may  originate  in  six  ways. 
1st,  From  exudation  which  is  infiltrated  among  the  elementary  nervous 
structures ;  2c?,  from  a  mechanical  breaking-up  of  these  structures  by 
hemorrhagic  extravasations,  whether  in  large  masses  or  infiltrated  in 
small  isolated  points ;  3d,  from  fatty  degeneration  of  the  nerve  cells, 
independent  of  exudation ;  ith,  from  the  mere  imbibition  of  serum 
which  loosens  the  connection  between  the  nerve  tubes  and  cells;  oth,  from 
mechanical  violence  in  exposing 
the  nervous  centres  ;  and  6th,  from 
putrefaction. 

1st,  Exudative  or  inflammatory 
softening  always  contains  granules 
and  granule  cells,  which  are  nume- 
rous according  to  the  degree  of 
softening.  The  granules  are  for 
the  most  part  seen  coating  the 
vessels  (Figs.  Ill,  311,  and ^2 9 4), 
and  the  cells  also  may  occasionally 
be  seen  there  in  various  stages  of 
development  (Fig.  113).  In  the 
demonstrations  that  are  made  under 
the  microscope,  they  are  frequently 
seen  diffused  among  the  tubes  (Fig. 
381),  which,  according  to  the  se- 
verity and  extent  of  the  lesion,  are 

easily  separated  from  one  another,  or  broken  up  in  a  variety  of  ways. 
When  recent,  the  serum  which  accompanies  the  exudation  is  infiltrated 
into  the  nervous  substance,  and  may  assist  occasionally  in  producing  soft- 


Fis.   881. 


Fig.  381.  Structure  of  inflammatory  exudative  softening  of  the  lumbar  portion  of 
the  spinal  cord,  showing  granule  cells  infiltrated  among  the  nerve-tubes  in  a  para- 
plegic individual.— (TFedi.)  250  diam. 

20 


306 


DISEASES   OF  THE   NEEVOUS   SYSTEM. 


ening,  although  for  the  most  part  it  is  rapidly  absorbed.  In  chronic 
cases  this  form  of  softening  may  be  regarded  in  one  sense  as  a  fatty 
degeneration,  although  Avhen  speaking  of  this  last  lesion,  I  have  stated 
my  reasons  for  considering  it  as  a  transformation  of  the  exudation,  and 
not  of  the  nervous  substance.  (See  p.  222.)  Simple,  tubercular,  and 
cancerous  exudations,  alike  cause  cerebral  or  spinal  softenings,  as  shown 
by  the  presence  of  the  characters  peculiar  to  each.     Tubercular  masses 


i' 


.-.'^ 


.0>' 


Fis.  382. 


Fig.  383. 


in  the  brain  are  generally  surrounded  by  a  layer  of  cerebral  substance 
exhibiting  all  the  characters  of  this  form  of  softening  (Fig.  383).  Can- 
cerous exudation  into  the  brain  is  very  rare  (Fig.  277). 

2d,  Hemorrhagic  softening. — When  blood  is  extravasated  with  force 
into  the  cerebral  structure,  it  breaks  up  the  nerve-tubes  of  the  part  and 

coagulates.       The    coagulum     then 

forms  a  solid  mass,  whilst  the  serum, 
more  or  less  tinged  with  colouring 
matter,  is  infiltrated  to  a  greater  or 
less  distance  and  absorbed.  Under 
such  circumstances,  the  softened  ner- 
vous tissue  surrounding  the  clot  pre- 
sents fragments  of  the  nerve-tubes 
alone,  which  under  the  microscope 
frequently  exhibit  a  peculiar  ten- 
dency to  form  circular,  oval,  or  irre- 
gularly-formed globules,  with  double 
outlines,  as  in  Fig.  384.  There  are 
none  of  the  granule  cells  so  charac- 
teristic of  an  inflammatory  softening, 
although  they  may  appear  later,  as 
the  result  of  exudation  from  the  cere- 
bral vessels  surrounding  the  clot.  In  such  cases  the  greatest  variation  in 
the  appearance  of  the  nerve-tubes  is  observable,  from  a  slight  diminution 
in  their  natural  firmness  and  consistence,  which  renders  them  easily 
separable,  or  causes  varicosities  or  swellings  in  them  to  be  readily  pro- 


Fis.  3S4. 


Fig.  382.  Structure  of  a  tubercular  exudation  in  the  cerebellum,  composed  of  gra- 
nules and  tubercle  corpuscles,  with  a  few  fragments  of  nerve-tubes. 

Fig.  383.  Structure  of  the  softened  cerebellum,  immediately  external  to  the  same 
tubercular  mass,  containing  a  larger  number  of  fragments  of  the  nerve-tubes,  with 
numerous  granular  corpuscles. 

Fig.  384.  Structure  of  the  softened  cerebral  substance,  surrounding  a  recent  clot 
of  blood,  showing  the  appearance  assumed  by  the  nerve-tubes  when  broken  up,  and 
softened  by  imbibition  with  serum. — See  Apoplexy,  case  of  Pitbladdo.    250  diam. 


CEREBRAL  AND   SPINAL   SOFTENINGS. 


807 


duced  on  pressure,  up  to  a   condition  when  tliey  exhibit  nothing  but 
fragments  and  separate  globules,  as  in  fig.  384. 

The  coloured  cerebral  softenings  wliich  are  subsequently  produced  as  a 
resultof  hemorrhage  arc  owing  to  the  transformations  which  go  on  in  the 
coagiilum  itself.  They  assume  a  bright  orange,  brick  red,  yellow,  fawn, 
or  dirty  brown  colour,  and  under  the  microscope  are  found  to  consist  of 
hematine  in  various  forms  and  tints.  Thus  the  whole  may  be  granular, 
or  mingled  with  crystals  of  hematoidine  or  melanine  ;  and  the  granules, 
granular  masses,  and  celloid  degenerations,  may  present  numerous  shades 
of  orange,  red,  brown,  black,  etc.  etc.  (See  Pigmentary  Degeneration, 
p.  227, "fi!  seq.) 

3'/,  True  fatty  softcninr/. — This  lesion,  that  is,  a  primary  fatty  dege- 
neration independent  of  exudation  or  hemorrhage,  is  one  of  the  exist- 
ence of  which  I  was  for  a  long  time  very 
doubtful.  Careful  investigation,  how^ever, 
has  satisfied  me,  that  it  does  occasionally, 
though  rarely,  present  itself,  apparently  as  a 
consequence  of  obstruction  of  arteries.  In 
this  case  the  vessels  are  not  coated  necessa- 
rily with  granular  exudation,  but  the  nerve- 
cells  undergo  the  fatty  degeneration  pi'ima- 
rily  and  are  enlarged.  The  walls  of  many 
of  them  also  are  dissolved,  leaving  triangu- 
lar or  crescentic-shaped  granular  masses  be- 
tween the  nerve-tubes.  This  alteration  is 
accompanied  with  diminution  of  the  cere- 
bral density,  and  the  nerve-tubes  are  also  easi- 
ly separated  and  bi-oken  up,  though  not  so 
readily  as  in  the  last  form  of  softening  noticed. 

4fh,  Serous  or  dropsical  softening. — This  kind  of  softening  is  due  to 
imbibition  of  the  serum,  which  is  effused  into  the  ventricles  in  cases  of 
hydrocephalus  and  other  diseases.  Hence  it  is  only  found  in  the  neigh- 
bourhood of  such  effusions,  and  most  commonly  in  the  central  portions 
of  the  brain,  as  in  the  white  matter  of  the  septum  lucidum,  fornix,  etc. 
It  is  the  white  softening  of  morbid  anatomists,  and  consists  structurally 
of  nothing  but  the  oedematous  normal  elements  of  the  parts,  without 
any  of  the  changes  peculiar  to  the  exudative,  hemorrhagic,  or  true  fatty 
softenings.  The  observations  of  Dr.  Robert  Paterson  of  Leith  tend  to 
show  that  the  brain  substance  is  very  porous,  and  that  if  a  slice  of  it  is 
placed  in  water,  it  readily  imbibed  a  considerable  quantity,  becoming  at 
the  same  time  more  soft.  Whether  such  softening  ever  occurs  in  the 
living  body  is  very  doubtful ;  it  is  most  probably  a  post-mortem  change. 
Sometimes  serum  is  found  to  a  considerable  extent  in  the  ventricles, 
without  softening  of  the  surrounding  parts.  The  fluid  apparently  in 
such  cases  has  not  passed  through  the  lining  membrane  of  the  ventri- 
cles.    At  other  times  this  has  occurred,  and  the  softening  so  occasioned 


Fig.  385. 


Fig.  385.  Structure  of  the  softened  pons  varolii,  in  a  ease  wliere  tlae  basilar  artery 
was  obstructed,  shewing  true  fatty  degeneration  of  the  nerve-cells,  among  somewhat 
softened  and  broken  up  nerve-tubes. — See  Cerebral  Hemorrhage,  case  of  Alexander 
Walker.  250  diam. 


308  DISEASES   OF   THE   NEPwVOUS  SYSTEM. 

is  found  to  be  greatest  near  tbe  central  parts,  and  to  diminish  according 
to  the  distance  from  them.  The  causes  which  pioduce,  and  at  others 
impede,  post-mortem  imbibition  are  unknown. 

6th,  Mechanical  softening. — I  have  frequently  seen  softenings  occa- 
sioned in  the  brain,  and  more  frequently  still  in  the  spinal  cord,  through 
crushing  the  nervous  texture,  after  death,  in  various  ways.  Thus  the 
saw  or  chisel  mav  occasion  mechanical  softenings  in  the  superficial  parts  of 
the  brain,  when  the  calvarium  is  being  removed  by  inexperienced  or  unskil- 
ful operators.  In  France,  where  the  hammer  is  used  for  this  purpose,  it  is  a 
frequent  cause  of  supei-ficial  softenings.  The  spinal  cord  is  especially  liable 
to  be  injured,  bv  slipping  of  the  chisel  or  lever  used  in  elevating  the  pos- 
terior spinous  processes  of  the  vertebrse.  Portions  of  soft  nervous  tissue, 
such  as  the  corpus  striatum,  have  frequently  had  their  texture  reduced 
to  a  pulpy  consistence  by  mere  handling,  or  by  constant  application  of 
the  fin<Ter  simplv  to  ascertain  whether  it  be  softened  or  no.  I  have 
seen  softeninors  exactly  resembling  such  as  may  be  occasioned  by  disease, 
produced  in  all  these  ways,  and  thus  give  rise  to  most  erroneous  conclu- 
sions. They  are  only  to  be  distinguished  by  a  microscopical  examina- 
tion, and  bv  a  careful  consideration  of  the  symptoms  observed  during 
life,  and  of  the  causes  which  probably  may  have  produced  them  after 
death. 

Qth,  Putrefactive  softening. — Tliis  may  occur  in  warm  weather,  from 
the  body  having  been  examined  long  after  death,  or  from  accidental 
causes.  Hence  the  necessity  of  always  stating  the  number  of  hours 
after  death  that  the  examination  is  made.  Such  softenings  are  always 
diffused  through  considerable  masses  of  cerebral  texture,  and  may  be  recog- 
nised bv  this  circumstance  combined  with  an  absence  of  all  the  signs 
which  distinguish  the  other  forms. 

Of  these  six  kinds  of  softening  found  in  the  body  after  death,  only  the 
first  three  occur  in  the  living  subject,  and  give  rise  to  symptoms,  and  of 
these  three,  the  pure  fatty  degeneration,  though  frequently  associated 
with  the  others,  has  been  so  seldom  noticed,  that  we  are  to  a  great  extent 
unacquainted  with  its  symptoms  as  a  special  lesion.  As  regards  the  last 
three,  they  have  been  frequently  confounded  by  morbid  anatomists  with 
the  others,  and  all  attributed  to  one  cause.  I  think  we  are  now  enabled 
to  distinguish  accurately  such  as  are  the  result  of  exudation  from  such  as 
are  not. 

From  a  careful  analysis  of  32  cases  of  softening  of  the  nervous  centres, 
which  I  published  in  1842-3,*  it  was  shown  that  difl:erent  symptoms 
were  connected  with  exudative  or  inflammatory,  from  those  which 
occurred  in  non-inflammatory  softening.  In  24  of  these  cases  in  which 
cerebral  softening  was  observed,  granular  coi-puscles  were  present  in  18, 
whilst  in  six  no  traces  of  these  bodies  could  be  found.  On  analysing  the 
svmptoms  of  the  24  cases,  a  marked  difi'erence  was  found  between  those 
resulting  from  the  two  lesions.  Thus,  in  the  cases  where  only  inflamma- 
tory softening  was  present,  well-marked  symptoms  invariably  existed, 
such  as  loss  of  consciousness,  preceded  or  followed  by  dulness  of  intel- 
lect, contraction  and  rigidity  of  the  extremities,  or  paralysis.  On  the 
other  hand,  in  the  six  cases  of  non-inflammatory  softening,  there  was  no 
paralysis  or  contraction,  and  no  dulness  or  disturbance  in  the  intellect. 
*  Edinburgh  Medical  and  Surgical  Journal,  Xos.  153,  155,  and  157. 


CEREBRAL  AND   SPINAL   SOFTENINGS.  309 

Again,  in  the  four  cases  wliere  both  lesions  were  present,  symptoms  were 
always  observed  in  the  side  of  the  body  opposite  to  the  seat  of  the 
inflammatory  softening,  but  none  existed  in  the  opposite  side  in  the  non- 
inflammatory. An  analysis  of  these  24  cases,  therefore,  leads  me  to  the 
conclusion,  that  the  two  kinds  of  softening  I  have  endeavoured  to  esta- 
blish, are  alike  distinguishable,  by  their  intimate  structure,  and  by  the 
symptoms  accompanying  them  during  life. 

Now  all  practical  men  agree  in  considering  it  a  matter  of  extreme  dif- 
ficulty to  reconcile,  with  any  certainty,  the  morbid  appearances  found  in 
the  brain,  with  the  symptoms  observed  during  life.  The  future  micro- 
scopic examination  of  the  softening  may  serve  to  prevent  much  of  the 
error  that  has  hitherto  been  committed.  For  instance,  softening  of  the 
fornix,  septum  lucidum,  and  central  parts  of  the  brain,  may  exist  in  two 
cases.  To  the  naked  eye  they  may  be  in  every  respect  identical,  and 
yet  the  microscope  enables  us  to  determine  that  the  one  contains  granular 
corpuscles,  whilst,  in  tlie  other,  not  one  of  these  bodies  is  to  be  found. 
It  becomes  evident,  then,  that  previous  to  this  distinction  having 
been  made,  two  diti'erent  lesions  were  confounded  together;  and  that  a 
difterent  train  of  symptoms  should,  under  such  circumstances,  be  occa- 
sioned, is  only  to  be  expected.  Again,  it  has  frequently  excited  surprise, 
that,  notwithstanding  the  existence  of  well-marked  symptoms  of  soften- 
ing, nothing  was  to  be  discovered  after  death.  Now  I  have  demon- 
strated in  several  instances  that,  although  to  the  naked  sight  no  morbid 
lesion  was  apparent,  still  portions  of  brain  might  contain  the  same  gra- 
nular corpuscles  as  are  to  be  seen  in  more  apparent  lesions;  and  that  by 
considering  such  parts  diseased,  all  the  symptoms  might  be  explained 
according  to  the  pathological  laws  I  have  previously  referred  to  (p.  115, 
et  seq.).  By  excluding  these  sources  of  error,  therefore,  and  by  distin- 
guishing the  lesion  dependent  on  inflammation  from  others  which  sti- 
mulate it,  we  shall  be  enabled  to  obtain  more  exact  data  for  future  inves- 
tigations. From  the  observations  recorded,  however,  the  two  following 
propositions  may,  I  think,  be  established.  \st.  That  patliologists  have 
often  confounded  softening  dependent  on  disease  during  life,  with  soften- 
ing occasioned  by  post-mortem  changes  or  mechanical  violence.  2f/, 
That  notwithstanding  the  most  anxious  search,  and  the  existence  during 
life  of  the  most  decided  symptoms  of  softening,  the  organic  disease,  though 
really  present,  has  frequently  escaped  observation. 


Proposition  1. —  That  patholof/ists  have  often  confounded  softening 
dependent  on  disease  during  life,  with  softening  occasioned  by  post- 
mortem changes  or  mechanical  violence. 

With  respect  to  this  proposition  it  may  be  observed  that,  in  many 
cases  where  no  symptoms  were  present  during  life,  extensive  softening 
of  the  brain  has  been  found  after  death.  This  is  a  well-known  fact,  and 
is  one  which  tends  in  no  small  degree  to  throw  confusion  on  the  patho- 
loo-y  of  nervous  diseases.  Thus,  in  one  case  of  a  series  I  published  in 
1843,*  there  was  extensive  softening  of  the  central  portion  of  the  brain, 

*  Pathological  and  Histological  Researches  on  Inflammation  of  the  Nervous  Centres. 
By  the  Author.     Edinburgh,  1843. 


310  DISEASES   OF  THE  NERVOUS  SYSTEM. 

corpora  striata,  and  optic  thalami,  which,  however,  contained  no  granu- 
lar corpuscles.  The  symptoms  attending  these  lesions  were  sudden 
insensibility  and  convulsions,  which  evidently  depended  on  a  capillary 
apoplexy  that  was  also  present.  No  paralysis  or  contraction  existed. 
Four  other  cases  were  recorded,  w  ith  more  or  less  softening  of  the  brain, 
without  head  symptoms,  and  without  granular  corpuscles  in  the  softened 
portions. 

Now  in  all  these  five  cases  there  was  an  extensive  softening,  the 
nature  of  which  it  was  impossible  for  any  one  to  distinguish  positively, 
by  unaided  sight.  In  none  of  them  did  granular  corpuscles  exist,  and 
in  none  did  those  symptoms  occur  which  are  peculiar  to  softenings  pro- 
duced during  life. 

In  addition  to  these  five  cases  there  were  four  others,  where,  conjoined 
with  an  exudative  softening  producing  particular  symptoms,  there  was 
also  a  softening,  occasioning  no  symptoms  whatever,  and  containing  no 
granule  cells.  The  circumstances  attendant  on  these  nine  cases,  there- 
fore, must  convince  us  that  softenings  produced  mechanically,  or  by  post- 
mortem changes,  have  frequently  been  mistaken  for  those  occurring  dur- 
ing life,  and  must  necessarily  be  so,  so  long  as  unaided  sight  is  made  the 
sole  means  of  forming  a  judgment  with  respect  to  their  nature. 

A  perusal  of  these  cases  must  satisfy  any  one  that  pathologists  have 
hitherto  been  confounding  two  distinct  lesions,  viz.,  a  softening  depen- 
dent on  vital  changes,  and  a  softening  dependent  on  mechanical  or  other 
causes. 


Proposition  2. — That  notwithstanding  the  most  anxious  search,  and 
the  existence  during  life  of  the  7nost  decided  symjjtoms  of  softening,  the 
organic  disease,  though  really  present,  has  frequently  escaped  observation. 

In  the  series  of  cases  alluded  to  there  are  several  which  serve  to  esta- 
blish this  proposition,  of  which  I  may  more  especially  refer  to  two. 

Case  1,  a  man  had  paralysis,  with  complete  resolution  of  the  limbs 
on  the  right  side,  and  intense  rigidity  of  those  on  the  left.  Death 
occurred  in  six  hours.  On  dissection,  a  large  coagulum  of  blood  was 
discovered  in  the  left  hemisphere,  thus  explaining  the  paralysis  on  the 
right  side.  In  the  right  hemisphere  an  old  apoplectic  cyst  was  found, 
and  a  number  of  small  cavities,  described  by  Dr.  Sims  as  chronic  soften- 
ing undergoing  a  cure.  Here,  then,  there  was  nothing  acute,  nothing 
to  explain  the  intense  rigidity.  A  microscopic  examination  demonstrated 
that  these  cavities  contained  numerous  granular  corpuscles  and  granules, 
thus  proving  tlie  existence  of  structural  changes  in  the  right  lobe  of  the 
brain,  and  explaining  the  rigidity  on  the  left  side  of  the  body. 

Case  2  was  that  of  a  man  who  entered  the  Infirmary,  under  Dr. 
Paterson,  in  1842.  All  the  symptoms  of  acute  softening  were  present; 
paralysis  of  the  left  side,  including  rigidity  and  contraction  of  the  left 
arm,  dnlness  of  intellect,  and  tonic  spasms  of  the  muscles  of  the  mouth 
and  neck.  The  right  side  was  also  atfected  in  a  slighter  degree.  As 
the  case  excited  considerable  interest,  great  care  was  taken  in  examining 
the  brain  after  death.  When  the  lateral  ventricles  were  opened,  it 
became   a  question  whether  the   right   corpus   striatum  was  softened. 


CEREBRAL   AXD   SPINAL   SOFTENINGS.  311 

Several  persons  applied  their  fino-ers,  and  endeavoured  to  ascertain  the 
point.  As  the  manual  examination  proceeded,  the  normal  consistence 
of  the  part  diminished,  until  at  length  it  presented  all  the  appearance  of 
pultaceous  softening.  In  this  state  it  was  shewn  to  Dr.  Paterson,  who 
naturally  enough  considered  it  to  be  the  result  of  disease.  I  ditFered 
from  him  in  opinion,  first,  because  I  had  carefully  observed  the  gradual 
increase  of  the  softenmg  in  the  manner  alluded  to;  and  secondly, 
because  disease  of  the  corpus  striatum,  in  one  side  of  the  brain,  could 
not  have  explained  the  well-marked  symptoms  which  existed  on  both 
sides  of  the  body.  When  the  pons  varolii  was  bisected,  Dr.  Peacock, 
who  conducted  the  examination,  conceived  it  to  be  softened  ;  others 
who  examined  it  could  perceive  no  difference  in  the  texture  ;  its  colour 
and  consistence  were  unchanged.  Reasoning  from  the  symptoms,  the 
lesion  was  verv  likely  to  exist.  But  how,  it  was  argued,  could  a  judg- 
ment be  formed  ;  we  ought  to  reason  from  facts,  not  theories  ?  Here, 
then,  was  an  evident  lesion  of  the  corpus  striatum,  which  explained 
nothing,  and  a  problematical  lesion  of  the  pons  varolii,  which,  however, 
did  it  exist,  would  satisfactorily  account  for  the  symptoms.  In  this 
state  of  uncertainty  the  microscope  was  sent  for,  and  I  demonstrated, 
and  made  evidentto  Drs.  Paterson,  Peacock,  and  all  the  students  pre- 
sent, that  the  corpus  striatum  contained  no  granular  corpuscles,  whilst 
in  the  pons  varolii  they  were  very  abundant.  I  have  endeavoured  to 
describe  what  took  place  on  this  occasion,  from  which  it  must  be  evident 
that  had  not  the  microscope  been  appealed  to,  the  right  corpus  striatum 
would  have  been  pronounced  softened,  whilst  the  real  lesion  in  the  pons 
varolii  might  have  escaped  observation.  Under  such  circumstances  this 
case  woutd  have  added  another  to  the  inexplicable  observations  with 
which  the  records  of  nervous  diseases  abound. 

What  renders  these  cases,  and  several  others  I  could  relate,  so  remark- 
able and  satisfactory  is,  that  they  are  not  instances  where  the  dissection 
was  performed  in  a  hurried  manner,  and  by  incompetent  persons.  On 
the  contrary,  from  the  particular  symptoms  connected  with  them  during 
life,  the  post-mortem  examination  was  in  all  conducted  with  extreme 
care.  The  physician  who  had  charge  of  the  case  was  present.  The 
examinations  were  witnessed  or  conducted  by  myself,  in  the  presence  of 
clerks  and  numerous  students,  and  I  may  say  that  we  were  all  in  doubt 
until  the  microscope  cleared  up  the  difficulty.  These  cases,  therefore, 
sufficiently/  demonstrate  that  the  naked  sight  is  positively  unable  to  detect 
lesions,  even  although  they  are  directly  indicated  hy  the  symjytoms,  and  care- 
fulhf  looked  for  hy  exjjerienced  morbid  anatomists. 

If,  then,  the  two  propositions  formerly  stated  have  been  satisfactorily 
proved,  and  it  is  agreed  that  pathologists  have  been  confounding  vital 
with  post-mortem  softening,  and  overlooking  the  former,  although  un- 
doubtedly present,  it  must  be  evident  that  many  of  the  contradictions 
which  have  apparently  existed  in  connection  with  the  pathology  of  ner- 
vous diseases  mav  be  accounted  for.  It  must  also  be  clear  that  no 
confidence  can  be  placed  in  the  analysis  of  cases,  however  numerous, 
when  the  sources  of  error  now  indicated  have  not  been  carefully  ex- 
cluded. 


312  DISEASES   OF  THE   NERVOUS  SYSTEM. 

ACUTE  HYDROCEPHALUS. 

Case  I.* — Acute  Hydrocephalus — Recovery. 

History. — Janet  Reid,  jet.  12 — admitted  June  12th,  1850.  About  three  weeks 
ago  she  fell  dowTi  and  struck  the  back  of  her  head  violently,  but  soon  recovered, 
and  remained  well  until  two  days  ago,  when  febrile  symptoms,  with  headache,  occurred. 
The  following  morning  these  continued,  and  vomiting  came  on,  with  great  restless- 
ness, and  crying  at  night. 

Symptoms  ox  Admission*. — On  admission,  she  is  very  drowsy,  and  starts  occa- 
sionally in  her  sleep.  When  roused  she  is  fretful  and  irritable,  and  complains  of 
headache.  The  pupils  are  dilated,  but  contractile  on  exposure  to  a  strong  light ; 
pulse  104,  of  good  strength  ;  skin  hot ;  tongue  covered  with  a  white  fur,  and  dry ; 
no  appetite:  great  thirst;  bowels  not  open  for  two  daj's.  Urine,  sp.  gr.  lOSO,  with 
phosphatic  deposits.  ^.  Calomel,  gr.  iij  ;  Pulv.  Scammon.  gr.v.,  Fiant  pulv.  tales 
duo.     Sumat  unum  statim,  et  alterum  jjost  horas  tres. — Applicent.  hirudines  iv.  capiti. 

Progress  of  the  Case. — June  13</t— Leeches  bled  well.  Took  both  powders,  and 
had  an  injection,  which  brought  away  one  stool  of  a  dark  greenish  colour.  Still  com- 
plains of  pain  in  the  head,  and  general  uneasiness  when  moved.  But  there  has  been 
no  more  vomiting,  and  there  is  no  intolerance  of  light.  Pupils  natural ;  pulse  120, 
rather  sharp ;  skin  still  hot  and  dry ;  continues  drowsy,  and  fretful  when  moved ; 
tongue  white  and  moist. — Sumat  Ext.  Setmce,  3ij,  ex  aqua,  et  repetatur posthoras  qtui/- 
iuor  si  opus  sit.  June  loth. — No  headache,  and  not  so  drowsy.  June  22d. — Since 
last  report  has  been  gradually  improving;  the  febrile  s}-mptoms  have  ceased,  and  she 
was  dismissed  quite  well. 

Case  Il.f — Acute  Hydrocephalus  in  a  Scrofulous  Child — Recovery. 

History. — John  M'Aulay,  set.  9,  son  of  a  servant — admitted  July  5,  1855.  This 
boy  is  of  a  scrofulous  constitution,  and  was  admitted  into  the  Surgical  Hospital,  June 
22d,  for  a  scrofulous  sore  on  the  left  ankle.  Three  days  afterwards  he  was  attacked 
with  scarlatina,  which  ran  a  mild  course,  and  from  which  he  was  convalescent  on  the 
29th.  June  30?/t,  however,  he  complained  of  not  having  slept,  vomited  several  times, 
and  was  very  restless.  July  1st,  he  refused  to  eat  anything,  and  in  the  course  of  the 
day  screamed  violently  several  times.  There  was  also  cephalalgia,  drowsiness,  pho- 
tophobia, and  great  irritation  when  roused.  In  this  condition  he  remained  until 
admitted  into  the  Medical  Clinical  ward,  the  tendency  to  constipation  having  been 
counteracted  by  the  administration  of  purgatives  twice. 

Symptoms  ox  Admissiox. — On  admission,  the  face  is  pinched,  and  expressive  of 
great  irritability.  He  cries  fretfully  when  touched  or  disturbed.  The  eyes  are  spas- 
modically closed,  and  he  resists  all  attempts  to  open  them :  but  when  this  is  done, 
both  pupils  are  seen  to  be  dilated,  and  not  moveable  on  exposure  to  the  light.  On 
being  left  quiet,  he  turns  away  from  the  light,  and  relapses  into  a  doze,  interrupted  by 
occasional  moanings.  Pulse  slow  and  feeble,  difficult  to  count  from  resistance  of  the 
child ;  skin  and  head  of  natural  temperature.     There  is  still  a  scrofulous  ulcer  on  the 

*  Reported  by  Mr.  E.  S.  Wason,  Clinical  Clerk, 
■f-  Reported  by  Mr.  Robert  Byers,  CUnical  Clerk. 


ACUTE  HYDROCEPHALUS.  813 

left  ankle,  discharging  pus  of  an  oftensive  odour.  Tongue  furred ;  refuses  food  ; 
bowels  constipated ;  has  no  cough  or  pulmonary  symptoms,  and  has  never  had  stra- 
bismus, grinding  of  teeth,  convulsion,  or  paralysis. —  To  have  leef  tea,  milk,  and  nutri- 
ents, with  I  iij  of  sherry  loine  daily.  ^ .  Pulv.  Jalap,  gr.  v. ;  Hydrarg.  Chlorid. 
gr.  ij.  ;  ft.  pulv.  hard  somni  sumendns. 

Progress  of  the  Case. — July  6th.— At  seven  a.m.  passed  a  copious,  dark,  offen- 
sive stool.  Has  been  persuaded  to  take  a  little  milk,  but  refuses  other  nourishment. 
Still  fretful  and  irritable,  but  the  nurse  says  he  did  not  scream  or  toss  about  so  much 
during  the  night.  Pulse  64,  weak.  Otherwise  the  same.  July  \V.h. — Since  last 
report  the  general  irritability  has  somewhat  diminished,  and  last  night  he  slept  well. 
Has  gradually  been  induced  to  take  more  nourishment.  Does  not  scream  now,  but 
moans  occasionally,  and  tosses  about  until  exhaustion  produces  sleep.  Now  and  then 
he  puts  liis  hand  to  the  forehead,  and  says  he  feels  pain  there.  His  sight  is  occa- 
sionally dim,  but  at  other  times  he  sees  weU.  Cannot  sustain  any  train  of  thought 
or  conversation  long.  Still  constipation,  which  is  relieved  every  third  day  with  the 
powder  of  calomel  and  jalap.  July  20th. — There  has  been  gradual  improvement  on 
the  whole,  although  much  variation  from  day  to  day.  Some  nights  are  more  restless 
than  others,  with  occasional  screaming.  He  stQl  puts  his  hand  to  the  head,  which  is 
sometimes,  he  says,  "  sore."  The  pulse  has  varied  from  60  to  80.  The  appetite  has 
improved,  and  he  takes  more  nourishment.  Sight  and  memory  more  perfect.  Au- 
gust 3d. — Has  been  occasionally  screaming  a  good  deal  at  night,  but  is  now  much 
better,  and  walks  about  on  crutches,  the  scrofulous  sore  on  the  ankle  being  no  better. 
August  8ih.—lt  having  been  stated  tliat  he  was  aftected  with  worms,  he  has  taken  some 
doses  of  the  etherial  extract  of  the  Male  Shield  Fern,  followed  by  purgatives.  These 
have  produced  several  stools,  but  no  worms.  His  appetite  and  general  health  have 
now  been  greatly  restored.  There  is  no  pain  in  the  head,  or  restlessness  at  night, 
and  he  was  sent  back  to  the  sui-gical  wards  to  have  his  ulcer  treated. 

Commentary. — In  the  two  preceding  cases  we  have  good  examples 
of  that  congestive  and  irritative  state  of  the  brain,  which  occurring  in 
children  has  been  regarded  as  indicative  of  acute  hydrocephalus. 
Whether  in  either  of  them  the  disease  had  proceeded  to  actual  effusion 
it  is  of  course  difficult  to  determine,  although  the  pain  in  the  head  and 
restlessness  passing  into  somnolence  render  this  probable.  In  the  first 
case,  where  the  child  was  tolerably  healthy,  febrile  phenomena  with  ex- 
citement were  more  pronounced  than  in  the  second  scrofulous  case,  in 
which  exhaustion  was  evident  from  the  first.  Hence  why  a  few  leeches 
and  laxatives  constituted  the  treatment  in  the  girl  Reid,  although,  it  will 
be  observed,  that  their  employment  produced  no  marked  improvement 
in  the  symptoms,  the  pulse  on  the  following  day  being  120,  sharp,  the 
skin  hot  and  diy,  with  a  continuance  of  the  drowsiness.  Notwithstand- 
ing, no  further  antiphlogistic  remedies  were  persisted  in,  and  two  days 
subsequently  the  patient  became  convalescent.  In  the  second  case  an 
opposite  plan  of  treatment  was  practised  from  the  first.  Here  the  pulse 
was  slow  and  feeble,  the  symptoms  were  indicative  of  exhaustion,  and 
this  child  not  only  had  a  scrofulous  sore,  but  had  recently  recovered  from 
an  attack  of  scarlatina.  Nutrients  with  wine,  therefore,  were  persever- 
ingly  pressed  upon  the  patient,  notwithstanding  the  deficient  appetite 
and  nausea,  with  the  eff"ect  of  ultimately  establishing  a  recovery. 


314  DISEASES   OF   THE   NERVOUS   SYSTEM. 


Case  III.* — Acute  Hydrocephalus — Phtliisis  Pulmonalis — Death — Effusion  into  the 
Lateral  Ventricles — N'on-Iafiammatory  softening  of  the  central  parts  of  the  Brain — 
Meningitis  at  the  base  of  Cranium — General  Tuberculosis. 

History. — Mary  Ann  Flynn,  xt  6 — admitted  June  26,  1845.  She  is  an  intelligent 
child,  of  scrofulous  and  cachectic  appearance,  and  greatly  emaciated.  From  her  own 
statement,  she  had  influenza  a  year  ago,  and  has  had  a  cough  ever  since.  Her  diet 
has  always  been  very  poor,  chiefly  consisting  of  potatoes  without  any  milk  or  animal 
food.  Latterly  she  has  experienced  pain  in  the  head,  has  been  feverish  and  restless 
at  night,  and  j-esterday  she  vomited  several  times. 

Symptoms  on  Admission. — On  admission  she  complains  of  headache,  pain  in  the 
back,  great  thirst,  nausea,  and  cough.     The  pain  in  the  head  is  felt  over  the  fore- 
head, sometimes  extending  to  the  entire  head ;  is  constant  but  not  severe  at  present. 
She  has  also  slight  pains  in  the  back,  not  increased  on  pressure.     Her  intellectual 
powers  are  for  her  age  unusually  good ;  pupils  and  eyeballs  natural ;  never  had  fits  or 
other  derangement  of  the  nervous  system.     Slie  has  no  appetite,  refuses  all  food,  but 
constantly  desires  drink  ;  tongue  covered  with  a  whitish  fur ;  mouth  dry.     She  has 
not  vomited  since  admission,  but  complains  of  distressing  nausea ;  abdomen  feels 
natural ;  had  diarrhoea  of  light  yellow  fluid  stools  two  days  ago,  which  has  now 
ceased;  has  frequent  prolonged  cough,  not  accompanied  by  much  expectoration. 
On  percussing  the  chest,  there  is  comparative  dulness  under  the  right  clavicle,  and 
on  auscultation  over  this  part,  a  loud  moist  rattle  accompanies  the  inspiration,  ex- 
tending down  to  the  third  ril).     Here  also  there  is  bronchophony.     Similar  signs 
exist  on  the  right  side  posteriorly,  at  the  apex  of  lung,  and  over  the  rest  of  the  chest 
there  is  great  harshness  with  inspiration,  and  prolonged  expiration  with  occasional 
sibilation.     Respirations  are  26  in  the  minute ;    pulse  150,   small  and  somewhat 
hard ;  heart  sounds  rapid,  but  normal  in  character ;  skin  hot,  covered  with  perspiration ; 
head  unusually  warm. — Applicent.  hirudines  iv.  temporibus — Habeat  Vini  Ipecac.  §  ss. 
Progress  of  the  Case. — June  21th. — The  emetic  operated  powerfully ;  nausea 
removed  ;  headache  relieved  by  the  leeches ;  othens'ise  the  same.     July  2d. — Since 
the  28th  there  has  been  frequent  vomiting,  for  which  naphtha,  hydrocyanic  acid,  and 
other  remedies,  have  been  given  without  benefit.     Little  food  has  been  taken.     Loud 
gurgling  audible  under  right  clavicle ;  constant  cough,  with  purulent  expectoration. 
The  surface  is  pale,  and  she  cannot  be  spoken  to  or  touched  without  causing  cries 
and  moaning.     Bowels  open ;  stools  natural.     There  has  been  occasional  diarrhoea, 
which  has  been  checked  by  chalk  mixture.     Constant  pains  in  the  head,  with  great 
restlessness  at  night.    Pupils  slightly  dilated ;  pulse  100,  of  good  strength.    Abradatur 
Capillitium  et  applicet  Emp.  Lyttce.     Milk  diet  with  beef  tea  and  luine  in  small  quanti- 
ties.    July  7th. — Has  continued  much  the  same  since  last  report,  the  vomitmg  being 
considerably  less  frequent,  however.     Last  night  it  is  reported  she  was  comatose, 
and  could  not  be  roused,  and  that  convergent  strabismus  of  the  left  ej'e  was  undoubt- 
edly present.     To-day  she  is  lying  on  the  right  side,   the  knees  drawn  up  to  the 
abdomen;  the  face  pale;  surface  cool;  respiration  easy.    She  does  not  answer  ques- 
tions, or  protrude  her  tongue  when  desired,  although  her  eyes  and  look  are  intelli- 
gent.    No   paralysis.     Metallic   resonance  when  she  speaks  or  cries  under  right 
clavicle.     Pulse  104,  of  good  strength.     Habeat  Calomel,  gr.  ij,  tertid  qudque  hord. 
July  I2th. — There  has  been  alternate  looseness  and  constipation  of  the  bowels,  the 
stools  being  of  a  spinach  colour.     Sometimes  better,  at  others  complaining  of  great 
pain  in  the  head.     The  expression  of  countenance  is  now  worn  and  haggard,  with 
evident  anxiety ;  eye  and  mind  still  peculiarly,  and  even  painfully  intelligent.     No 

*  Reported  by  Mr.  D.  P.  Morris,  Clinical  Clerk. 


ACUTE   HYDROCEPHALUS.  315 

convulsion  or  paralysis,  but  great  restlessness  occasionally  at  night.  At  other  times 
she  sleeps  well.  Pulse  is  more  frequent  and  weak,  generally  about  150  a  minute. 
Omit.  Pulv.  Calomel.  Eabeat  Vini,  3  ij-,  secundd  qvAque  hord.  July  I3th. — Has 
been  gradually  sinking  since  last  report.  To-day  at  the  visit,  pulse  ISO,  feeble. 
Still  intelligent,  and  answers  questions.  Tongue  of  unchanging  colour.  Died  at  five 
P.M.,  apparently  from  exhaustion,  without  previous  coma,  strabismus,  convulsiousi 
rigidity,  or  paralysis. 

Sectio  Cadaveris. — Forty-three  hours  after  death. 

Body  greatly  emaciated. 

He.ud. — On  removing  the  dura  mater  from  the  superior  surface  of  the  hemispheres, 
the  arachnoid  covering  them  was  found  unusually  dry,  and  the  pia  mater  somewhat 
pale.  On  stripping  the  membranes  from  the  convolutions,  and  holding  them  up  before 
the  light,  they  could  be  seen  to  be  sprinkled  at  irregular  distances  with  minute  white 
hard  points,  having  the  appearance  of  tubercle,  deposited  in  the  sub-arachnoid  tissue. 
The  glaudulae  Pacchioni  could  easily  be  distinguished  from  them  by  their  situation, 
softer  consistence,  and  larger  size.  On  removing  slices  from  the  hemispheres,  fluctua- 
tion of  fluid  ua  the  ventricles  could  readily  be  felt  below.  A  puncture  was  cautiously 
made  in  the  roof  of  the  left  lateral  ventricle,  and  §  iiiss  of  colourless  serum  were 
removed  with  a  pipette.  On  declining  the  head  towards  the  left  side,  3  j  more  fluid 
was  removed,  which  had  evidently  passed  from  the  right  ventricle  into  the  left 
through  the  foramen  of  Monro.  This  last  portion  was  turbid,  and  contained  small 
floating  fragments  of  lymph.  On  opening  the  right  ventricle  it  was  collapsed.  The 
foramen  of  Monro  was  the  size  of  a  large  pea.  The  fornix,  internal  walls  of  the 
ventricle  and  cerebral  portions  in  the  neighbourhood  of  the  ventricles,  were  of  pulpy 
consistence,  but  of  their  normal  colour.  On  removing  the  brain  from  the  cranium, 
the  pons  varolii,  medulla  oblongata,  and  corpora  albicantia,  were  seen  to  be  covered 
with  a  layer  of  pale  gelatinous  lymph,  one-eighth  of  an  inch  in  thickness.  This  layer 
only  extended  to  the  medulla  oblongata  inferiorly,  where  it  passed  through  the 
foramen  magnum,  as  was  proved  by  careful  examination  of  the  spinal  cord,  which 
was  healthy  throughout.  The  third  and  fourth  ventricles  of  the  bram  were  enlarged, 
and  distended  with  serum.  The  left  lateral  ventricle  was  also  enlarged,  especially 
its  posterior  and  inferior  cornua.  The  enlargement  of  the  right  lateral  ventricle  was 
confined  principally  to  the  anterior  cornu. 

Chest. — Pleuras  on  right  side  sprinkled  with  miliary  tubercle,  situated  below  the 
serous  surface.  Both  lungs  studded  throughout  with  hard  miliary  tubercle,  of  a  grey 
colour ;  in  some  places,  however,  it  was  yellow  and  soft.  The  intervening  pulmo- 
nary tissue  was  of  a  bright  red  colour,  engorged,  but  pervious  to  air.  In  the  supe- 
rior lobe  of  right  lung  the  tubercles  were  closely  aggregated  together,  and  contained 
numerous  anfractuous  cavities  varying  in  size.  Some  were  lined  by  a  distinct  mem- 
brane, and  all  were  filled  with  scrofulous  pu.s.  Heart  and  vessels  healthy.  The 
bronchial  glands  enlarged  from  infiltration  of  yellow  cheesy  tubercle,  mixed  with 
pigmentary  deposit. 

Abdomes. — Liver  of  natural  size.  Gall  ducts  and  gall  bladder  distended  -n-ith 
fluid  green  bile.  Kidneys  healthy  in  size  and  general  structure,  but  the  cortical 
substance  sprinkled  over  with  minute  grains  of  tubercle.  Stomach  healthy.  The 
ilium  was  the  seat  of  tubercular  ulceration  throughout,  situated  principally  in  the 
aggregate  glands.  Large  intestines  healthy.  Mesenteric  and  lumbar  glands  for  the 
most  part  enlarged  in  consequence  of  tubercular  infiltration.  Spleen  throughout 
studded  with  yellow  cheesy  tubercle,  in  granules  varying  in  size  from  a  pin's  head 
to  that  of  a  pea.  Peritoneum  liere  and  there  dotted  over  with  hard  miliary  tubercle, 
deposited  however  below  the  serous  membrane. 


316  DISEASES  OF  THE  NERVOUS  SYSTEM. 

MiCRCSCOPic  ExAMiNATiox. — The  pale  gelatinous  Ij-mph  at  the  base  of  the  brain 
was  principally  composed  of  molecular  matter,  in  whicli  a  few  granular  cells  might 
here  and  there  be  detected.  The  turbid  fluid  at  the  floor  of  the  ventricles  contained 
epithelium  cells,  some  of  which  were  undergoing  the  fatty  degeneration.  The  white 
cerebral  softening  contained  no  granules  nor  granule  cells.  The  hard  grey  and  soft 
yellow  tubercles  in  various  parts  of  the  body  were  carefully  examined,  and  were 
found  to  present  their  usual  characters  (Figs.  133,  135). 

Commentary. — This  is  a  well  characterised  case  of  acute  hydroce- 
phalus in  a  child  also  affected  with  general  tuberculosis.  From  the  first 
it  was  certain  that  it  would  be  fatal,  for  in  addition  to  the  cerebral  lesion 
we  had  to  do  with  an  advanced  phthisical  condition.  AVith  the  excep- 
tion of  a  few  leeches  applied  immediately  on  admission,  and  afterwards 
calomel  in  small  doses,  the  treatment  generally  was  nutrient.  The 
appearances  after  death  are  strictly  in  accordance  with  all  the  symptoms 
which  were  carefully  observed  during  life.  Her  mind  througliout  was 
unaffected,  except  when  occasional  drowsiness  or  coma  prevailed,  and 
the  circumference  of  the  hemisphere  was  normal,  while  the  lesions 
observed  were  confined  to  the  ventricles  and  base  of  the  cerebrum. 
Then  there  was  no  paralysis  or  convulsion,  and  the  softening  of  the  cen- 
tral parts  was  proved  to  be  serous.  The  pain,  irritation,  stupor,  and 
other  symptoms,  are  readily  explicable  by  the  tubercular  meningitis  and 
gradual  distension  of  the  ventricles  with  fluid. 

The  nature  of  acute  hydrocephalus  has  been  keenly  disputed,  and 
whether  it  be  inflammatory  or  non-inflammatory,  and  should  be  treated 
with  antiphlogistics  or  nutrients,  will  be  found  to  be  discussed  at  great 
length  in  systematic  works  and  numerous  monographs.*  The  fact  is, 
that  the  group  of  symptoms  indicating  the  occurrence  of  water  in  the 
brain  is  altogether  insufficient  to  prove  the  existeiice  of  this  morbid  pro- 
duct in  acute  cases.  What  we  observe  are  symptoms  of  excitement, 
gradually  passing  into  those  of  depression,  occasionally  accompanied 
with  paroxysms  of  pain,  restlessness,  and  screaming,  alternating  with 
drowsiness,  exhaustion,  and  coma.  These  symptoms  are  common  to 
various  lesions  of  the  brain,  and  mav  be  the  result  of  mere  congestion, 
or  of  this  state  terminating  in  effusion  and  frequently  in  exudation. 
Hence  why  sometimes  after  death  we  find  no  lesion  whatever  ;  at  others 
more  or  less  distension  of  the  ventricles  with  serum,  and  very  commonly 
in  addition  exudation  at  the  base  of  the  cranium.  In  every  case  the 
symptoms  are  referable  not  so  much  to  one  or  the  other  of  these  lesions, 
as  to  something  which  they  all  have  in  common,  and  this  undoubtedly 
is  more  or  less  pressure  on  vai'ious  portions  of  the  brain,  causing  first 
irritation  and  then  perversion  of  function,  or  so  operating  as  to  excite 
some  parts  and  to  depress  others.  In  the  great  majority  of  cases  the 
fluid  distending  the  ventricles  is  more  allied  to  the  dropsies  than  to  the 
exudations.  Nay,  even  when  lymph  is  thrown  out  at  the  base  of  the 
brain,  the  amount  of  serum  in  the  ventricles  is  altogether  disproportioned 
to  the  quantity  of  coagulated  fibrin  deposited.  Hence  I  am  disposed  to 
think  that,  even  when  evidence  of  so-called  inflammation  does  exist,  as  in 

*  See  the  author's  article  on  Hydrocephalus,  in  the  Library  of  Medicine.  Yol.  ii. 
London,  1840. 


ACUTE  HYDEOCEPHALUS.  817 

Case  III.,  still  the  fluid  -which  distends  the  ventricles  is  owing  to  a 
mechanical  obstruction  of  the  vessels,  causing  dropsical  eff'usion.  As  to 
the  central  white  softening  so  commonly  found  in  hydrocephalic  cases, 
it  is,  in  the  vast  majority  of  instances,  a  post-mortem  appearance,  caused 
by  mechanical  imbibition  of  the  serum  into  the  porous  substance  of  the 
w-hite  tubular  structure  of  the  brain.  I  have  seen  this  softening  most 
extensive  in  cases  where,  immediately  before  death,  the  transmitting 
functions  of  the  white  central  parts  were  perfect ;  and  the  fact  that  no 
relation  exists  between  the  symptoms  during  life  and  such  softening  after 
death  has  been  noticed  by  numerous  observers. 

In  a  special  work  on  this  subject  (London  :  1843),  Dr.  Risdon  Ben- 
nett, looking  to  the  scrofulous  character  of  the  children  usually  aftected 
with  this  disease,  refers  its  nature  to  "  vital  changes  in  the  brain,  chiefly 
in  the  central  white  parts,  of  the  character  probably  of  tubercular  dege- 
neration,— and  that  softening,  eft'usion  into  the  ventricles,  and  meningitis, 
are  all  consequences  of  antecedent  alterations  of  nutrition." — (Pp.  148- 
9.)  This  view,  which  contains  the  general  truth,  may,  I  think,  now  be 
more  specifically  stated  as  follows: — AH  circumstances,  including  scrofula, 
which  weaken  the  general  nutrition  of  the  economy,  tend  to  occasion 
languor  and  obstruction  of  the  cerebral  circulation.  This  defective  nutri- 
tion is,  in  young  children,  especially  liable  to  occasion  congestions  within 
the  cranimn,  causing  effusions  and  exudations,  either  simple  or  tubercu- 
lar, and  as  a  mechanical  result  of  such  effusion,  those  softenings  so  fre- 
quently found  after  death.  Such  appears  to  me  the  true  pathology  of 
acute  "hvdrocephalus,  including  the  "  hydrocepbaloid  disease "  of  Dr. 
Marshall  Hall. 

In  the  treatment  of  this  disease  much  stress  has  been  laid  by  practi- 
tioners on  the  question,  as  to  whether  in  any  given  case  the  symptoms 
are  or  are  not  dependent  on  inflammation,  and  if  so,  what  may  be  the 
character,  seat,  and  stage  of  the  inflammation.  If  the  disease  be  inflam- 
matory, blood-letting,  with  antiphlogistics  and  calomel,  has  been  enjoined. 
When,  on  the  othe^-  hand,  it  arises  from  diarrhcea,  or  after  exhaustive 
diseases,  an  opposite  line  of  treatment  has  been  the  rule.  The  profession 
cannot  be  too  grateful  to  Dr.  Marshall  Hall  for  clearly  pointing  out  how 
all  the  symptoms  of  hydrocephalus  frequently  arise  in  children  after 
long-continued  diarrhoea,  febrile  eruptions,  or  other  exhaustive  causes, 
and  how  they  may  frequently  be  restored  under  such  circumstances  by 
nutrients  and  stimulants.  But  it  may  now  be  asked  whether,  in  fact,  we 
possess  the  means  of  clearly  distinguishing  the  inflammatory  from  the 
non-inflammatory  forms,  and  whether,  if  we  did,  we  are  justified  in 
treating  the  former  by  antiphlogistic  remedies? 

In  reply  to  these  questions,  I  would  observe  in  the  first  place  that  all 
authors  are  agreed  as  to  the  difficulty  of  separating  acute  hydrocephalus 
from  remittent  fever,  and  no  one,  so  far  as  I  am  aware,  has  ever  pre- 
tended that  they  could  point  out  with  exactitude  the  symptoms  which 
distinguish  cases  in  which  there  are,  and  those  in  which  there  are  not, 
exudations  of  lymph  within  the  cranium.  After  the  most  careful  exa- 
mination of  many  cases,  both  during  life  and  after  death,  I  feel  satisfied 
that,  conjoined  with  exactly  the  same  train  of  symptoms,  we  may  some- 
times find  only  eff'usion  of  serum  in  the  ventricles,  with  white  softening, 
and  at  others  more  or  less  meningitis  of  the  base.     Again,  I  also  feel 


318  DISEASES   OF  THE   NERVOUS   SYSTEM. 

satisfied  that  this  meningitis,  as  proved  after  death  by  the  existence  of 
layers  of  lymph,  so  far  from  indicating  a  so-called  sthenic  constitution  in 
children,  much  more  frequently  occurs  in  scrofulous  and  weak  children. 
Of  this,  Case  III.  is  an  example,  where  with  phthisis  and  genei'al  tuber- 
culosis, there  was  found  conjoined  with  eftusion  into  the  ventricles, 
inflammatory  exudation  at  the  base  of  the  cranium.  The  distinctions, 
therefore,  hitherto  so  much  dwelt  upon,  of  two  distinct  forms— an 
inflammatory  and  a  non-inflammatory,  as  guides  to  treatment — have  no 
real  existence,  and  are  opposed  to  all  positive  researcb,  as  well  as  to  a 
large  experience  in  the  observation  and  treatment  of  individual  cases. 
When,  in  addition,  it  is  considered  that  all  the  symptoms  of  acute  hydro- 
cephalus are  referable  to  more  or  less  pressure  on  different  parts  of  the 
brain  ;  that  this  pressure  may  be  occasioned  by  congestion,  eftusion,  or 
exudation  ;  and  that  we  have  no  means  of  determining  which  or  how 
much  of  each  is  present  in  any  individual  case,  it  must,  I  think,  be 
certain  that  it  is  impossible  in  the  vast  majority  of  cases,  and  highly 
doubtful  in  all,  to  determine  the  existence  of  meningitis  or  cerebritis  as 
a  concomitant  of  acute  hydrocephalus,  Lastlv,  the  svmptoms  of  the 
"hydrocephaloid  disease,"  so  well  described  by  Dr.  Marshall  Hall,  in 
which  all  the  phenomena  of  hydrocephalus  occur,  and  which  are  only 
distinguishable  by  the  circumstance  that  they  originate  from  exhaustive 
causes,  should  alone  make  us  pause  before  we  have  recourse  to  a  lowering 
system  of  practice. 

But  supposing  we  had  the  power  to  detect  in  any  given  case  the 
occurrence  of  active  exudation  going  on  within  the  cranium,  should  we 
even  then  be  justified  in  having  recourse  to  blood-letting,  general  or 
local?  The  considerations  we  have  previously  entered  into  (p.  251, 
et  seq.),  first,  as  to  the  incompetency  of  this  remedy  (and  of  antiphlo- 
gistics  generally)  to  meet  the  end  in  view,  and  secondly,  as  to  the  fact 
that  we  can  only  reach  the  circulation  within  the  cranium,  by  influ- 
encing the  force  of  the  heart  (p.  115,  et  seq.),  are  sufticient  answers  to 
this  question.  It  follows  then,  that  the  uncertainty  of  diagnosis,  as  well 
as  the  evil  effects  likely  to  result  from  a  lowering  practice  in  these  cases, 
wdiich  almost  always  occur  in  weak  children,  are  not  only  opposed  to 
it,  but  perhaps  sufficiently  explain  the  acknowledged  great  mortality  of 
the  disease.  For  the  like  reasons  the  use  of  calomel  to  cause  absorption 
of  matters,  whose  existence  we  have  no  means  of  detecting,  appears 
equally  unreasonable,  even  supposing  it  had  been  proved  to  possess  an 
absorbing  power,  which  it  certainly  has  not. 

On  the  other  hand,  the  two  first  cases  we  have  recorded  are  examples 
of  what  may  be  done  by  an  opposite  plan  of  treatment  in  acute  hydro- 
cephalus, and  in  the  third  case,  we  believe  the  practice  followed  to  have 
been  the  only  warrantable  one  in  the  desperate  and  necessarily  fatal 
circumstances.  It  bore  reference  to  improving  the  general  constitution 
and  nutritive  powers  of  the  patient,  which  in  all  cases  connected  with  a 
scrofulous  habit,  are  the  indications  to  be  more  or  less  energetically 
followed  according  to  the  severity  and  duration  of  the  disease.  The 
calomel  given  as  an  alterative  utterly  failed. 


CEREBRAL   MENINGITIS.  319 

CEREBRAL  MENINGITIS. 

CASE  IV.* — General  Acute  Meningitis  supervening  on  Pleuro- Pneumonia. 

History. — David  Murray,  set.  43,  a  coal-heaver — admitted  January  18,  1854. 
He  has  been  an  intemperate  man,  and  a  week  previous  to  admission  was  seen  by 
one  of  the  pupils  to  be  affected  by  delirium  tremens.  He  now  says,  that  on  the  13th 
(which  was  the  first  day  of  thaw  after  frost  and  snow)  he  was  much  exposed  to  the 
weather  while  at  work,  but  felt  no  ill  effects  until  the  morning  of  the  15th  at  four 
o'clock,  when  he  awoke  very  sick,  and  vomited  several  times.  He  kept  his  bed, 
feeling  feverish,  and  in  the  afternoon  began  to  cough.  On  the  morning  of  the  16th 
he  experienced  a  sharp  pain  in  the  right  chest,  about  three  inches  below  the  nipple, 
which  was  increased  hy  coughing,  and  inspiring  deeply,  and  prevented  his  lying  on 
that  side.     He  had  no  rigor  nor  headache. 

Symptoms  on  Admission. — On  admission,  respiration  is  impeded  by  interrupted 
inspirations,  which  give  pain.  Over  the  lower  half  of  the  right  lung  posteriorly, 
there  is  marked  dulness  on  percussion,  loud  crepitation  on  inspiration,  and  bron- 
chopony.  The  sputa  are  scanty,  consisting  of  gelatinous  matter,  with  rusty  brown 
patches.  No  dyspnoea.  Pulse  120,  strong  and  full;  skin  hot  and  dry  ;  tongue  dry, 
furred,  and  fissured ;  great  thirst ;  no  appetite ;  bowels  open.  Has  no  headache  at 
present,  but  says  he  is  restless  at  night,  and  sleeps  badly.  Other  functions  normal. 
To  have  one-third  of  a  grain  of  tartrate  of  antimony  in  solution  every  two  hours. 

Progress  of  the  Case. — January  '12cl. — Since  last  report  the  pneumonia  has 
followed  its  usual  course. — (See  Pneumonia.)  On  the  20th  crepitation  had  disap- 
peared, but  has  returned  to-day.  Yesterday  evening  was  ordered  a  diuretic  draught 
containing  Sp.  JEther.  Nit.  3  j.  The  pulse  130,  weak,  and  at  the  visit  his  replies  to 
questions  were  a  little  confused.  January  23  J. — Yesterday  afternoon  he  was  ob- 
served to  mutter  incoherently,  but  remained  quiet  until  eight  p.m.,  when  he  became 
violently  delirious.  He  had  a  very  wild  and  fierce  expression  of  eye  and  counte- 
nance, insisted  on  getting  up,  would  not  be  controlled,  and  struggled  violently  with 
those  who  endeavoured  to  restrain  him.  He  spoke  little,  but  made  incoherent 
noises.  The  pupils  were  much  dilated ;  the  pulse  very  rapid  and  weak.  The  head 
was  shaved,  and  constant  cold  applied.  Prostration,  however,  coming  on,  wine  and 
stimidanU  were  given  freely.  He  continued  now  and  then  to  struggle  violently ; 
strabismus  was  apparent  latterly.     Died  exhausted  at  five  a.m.  this  morning. 

Sectio  Cadaveris. — Thirty-one  hours  after  death. 

Body  greatly  emaciated. 

Head. — On  removing  the  skull  cap,  the  dura  mater  presented  a  uniform  yellowish 
tint,  dependent  on  a  recent  exudation  below  it.  On  removal,  the  subarachnoid 
tissue  was  infiltrated  with  a  soft  exudation,  which  covered  the  entire  surface  of  both 
hemispheres,  and  of  the  cerebellum.  It  was  as  abundant  at  the  base  as  on  the 
superior  surface  of  the  brain.  On  cutting  into  the  cerebral  substance,  it  was  ob- 
served that  the  yellow  exudation  accompanied  the  inflexions  of  the  pia  mater 
between  the  convolutions.  The  lateral  ventricles  contained  §  iss  of  turbid  serum. 
The  lining  walls  of  the  ventricles  were  a  little  congested ;  the  choroid  plexuses 
healthy.    The  septum  lucidum  rather  soft,  but  the  other  portions  of  the  brain  normal. 

Thorax. — Three  lower  fourths  of  the  right  lung  presented  the  characters  of  grey 

*  Reported  by  Mr.  Robert  Bird,  Clinical  Clerk. 


320  DISEASES  OF  THE   NERVOUS   SYSTEM. 

hepatization  posteriorly.  The  anterior  surfaces  were  healthy.  The  pleurae  covering 
this  lung  were  partially  adherent,  with  some  shreds  of  recent  lymph.  Other  thoracic 
organs  healtliy. 

Abdomen. — The  liver  enlarged,  weighing  6  lbs.  4  oz.,  of  pale  colour,  and  soft. 
The  spleen  also  soft  and  pulpy.     Other  abdominal  organs  healthy. 

Microscopic  Examination. — The  exudation  poured  out  in  the  sub-arachnoid 
cavity  liad  everywhere  undergone  the  transformation  into  pus.  The  turbid  fluid  in 
the  lateral  ventricles  also  contained  some  pus,  with  a  few  epithelial  cells.  The 
cerebral  tissue  was  healthy.  The  liver  cells  contained  an  unusual  amount  of  fatty 
granules.  The  pneumonic  portion  of  the  right  lung  was  infiltrated  with  fluid  mole- 
cular matter  and  pus  corpuscles,  most  of  which  were  more  or  less  collapsed,  and  all 
of  them  verj'  granular.     The  whole  evidently  in  a  state  of  disintegration. 

Commentary. — In  tliis  man,  who  was  intemperate,  and  labouring 
under  pneumonia  which  was  progressing  favourably,  there  supervened 
at  noon  on  the  seventh  day  of  the  disease  a  little  confusion  in  his  ideas, 
which  in  the  course  of  the  afternoon  passed  into  violent  delirium,  caus- 
ing strabismus  and  dilated  pupils.  At  night  he  became  comatose,  and 
died  at  five  o'clock  next  morning.  At  the  commencement  of  the  pneu- 
monia he  had  vomited,  a  symptom  perhaps  referable  in  him  to  cerebral 
irritation,  a  condition  which  the  febrile  state  he  was  subsequently  thrown 
into,  however,  did  not  appear  to  augment  in  any  unusual  degree.  On 
examining  the  head  after  death,  the  subarachnoid  cavity  and  involutions 
of  the  pia  mater  over  the  whole  surface  of  the  brain  were  loaded  with 
purulent  matter,  and  §  iss  of  turbid  serum  was  infused  into  the  lateral 
ventricles.  This,  therefore,  was  an  instance  of  very  rapid  death  from 
meningitis,  a  result  partly  attributable  to  his  previous  intemperate  habits, 
and  partly  to  the  circumstance  that  the  disease  appeared  at  a  time  when 
he  was  already  much  exhausted  by  the  pneumonic  attack.  In  this,  as 
in  Case  III.,  it  is  observable  that  the  occurrence  of  extensive  exudation 
is  in  no  way  incompatible  with  depression  of  the  bodily  powers,  a  fact 
altogether  opposed  to  the  supposed  connection  between  inflammation 
anda  sthenic  state  of  the  constitution.  In  fact,  the  extent  as  well  as 
the  fatality  of  the  cerebral  disease  is  probably  to  be  attributed  to  the 
exhaustion  of  the  vital  powers  at  the  time  of  its  occurrence. 

The  pneumonia  went  through  its  usual  progress,  and  on  the  day  when 
the  meningitis  commenced,  the  returning  crepitation  was  audible.  On 
examination  after  death,  the  whole  pulmonary  exudation  was  found 
softened  and  converted  into  pus,  which  was  already  undergoing  rapid 
disintegration.  To  this  part  of  the  case  we  shall  again  allude  under  the 
head  of  pneumonia. 

Case  V.* — Acute  Meningitis  at  the  Base  of  Brain — Serom  Effusion  into  the  Ventricles, 
with  ivhite  softening  of  cerebral  substance — Phthisis. 

History.— Helen  Walker,  set.  21,  a  servant,  admitted  July  4,  1853.  She  has  for 
some  years  been  subject  to  cough  and  dyspncea,  but  says  she  never  had  any  serious 
illness  until  eleven  days  ago.  She  then  experienced  rigor,  pain  in  the  head,  thirst, 
and  other  febrile  symptoms.  The  headache  has  been  variable  in  intensity,  being 
sometimes  slight,  at  others  very  severe. 

*  Reported  by  Mr.  G.  C.  Pirrie,  Clinical  Clerk. 


CEREBRAL    MENINGITIS.  321 

SYirpTOMS  ox  Adm:issio.n'  — On  admission,  she  appears  to  be  very  weak  and  lan- 
guid. Complains  of  severe  frontal  headaclie,  which  is  increased  towards  night.  The 
eyes  are  dull  and  heavy ;  pupils  unaffected.  Xo  muscje  vohtantes,  tinnitus  aurium, 
or  vertigo.  Is  quite  conscious,  but  has  a  tendency  to  stupor.  The  febrile  symptoms 
have  now  for  the  most  part  disappeared.  Xo  thirst ;  appetite  impaired ;  tongue 
furred :  pulse  84,  soft.  On  examination  of  the  chest,  all  the  signs  of  phthisis,  with 
cavities  in  both  lungs,  were  detected.  The  other  functions  are  normal.  She  re- 
quested to  have  an  emetic,  which  had  previously  relieved  her,  and  one  of  ipecacu- 
anha and  sulphate  of  zinc  was  given. 

Progress  of  the  Case. —  July  oth.—ihe  emetic  has  not  produced  the  same 
reUef  as  formerly.  Headache  continues.  In  other  respects  the  same.  Six  Leeches  to  he 
applkd  (o  the  temple-s.  JuJy  6th. — Last  night  wandering  of  the  mind,  with  slight 
deUrium.  To-day,  great  depression,  and  stupor.  As  the  bowels  have  not  been  reliev- 
ed, to  have  a  drop  of  croton  oil.  on  sugar,  to  be  followed  by  an  enema,  if  necessary. 
Head  to  be  shaved,  and  cold  applied^  Beef  tea  and  nutrients.  July  1th. — Last  night 
great  incoherence  of  mind,  with  raving.  To-day  at  visit,  still  muttering.  Eyes  are 
heavy ;  pupils  contracted  ;  tongue  moist  and  white.  Takes  no  nourishment ;  bowels 
open  ;  pulse  120,  regular,  but  weak.  July  8th. — Xo  change.  Coma  coming  on. 
A  blister  to  be  applied  to  the  occiput.  July  9th. — Coma,  with  occasional  low  mutter- 
ing delirium ;  picking  at  the  bed  clothes,  pulse  almost  imperceptible.  Died  on  the 
morning  of  the  10th. 

Sectio  Cadaveris. —  Thirty-six  hours  after  death. 

Body  thin,  but  not  much  emaciated. 

Head. — The  arachnoid  surfaces  were  very  dry.  The  lateral  ventricles  contained 
about  3  11  of  shghtly  turbid  serum.  The  walls  of  the  ventricles  and  central  white 
portions  of  the  brain  in  their  neighbourhood  were  pultaceous,  and  easily  broke  down 
under  a  stream  of  water,  presenting  a  rough  surface,  and  on  section  a  ragged  edse, 
but  retaining  their  natural  colour.  At  the  base  of  the  brain,  the  crura  cerebri  are 
surrounded  with  soft  yellow  exudation,  which  is  situated  in  the  subarachnoid  cavity, 
and  extends  to  the  thalami  optici,  and  slightly  into  the  locus  perforatus  posticus. 
Xo  tubercle  can  be  seen  in  the  meninges,  and  about  3  ij  of  serum  were  collected  in 
occipital  depressions  after  removal  of  the  brain. 

Chest. — Both  lungs  were  infiltrated  with  tubercle,  especially  the  upper  lobes. 
A  cavity  the  size  of  a  hazel-nut  at  the  summit  of  left  lung,  and  there  were  several 
in  the  upper  lobe  of  right  lung,  communicating  with  one  another. 

Abdomex. — Abdominal  organs  healthy. 

Microscopic  Examixatiox. — In  the  slightly  turbid  fluid  of  the  ventricles  were 
several  epithelial  cells  from  the  choroid  plexuses,  undergoing  the  fatty  degeneration. 
The  ptiltaceous  white  softening  surrounding  the  ventricles,  contained  no  granule 
ceUs  or  masses,  and  consisted  of  the  tubes,  easily  broken  down  between  glasses,  pre- 
senting numerous  large  varicosities,  circles  with  double  lines,  etc  (Fig.  363.)  The 
exudation  at  the  base  was  chiefly  molecular,  with  here  and  there  traces  of  pus. 

Commentary. — This  case  is  in  many  respects  like  those  formerly 
given  under  the  head  of  acute  hydrocephalus,  and  serves  to  illustrate  the 
occurrence  of  acute  meningitis  with  serous  effusion,  in  a  phthisical  and 
exhausted  subject.  In  this,  as  in  the  instances  referred  to,  the  leeches 
applied  to  the  temples,  with  a  view  of  relieving  the  headache,  were  of 
no  benefit  whatever,  even  temporarily.  The  day  after  their  application 
all  the  symptoms  and  weakness  were  more  pronounced  ;  in  other  words, 
the  disease  proceeded  onwards  towards  the  fatal  termination.     The  struc- 

21 


322  DISEASES   OF   THE   XEEVOUS   SYSTEM. 

ture  of  the  exu-ktioii  at  the  base  of  the  cranium,  and  the  incipient  fatty 
degeneration  in  the  serum  of  the  ventricles,  indicate  that  these  lesions 
were  of  much  longer  standing  than  might  have  been  supposed  from  a 
consideration  merely  of  the  symptoms  of  the  case. 

Case  XL*— Acute  Meningitis  at  the  base  of  the  Brain— Effusion  of  Serum  into  the 
Lateral  Ventricles — Effete  Tubercle  in  the  Fans  Varolii  and  Lungs. 

History. — John  Robertson,  set.  35,  a  discharged  soldier— admitted  June  2.5, 
1850.  He  lias  been  of  intemperate  habits,  and  latterly,  owing  to  poverty,  has  had 
a  very  poor  diet,  and  been  insufficiently  clothed.  On  the  13th  he  first  experienced 
headache  and  febrile  symptoms.  On  the  21st  there  was  vomiting,  with  cough  and 
expectoration,  and  on  the  23d  great  restlessness  and  delirium  at  night.  These 
symptoms  have  continued  ever  since. 

Symptoms  ox  Admission'. — On  admission  he  is  in  a  state  of  great  prostration. 
He  lies  quietly  on  his  back,  frequently  talking  incoherently,  but  is  easily  roused 
when  spoken  to,  and  then  answers  questions  sensibly.  Countenance  pale ;  eyes 
suffused;  pupUs  rather  contracted.  He  has  no  pain  anywhere.  His  hands  and 
arms  are  in  a  constant  state  of  tremor,  the  former  engaged  in  clutching  the  bed- 
clothes. Evacuations  normal,  not  involuntary ;  tongue  white  and  dry ;  deglutition 
difficult ;  chest  everywhere  resonant ;  expiration  prolonged  and  harsh  ;  httle  cough 
at  present,  and  no  expectoration  ;  pulse  64.  feeble.  Has  been  treated  before  admis- 
sion with  calomel  and  antimonials.  To  have  §  iij  of  whiskey  daily  iviih  nutrients. 
5 .  Sp.  JEther.  Nit.  |  ss  ;  Mist.  Scilla,  §  iiiss :  Aquce,  §  jss.  M.  Sumat  %  ss  quartd 
qudque  hord.     Head  to  he  shaved  and  a  blister  applied. 

Progress  of  the  Cxse.— June  26th. — Passed  a  restless  night,  with  considerable 
delirium.  To-day  is  no  better.  Moist  rales  audible  at  the  base  of  lungs  posteriorly. 
Weakness  increasing.  To  have  radrients.  June  21th. — Has  refused  all  kinds  of  food 
and  drink.  Coma  is  now  coming  on.  The  extremities  are  cold;  face  livid;  respi- 
ration laborious ;  pulse  60,  can  scarcely  be  felt.  The  urine  has  been  drawn  off  by 
catheter,  and  is  quite  normal  Bowels  not  open  for  two  days.  5  Amnion.  Carb.  gr. 
xiii. ;  Mid.  Carnph.  3  iv. ;  Solva.  Sumat  3  ss  quartd  qudque  hord.  June  28th. — Be- 
came gradually  weaker,  and  expired  at  four  o'clock  this  morning. 

Sectio   Cadavcris. — Fifty-six  hours  after  death. 

Body  somewhat  emaciated. 

Head. The  convolutions  on  the  surface  of  the  cerebral  hemispheres  were  some- 
what flattened,  but  not  preternaturally  dry.  The  substance  of  the  brain  was  nor- 
mal The  lateral  ventricles  distended  with  turbid  serum,  slightly  tinged  with  blood, 
to  the  extent  of  |  ij.  Central  substance  of  brain  healthy.  The  sub-araclmoid  tissue 
at  the  base  everj-where  infiltrated  with  recent  coagulated  lymph.  In  the  substance 
of  the  pons  varolii  was  a  tubercular  mass,  the  size  of  a  pea,  firm  externally,  soft 
towards  the  centre,  and  surrounded  by  a  zone  of  congested  vessels.  The  membranes 
covering  the  hemispheres,  and  otlier  portions  of  the  brain,  healthy. 

Thorax  — Heart  healthy.  Pleurae  on  both  sides,  adherent  by  chronic  bands  of 
lymph,  especially  at  the  apices  of  the  lungs.  Here  both  lungs  were  indurated  and 
puckered,  and  contained  several  cretaceous  and  calcareous  concretions.  Their  ante- 
rior margins  were  emphysematous,  and  the  posterior  and  inferior  portions  engorged,  and 
the  bronchi  more  or  less  filled  with  purulent  mucus.     Here  and  there,  scattered 

*  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


CEREBRAL   MENINGITIS.  323 

throughout  the  inferior  portions  of  both  lungs,  were  masses  of  old  tubercle,  con- 
verted into  calcareous  matter,  and  varying  in  size  from  a  barley-corn  to  that  of  a 
cherry  stone. 

Abdomen'. — Abdominal  organs  healthy. 

Micuoscopic  ExAMiN'.iTiox. — The  turbid  serum  in  the  lateral  ventricles  contained 
numerous  granule  cells,  and  a  few  blood  corpuscles.  The  lymph  at  the  base  of  the 
brain  was  molecular,  with  here  and  there  mas.ses  of  pus  corpuscles  in  a  state  of  dis- 
integration. The  cerebral  substance  around  the  tubercular  mass  in  the  pons  varohi 
was  healthy. 

Commentary. — In  this  case  prostration  was  so  marked  that  stimu- 
lants and  nutrients  were  given  on  his  admission,  but  without  the  etiect 
of  overcoming  his  exhaustion.  It  is  to  be  observed,  that  aUhough  for- 
merly of  a  tuberculous  constitution,  which  had  left  traces  of  its  existence 
both  in  the  brain  and  lungs,  he  had  overcome  this  to  such  a  degree  that 
on  exposin-e  once  again  to  exhausting  causes,  a  simple  or  inflammatory 
rather  than  a  tuberciUar  exudation  was  the  result.  The  structure  of  the 
exudation  at  the  base  of  the  cranium,  and  the  granule  cells  in  the  serous 
fluid  of  the  ventricles,  indicated  that  the  lesion  was  already  somewhat 
chronic.  In  this,  as  well  as  the  preceding  case,  it  appears  to  me  that 
the  original  headache  and  fever  indicated  the  period  of  congestion  and 
exudation,  that  vomiting  pointed  to  commencing,  and  stupor  to  more 
intense  pressure  from  the  subsequent  eflfusion. 

The  seat  of  meningitis  is  the  so-called  subarachnoid  cavity,  in  ■which 
there  is  a  quantity  of  loose  areolar  tissue,  richly  furnished  with  blood- 
vessels. It  generally  results  that  the  exudation  poured  into  this  cavity, 
instead  of  undergoing  the  transformation  into  fibres  which  usually  occurs 
on  serous  surfaces,  follows  the  law  which  regulates  its  passage  into  pus. 
Hence  I  have  ascertained  that  what  is  generally  called  a  recent  layer  of 
coagulable  lymph,  covering  the  convolutions  in  meningitis,  is,  in  point 
of  fact,  a  layer  of  pus.  That  the  exudation  should  not  readily  be  poured 
out  into  the  cavity  of  the  arachnoid  is  explicable  by  the  circumstance, 
that  the  solid  and  unyielding  walls  of  the  cranium  would  oppose  any  ten- 
dency to  the  enlargemeitt  of  that  space.  Indeed,  the  greater  the  amount 
of  exudation  or  eft'usion,  especially  in  the  deeper  parts  of  the  brain,  the 
more  would  the  two  layers  of  the  arachnoid  be  compressed  together,  and 
hence  arises  the  dryness  of  this  membrane  in  meningitis  with  efi'usion 
into  the  ventricles. 

It^  as  I  have  stated,  the  exudation  in  acute  meningitis  be  examined 
microscopically,  it  w^ill  be  found  to  consist  principally  of  pus  corpuscles, 
presenting  an  unusually  molecular  character,  and  associated  with  nume- 
rous loose  molecules  and  granules.  In  the  chronic  forms  the  pus  cor- 
puscles are  seen  to  be  broken  down,  and  the  whole  is  reduced  to  an 
amorphous  granular  mass,  more  or  less  mingled  with  fat  granules.  The 
blood-vessels,  also,  which  enter  into  this  mass  may  frequently  be  seen  under- 
going the  fatty  degeneration.  When  the  ventricles  are  the  seats  of  exu- 
dation there  are  generally  in  the  fluid  epithelial  cells  of  a  globular  form, 
which  present  various  appearances  according  as  they  are  swollen  through 
endosmose,  or  have  undergone  the  fatty  degeneration  and  become 
granular  cells.  I  have  also  noticed  a  great  variety  of  changes  in  the 
villi  of  the  choroid  plexus  under  such  circumstances.     Occasionally  their 


32-i  DISEASES   OF   THE   NEEVOUS  STSTEiT. 

epithelial  coating  is  much  increased  in  thickness,  and  at  other  times  is 
raised  up  in  the  form  of  small  bullfe,  being  probably  the  incipient  stage 
of  simple  cystic  formation.  They  frequently  also  contain  a  greater  or 
less  number  of  the  amyloid  bodies  represented,  Fig.  349,  the  connection  of 
Avhich  ^vith  active  disease  in  the  ventricles,  however,  has  not  yet  been 
demonstrated. 

As  to  the  diagnosis,  notwithstanding  the  efforts  which  have  been  made 
to  distinguish  meningitis  of  the  convolutions  from  that  of  the  base,  or 
either  of  these  from  a  simple  effusion  into  the  ventricles,  I  have  in  vain 
sought  for  any  precise  symptoms  which  could  be  relied  on  as  indica- 
tive of  the  situation  of  the  disease.  Pain  in  the  head,  vomiting, 
drowsiness,  and  coma,  causing  slow  and  subsequent  rapid  pulse,  suc- 
ceeded by  more  or  less  jactitation  and  convulsion  before  death,  are  the 
leading  symptoms.  The  gradual  mode  of  invasion,  and  the  succession 
of  these  symptoms  to  one  another,  are  also  characteristic,  and  differ 
from  those  which  attend  sudden  attacks  caused  by  hemorrhage,  and  the 
slow  progress  of  chronic  cerebritis.  They  are  all  the  results  evidently 
of  general  pressure  on  the  brain,  and  hence  why  mere  effusion  cannot 
be  distinguished  from  meningitis.  The  febrile  state  attending  meningitis 
cannot  be  depended  on  as  a  source  of  distinction,  and  the  other  symptoms 
are  pretty  much  the  same. 

Hitherto  the  treatment  of  meningitis,  whether  real  or  supposed,  has 
been  antiphlogistic,  but  it  is  impossible  to  say  that  any  benefit  has  ever 
been  effected  by  the  practice.  The  early  stage  of  the  disease  is  gene- 
rally overlooked,  the  vomiting  and  pain  in  the  head,  so  long  as  the 
patient  retains  his  consciousness,  seldom  leading  to  a  suspicion  of  menin- 
gitis. It  is  only  when  exudation  or  effusion  has  been  poured  out  in 
such  quantity  as  to  cause  drowsiness  and  stupor  that  our  suspicions  are 
awakened,  and  thus  it  is  veiy  difficult  to  understand  how  bleeding  or 
purging  could  facilitate  its  absorption.  Besides,  we  have  seen  that  the 
tendency  of  such  exudation  is  to  pass  into  pus ;  hence  the  treatment 
which  favours  the  transformation  of  cell  growth,  as  previously  explained 
(Section  III.  p.  257,  et  seq.)^  must  be  the  most  effectual.  For  this  pur- 
pose time  is  required,  and  the  vital  strength,  instead  of  being  lowered, 
should  be  supported.  It  becomes,  however,  in  actual  practice  veiy  diffi- 
cult to  carry  out  these  indications.  The  drowsiness  and  coma  greatly 
interfere  with  the  means  we  possess  of  nourishing  the  patient,  because  ali- 
ment cannot  be  introduced  in  sufficient  quantity,  whilst  the  depression  of 
the  nervous  force  so  disorders  the  whole  glandular  system  as  to  occasion  a 
profound  alteration  of  the  nutritive  functions.  Under  such  circumstances 
the  mucous  membranes  become  deranged,  the  tongue  and  throat  parched, 
the  stomach  contracted,  the  bowels  constipated,  and  it  often  has  appeared 
to  me  that  under  such  circumstances  patients  literally  die  of  exhaustion 
from  want  of  food.  The  tissues  become  deteriorated,  while  the  absence 
of  volition  and  sensation,  as  in  cases  of  fever,  favours  the  sloughing  process 
over  the  dependent  parts  of  the  body,  which  are  continuously  pressed  upon. 
All  these  changes  are  remarkably  well  seen  in  those  cases  of  the  disease 
which  occur  without  any  complication,  and  when  the  tissue  of  the 
brain  itself  is  free  from  organic  lesion.  In  such  instances  a  man  is 
deprived  of  his  intellectual  faculties  merely ;  he  is  reduced  to  the  con- 
dition of  an  animal  Avhich  has  lost  its  cerebral  lobes  ;  but  the  man  cannot 


CEREBRAL    MENINGITIS.  325 

be  kept  alive  in  eoiisequence  of  the  pressure  on  the  encephalon  derangino- 
the  nutritive  functions,  whereas  a  bird,  after  the  experiment,  may  be  fed 
and  I'etain  its  vitality  for  nionths.  Still  the  duty  of  the  medical  prac- 
titioner is  to  support  the  economy  as  much  as  possible — to  give  nutri- 
ents with  moderate  stimulants — to  foresee  the  possibility  of  sloughs 
forming  on  the  back  and  nates,  and  do  all  in  his  power  to  prevent  them 
— to  unload  the  bowels  and  bladder  from  time  to  time  artificially,  and 
thus,  as  far  as  possible,  counteract  their  torpid  action — and  in  this  way 
endeavour  to  gain  time,  which  will  enable  the  exudation  to  pass  through 
its  natural  transformations,  and  ultimately  to  be  absorbed. 

It  has  always  appeared  to  me  that  the  collection  of  mere  serous  fluid, 
whether  in  the  ventricles  or  over  the  surface  of  the  brain,  either  with  or 
without  exudation,  is  consecutive  on  obstruction  of  the  vessels,  and  is 
therefore  more  allied  to  the  dropsies  than  to  the  inflammations.  Thus, 
when  lymph  is  poured  into  the  subarachnoid  tissue  at  the  base,  it  com- 
presses the  vessels  leading  to  the  choroid  plexuses  and  lining  mem- 
brane of  the  ventricles,  and  so  induces  eft'usion  ;  and  consequently  effu- 
sion follows,  and  does  not  precede  the  exudation.  It  is  the  collection  of 
serum  which  does  the  mischief,  presses  on  the  brain,  and  causes  the 
somnolence  and  coma.  If  so,  the  occurrence  of  these  symptoms  should 
be  regarded  as  secondary  instead  of  as  primary,  and  as  analogous  to  the 
ascites  or  anasarca  following  hepatic  or  renal  disease.*  I  liave  occasion- 
ally seen  in  the  ventricles  of  the  brain  what  may  be  called  a  desquama- 
tive meningitis,  occasioned  by  the  same  minute  changes  which  cause  the 
corresponding  disorder  in  the  kidneys.  These  pathological  considera- 
tions are,  it  appears  to  me,  wholly  opposed  to  the  idea  of  blood-letting  and 
antiphlogistics  being  beneficial  after  exudation  and  effusion  has  occurred. 

Case  VII. f — Chronic  Meningitis — Serous  Effusion  into  the  Ventricles — Tubercular 
Mass  in  left  lobe  of  the  Cerebellum — Cretaceous  Tubercle  in  the  Lungs,  with  Fibrous 
Cicatrix. 

History. — James  Scott,  set.  30,  a  writer's   clerk — admitted   October  29,  1849. 

*  This  view  was  singularly  confirmed  by  a  case  which  entered  my  clinical  ward 
during  the  summer  of  1857.  It  was  tliat  of  George  M'Leod,  a3t.  25,  a  policeman, 
of  sound  constit\ition.  A  month  before  admission  he  experienced  headache,  wliich 
gradually  increased  in  intensity.  Nine  days  before  admis.sion  vomiting  came  on, 
which  was  frequently  repeated  after  taking  food.  On  admission  he  was  drowsy,  and 
rapidly  became  comatose,  the  pulse  60,  respiration  slow.  During  the  subsequent  nine 
daj's  he  was  two  or  three  times  less  soporous,  and  on  one  occasion  even  answered 
questions  confusedly.  Latterly  tlie  pulse  became  rapid,  and  he  died  without  convul- 
sion or  paralysis.  A  post-mortem  examination  showed  the  presence  of  a  firm,  chronic 
exudation,  upwards  of  one-eighth  of  an  inch  thick  at  the  base,  surrounding  the 
basilar  and  carotid  arteries,  and  infiltrated  through  the  subarachnoid  cavity,  so  as  to 
surround  the  pons  varolii.  The  ventricles  contained  3  ij  of  clear  serum.  The  indu- 
rated exudation,  on  microscopic  examination,  was  shown  to  be  chronic,  and  with  its 
contained  vessels  commencing  to  undergo  the  fatty  degeneration.  The  serum  con- 
tained nothing  but  a  few  epithelial  cells.  In  this  case  cupping,  leeches,  ice  applied 
to  the  shaven  scalp,  and  counter-irritants,  were  of  no  benefit  whatever,  and  the  only 
thing  that  appeared  to  do  good  was  unloading  the  bowels  by  means  of  enemata ; 
latterly,  brandy  and  beef-tea  were  administered.  I  am  of  opinion  that  the  exudation 
at  the  base  was  poured  out  long  before  he  entered  the  house,  but  that  the  subsequent 
effusion  into  the  ventricles,  producing  pressure  on  the  brain,  and  causing  the  coma, 
came  on  after  his  admission. 

f  Reported  by  Mr.  Alexander  Cbristison,  Clinical  Clerk. 


326  DISEASES   OF  THE   NEEVOUS   SYSTEM. 

The  only  account  that  can  be  obtained  of  him  is  that  he  was  seized  with  vomiting 
about  a  week  ago,  and  has  been  ill  ever  since. 

Symptoms  on  Admission. — On  admission  he  seems  to  be  labouring  under  mental 
oppression.  There  is  considerable  deafness  and  confusion  of  ideas,  so  that  he  cannot 
answer  questions.  He  does  not  complain  of,  nor  does  he  appear  to  suffer  pain.  The 
eyes  are  somewhat  suffused.  Tongue  furred,  and  covered  with  a  moist  fur.  Skin 
hot  and  drj^.  Pulse  70,  full.  Drinks  freely  when  water  is  given  him.  No  paralysis 
can  be  detected.  Other  functions  normal.  Ilmd  to  he  shaved,  and  cold  applied.  A 
saline  mixture. 

Progress  of  the  Case. — Octo&er  30. — In  the  same  state,  the  bowels  have  been 
freely  moved.  Some  headache,  with  wandering  of  ideas.  §  viij  of  Hood  io  he  re- 
moved hy  cupping  from  the  neck.  October  31. — No  relief  from  loss  of  blood.  Stupor 
more  pronounced,  with  slight  twitchings  in  the  fiice  and  hands.  At  the  visit,  coma 
is  complete,     lb  have  a  turpentine  injection,  but  he  expired  about  1  p.m. 

Sectio  Cadaveris. — Twenty-four  hours  after  death. 

Body  robust  and  well  formed. 

Head. — On  removing  the  calvariura  the  cerebral  meninges  were  unusually  dry, 
and  the  convolutions  somewhat  flattened.  The  lateral  ventricles  were  much  dis- 
tended, and  contained  §  ij  of  clear  fluid.  Cerebral  substance  firm  and  normal.  The 
left  lobe  of  the  cerebellum  was  firmly  adherent  to  the  dura  mater  covering  it.  On 
being  cut  through,  there  was  found  a  hardened  mass  embedded  in  it,  the  size  of  a 
pigeon's  egg,  resting  iuferiorly  on  a  thin  stratum  of  the  softened  cerebellar  structure, 
about  one-eighth  of  an  inch  in  thickness,  and  of  a  reddish  hue.  It  was  of  yellowish 
colour  and  cheesy  consistence,  most  dense  in  the  centre.  Other  portions  of  the 
brain  healthy. 

Chest. — The  pleurse  at  the  apices  of  both  lungs  were  coherent  by  chronic  bands 
of  lymph.  Immediately  below  the  adiiesions  on  both  sides  were  several  cretaceous 
encysted  masses,  about  the  size  of  peas,  surrounded  by  dark,  indurated  pulmonary 
tissue.  On  the  external  surface  of  the  apex  of  the  left  lung,  was  a  dense 
fibrous  cicatrix,  three-fourths  of  an  inch  long.  The  bronchial  glands  were  enlarged, 
and  infiltrated  with  chronic  tubercle,  mostly  cretaceous.  Other  thoracic  organs 
healthj'. 

Abdomen. — Abdominal  organs,  with  the  exception  of  the  scrotum,  which  contained 
some  chronic  fistula?,  healthy. 

Microscopic  Examination. — The  centre  and  circumference  of  the  tubercular 
mass  closely  resembled  the  figures  represented  (Figs.  882,  38B) ;  but  the  external 
softened  cerebral  substance  contained  a  larger  number  of  granular  cells.  The  serous 
fluid  in  the  ventricles  only  contained  a  few  epithelial  cells. 

Commentary. — In  this  case,  the  meninges  covering  the  left  cerebellum 
were  thickened  and  adherent  to  the  dura  mater  :  and  below  them  was 
found  a  tubercular  mass  the  size  of  a  pigeon's  egg.  How  long  this  lesion 
had  existed  it  is  impossible  to  say,  but  its  presence,  by  compressing  the 
vessels  at  the  base  of  the  cranium,  was  well  calculated  to  render  any 
temporary  congestion  more  liable  to  terminate  in  eft'usion.  This,  what- 
ever the  exciting  cause,  was  what  I  presume  must  have  occurred,  pro- 
ducing dropsy  of  the  ventricles,  Avith  the  usual  symptoms  of  pressure  on 
the  brain,  and  proving  fatal.  The  case  corroborates  also  the  view  that 
such  effusions  are  rather  the  result  of  pre-existing  lesions,  than  a  direct 
consequence  of  intiammation. 


CEREBEAL    MENINGITIS.  327 


Case  \1U.*— Chronic  Cerebral  Meningitis;  Induration  surrounded  by  softening  of  a 
Portion  of  the  Left  Cerebral  Hemisphere. 

History. — Mrs.  Swan,  set.  35,  -n-ife  of  a  coach-builder,  admitted  December  8,  1850. 
She  had  always  enjoyed  good  health  up  to  four  years  ago,  when,  having  contracted 
sypliilis,  and  having  taken  a  large  quantity  of  mercury,  she  began  to  complain  of 
headache,  indigestion,  occasional  vomiting,  constipation,  and  drowsiness.  About 
six  months  ago,  she  had  a  fit,  from  which  she  recovered  in  the  course  of  half  an 
hour.  She  suflered  from  similar  attacks  afterwards,  at  intervals  of  from  two  to 
three  weeks.  These  attacks  were  ushered  in  by  severe  headache,  tinnitus  aurium, 
vertigo,  and  dimness  of  vision,  and  they  were  followed  by  great  muscular  debility. 
During  the  paroxysms,  which  lasted  for  various  lengths  of  time,  she  was  insensible ; 
there  were  frothing  at  the  mouth,  and  twitchings  of  the  muscles  of  the  hmbs.  espe- 
cially of  the  right  arm.  The  last  fit  occurred  two  months  since.  Four  weeks  ago, 
she  experienced,  without  any  accompanying  fit  or  insensibility,  a  twitching  of  the 
muscles  of  the  right  arm,  together  with  a  feeling  of  numbness  in  the  fingers  of  the 
right  hand.  She  subsequently  experienced  less  power  m  the  right  arm,  and  some 
numbness  in  the  right  leg. 

Symptoms  on  Admission'. — On  admission,  she  appears  debilitated  and  consider- 
ably emaciated.  There  is  great  mental  confusion,  and  she  often  wanders.  She 
complains  of  intense  pain  in  the  head.  Tliere  is,  however,  no  flushing  of  the  face, 
nor  congestion  of  the  eyes,  and  no  delirium.  There  is  diflBculty  and  slowness  of 
articulation.  The  right  side  of  the  face  is  slightly  paralysed  The  tongue,  when 
protruded,  is  slightly  turned  to  the  right  side.  There  is  no  diminution  of  sen.sibility. 
The  power  of  motion  in  the  right  arm  is  diminished ;  she  cannot  close  the  hand,  or 
hold  anything  firmly.  Sensibility  is  unimpaired.  The  right  leg  is  not  affected  with 
any  diminution  of  muscular  power,  though  tliere  is  a  feeling  of  dragging  when  the 
limb  is  moved.  The  pulse  is  regular  and  of  good  strength  :  no  cough ;  complains  of 
loss  of  appetite ;  tongue  moist,  wliite ;  no  vomiting  nor  sickness.  Bowels  consti- 
pated ;  menstruation  is  irregular,  and  the  discharge  scanty ;  menstruated  last,  six 
weeks  ago.     Urine  muddy,  of  1023  sp.  gr. ;  becomes  clear  on  heating. 

Progress  op  the  Case. — From  this  period  until  the  4th  of  January.  18.51,  she 
remained  pretty  much  in  the  same  condition,  on  some  days  the  confusion  of  intellect 
and  difficulty  of  speech  being  somewhat  less  than  on  others.  The  treatment  con- 
sisted of  the  occasional  application  of  leeches,  and  latterly  of  a  blister  to  the  nape  of 
the  neck,  and  purgatives.  On  the  day  mentioned,  however,  she  was  found  comatose 
— did  not  answer  questions,  though  she  seemed  to  know  that  she  is  addressed — 
pupils  moderately  dilated — respiration  stertorous.  There  was  slight  twitching  of  the 
muscles  of  the  right  side  of  the  face.  The  right  arm  was  rigidly  flexed,  and  offered 
great  resistance  when  an  effort  was  made  to  extend  it.  January  5. — To-day  appears 
better.  No  stupor.  Expression  not  so  drowsy.  No  stertorous  breathmg.  Has 
spoken  a  little.  Has  no  sickness  or  vomiting.  There  are  still  occasional  twitchings 
of  the  muscles  of  the  right  side  of  the  face.  Right  arm  not  so  rigidly  flexed.  Ordered 
a  purgative  enema  immediately.  January  6. — Has  again  relapsed  into  a  state  of 
coma.  Breathing  easy.  Twitchings  of  the  muscles  of  the  right  side  of  the  face,  of 
the  rigVit  arm,  and  occasionally  of  the  riglit  leg,  have  again  presented  themselves. 
Pulse  rather  full,  and  slow.  Bowels  freely  opened  by  the  enema.  Sensibilitj-  in 
affected  parts  still  unimpaired.  January  7. — Continues  in  much  the  same  condition. 
Does  not  seem  conscious  when  spoken  to.     Sensibility  stUl  unimpaired.     Pulse  fre- 

*  Reported  by  Mr.  Henry  Thom,  Clinical  Clerk. 


328  DISEASES   OF   THE   ^'ERV0U3   SYSTEM. 

quent,  and  smaller  than  yesterday.  Increased  rigidity  of  the  right  arm  and  leg, 
with  occasional  twitchmgs.  January  8. — Pulse  frequent  and  very  small.  Breath- 
ing not  stertorous.  Lies  on  the  left  side ;  and  the  muscles  of  the  neck  are  so  rigid 
that  the  head  is  quite  immovable.  Apparently  sensible,  though  she  can  neither 
hear,  speak,  nor  protrude  the  tongue.  Twitchings  stiU  occasionally  occur  on  right 
side  of  face,  right  arm,  and  right  leg.  Right  arm  rigidly  contracted.  Died  early  on 
the  morning  of  the  9th. 

Sectio  Cadaveris. —  Thirty  hours  after  death. 

Rigor  mortis  well  marked. 

He.a,d.  — There  were  strong  adhesions  between  the  calvarium  and  dura  mater  over 
the  vertex,  at  which  place  the  latter  membrane  was  considerably  thickened.  The 
arachnoid  membrane  covering  the  posterior  half  of  the  left  cerebral  hemisphere  was 
thickened,  dense,  and  opaque,  closely  adherent  to  the  pia  mater  below.  The  thick- 
ening and  adhesion  existed  to  its  greatest  extent  over  a  space  about  the  size  of 
half-a-crown,  situated  about  two  inches  external  to  the  falx,  and  at  the  anterior  por- 
tion of  the  middle  third  of  the  hemisphere.  Here  the  arachnoid  membrane,  united 
with  the  pia  mater,  was  one-eighth  of  an  inch  thick ;  and  the  dense  layer  being  care- 
fully dissected  off.  exposed  a  discoloured  spot  in  the  cerebral  convolutions  measuring 
an  inch  and  a  half  from  before  backwards,  and  one  inch  transversely.  The  centre 
of  this  spot  was  indurated  to  the  feel,  whilst  its  circumference  was  soft  and  pulpy. 
In  the  centre  there  was  observed  a  hard  deposit,  the  size  of  a  pea,  of  a  bright  yellow 
colour,  surrounded  by  a  purple  areola,  passing  into  a  pink  colour,  and  disappearing 
gradually  towards  the  margin  of  the  spot  alluded  to.  On  making  sections  through 
this  diseased  portion,  the  discolouration  was  found  to  extend  inwards  and  occupy  a 
space  about  the  size  of  a  walnut.  It  contained  imbedded  in  its  substance  five  other 
indurated  masses,  varying  in  size  from  a  miUet  seed  to  that  of  a  pea,  and  similar  to 
the  one  formerly  noticed.  The  boundaries  of  this  diseased  mass  intemaDy  presented 
the  same  colour  and  consistence  as  were  noticed  on  the  surface,  with  the  exception 
perhaps  that  the  disappearance  of  colour  was  more  gradual  internally,  and  passed 
into  a  pulpy  white  softening  of  the  cerebral  hemisphere,  which  extended  from  it  in 
a  straight  line  untU  it  terminated  in  the  external  portion  of  the  left  optic  thalamus. 
The  two  lateral  ventricles  contamed  each  about  half  a  drachm  of  slightly  sanguino- 
lent  fluid,  and,  in  the  left  one,  a  vesicle  the  size  of  a  pea,  containing  amber-coloured 
matter,  sprung  from  the  choroid  plexus.  Other  portions  of  the  encephalon  were 
healthy. 

Chest. — Heart  healthy.  Valves  normal  No  adhesion  of  the  pleurje.  The 
bronchi,  when  cut,  poured  out  a  sero-sanguinolent  fluid.  Left  lung  throughout 
spongy  and  crepitant,  with  much  pigmentary  matter  scattered  through  it.  Right 
lung  was  non-crepitant  and  engorged  posteriorly  and  inferiorly,  presenting  a  mottled 
appearance  when  cut,  from  a  number  of  minute  granulations  scattered  throughout. 
All  the  other  viscera  were  quite  healthy. 

Microscopic  Examkatiox. — The  yellow  indurated  masses  described  as  scattered 
throughout  the  diseased  portion  of  the  left  cerebral  liemisphere  consisted  of  a  dense 
aggregation  of  molecules  and  granules,  without  tubercle,  pus,  or  any  kind  of  cor- 
puscle. The  cerebral  structure  surroimding  these  masses  was  loaded  with  innume- 
rable granular  cells  and  masses,  which  existed  throughout  the  whole  discoloured 
portion  of  the  brain,  but  became  less  and  less  numerous  in  the  internal  white  soften- 
ing as  it  approached  the  left  optic  thalamus.  Indeed  the  most  internal  portion  of 
the  white  softening  near  the  optic  thalamus  contained  none  of  them. 

Commentary. — This  woman,  when  she  first  came  under  my  notice, 


CEREBRITIS.  329 

presented,  in  a  very  characteristic  form,  the  general  aspect  and  symp- 
toms of  softening  of  the  brain.  The  dulness  and  confusion  of  intellect, 
without  loss  of  volition  and  sensation — the  weakness  of  the  right  side 
of  the  bodv,  and  contraction  of  the  right  arm — latterly  the  rigidity  of 
this  extremity  and  the  coma,  could  leave  little  doubt  as  to  the  nature  of 
the  lesion,  and  its  seat  in  the  left  hemisphere.  From  the  account  received 
of  her  history,  which,  however,  was  not  entirely  to  be  depended  on,  it 
appeared  that  for  four  years  previously  she  had  been  subject  to  head 
svmptoms  and  "fits"  of  an  epileptic  character,  at  all  events  involving 
temporary  loss  of  the  mental  functions,  and  convulsive  movements  of  the 
limbs,  especially  on  the  right  side.  This  account  was  confirmed  by  the 
post-mortem  examination,  which  exhibited  chronic  thickening,  and  ad- 
hesion to  the  brain,  of  the  meninges  on  the  left  side,  in  addition  to  an 
inflammatory  circumscribed  softening,  commencing  in  the  circumference 
of  the  same  "hemisphere,  and  extending  inwards  to  the  optic  thalamus  of 
the  same  side.  The  yellow  masses  described  were  evidently  a  chronic 
form  of  exudation,  audit  is  very  difficult  to  determine  whether  they  ori- 
ginated or  followed  the  meningitis.  Certainly  they  occasioned  the  sur- 
rounding discoloration  and  exudation,  which  had  extended  inwards  to  the 
central  portions  of  the  encephalon. 

As  regards  the  connection  of  the  symptoms  with  the  post-mortem 
appearances,  we  can  have  little  difficulty  in  ascribing  the  commencing 
symptoms  and  "fits"  to  the  meningitis,  which  increasing  in  intensity, 
caused  pressure  on  the  cranial  portion  of  the  cord,  and  occasioned  the 
convulsions.  The  same  lesion,  conjoined  with  the  external  softening  and 
corresponding  change  of  circulation  within  the  cranium,  was  the  cause 
of  the  confusion  of  intellect  and  stupidity  latterly  observed,  whilst  the 
continued  irritation  originating  in  the  local  cerebral  inflammation,  ope- 
rating through  the  anterior  portion  of  the  optic  thalamus,  and  perhaps  a 
portion  of  the  corpus  striatum,  caused  the  contraction  and  rigidity  ob- 
servable in  the  right  arm.  It  is  of  course  impossible  to  determine  the 
amount  of  pressure  and  its  direction,  which  any  lesion  may  occasion,  ex- 
cept from  its  eflfect.  But  it  seems  to  me  that  this  case  is  an  illustration 
of  the  correctness  of  the  pathological  laws  formerly  given.  The  first 
symptoms  are  those  of  excitation,  and  are  paroxysmal ;  these  pass  into 
more  permanent  symptoms;  and  as  the  organic  disease  proceeds  from 
the  circumference  to  the  centre,  we  observe  the  intelligence  aftected  most, 
motion  secondarily,  and  sensation  not  at  all. 


CEREBRITIS. 

Case   IX.* — Acute   Cerehritis — Abscesses  in  the  Brain — Old    Tubercle  in  various 
Organs — Chronic  Peritonitis. 

History. — Mary  Melville,  set.  22 — admitted  July  20,  1851.  A  girl  of  abandoned 
character,  concerning  whom  no  further  information  could  be  obtained,  than  that  she 
had  been  drinking  to  excess,  and  had  sunk  into  a  state  of  stupor,  from  which  she 
could  not  be  recovered. 

*  Reported  by  Mr.  D.  0.  HoQe,  CHnical  Clerk. 


330  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Symptoms  ox  Admission. — On  admission  slie  was  insensible,  but  three  hours  after 
being  phiced  in  bed,  so  far  recovered  consciousness  as  apparently  to  understand 
questions  put  to  her,  although  she  could  not  articulate.  She  cannot  move  the  riglit 
arm,  although  the  other  limbs  are  moved  freely.  The  eyes  are  sufiused :  pupils  and 
eye-brows  contracted;  general  appearance  that  of  prostration.  Pulse  120,  weak; 
left  hand  occasionally  applied  to  tlie  head,  as  if  pain  was  felt  there ;  skin  cool ; 
breath  smells  strongly  of  whiskey ;  breathing  a  little  accelerated,  but  no  abnormal 
rales.  Head  to  he  shaved,  and  ice-cold  applications  to  he  constantly  made.  To  have  ^  ss 
of  castor  oil  in  pepjyermint  ivater. 

Progress  of  the  C.\se. — July  2\st. — Was  delirious  during  the  night  and  became 
violent,  raving  incessantly,  and  trying  to  get  out  of  bed,  so  that  it  was  necessary  to 
put  on  the  strait- waistcoat.  Bowels  have  not  been  relieved.  Pulse  130,  weak. 
To  he  cupped  at  the  back  of  the  neck  to  ^  viij.  To  have  a  turpentine  injection.  July 
22d — Still  delirious.  During  the  night  vomited  several  times.  "Will  take  no  nourish- 
ment. The  right  arm  is  occasionally  convulsed.  Bowels  have  been  freely  opened. 
In  other  respects  the  same.  A  Mister  to  he  applied  to  the  sinciput.  Nourishment  to 
he  given  in  small  quantities,  frequently  repeated,  with  §  iv  of  wine.  July  23rf. — Delirium 
not  so  violent  during  the  night,  consisting  of  low  muttering.  At  present  seems 
exhausted.  Pulse  126,  small  and  weak.  Vomiting  occurs  now  and  then,  but  not  so 
frequently.  Blister  has  not  risen.  To  continue  nourishment,  with  5  vj  icine.  July 
21th. — Since  last  report  the  violent  symptoms  and  vomiting  have  ceased,  and  she 
appears  to  suffer  no  pain,  although  the  intellect  remains  confused.  She  was  also 
observed  to  move  the  right  arm,  as  well  as  the  other  limbs  occasionally.  She  also 
took  the  beef  tea,  and  other  nutrients,  with  wine.  On  the  night  of  the  26th  coma 
came  on,  and  the  pupils  were  dilated.  To-day  she  is  completely  insensible,  breathing 
heavily,  with  tracheal  rales;  eyelids  closed;  pupils  natural,  insensible  to  light;  evi- 
denth'  sinking.     Died  earh^  on  the  morning  of  the  28th. 

Sect'to   Cadaverls. — Thirty-four  hours  after  death. 

Body  well  formed,  not  emaciated. 

Head. — On  removing  the  skull  cap  and  dura  mater,  the  arachnoid  and  pia  mater 
covering  the  hemispheres  are  seen  to  be  unusually  congested.  About  the  middle  of 
the  right  hemisphere  was  a  patch  the  size  of  a  sixpence,  of  a  dirty  yellow  colour, 
which,  on  being  cut  into,  was  found  to  be  the  vault  of  an  abscess,  as  large  as  a  wal- 
nut, lined  by  a  soft  and  vascular  membrane,  and  containing  one-half  ounce  of  dirty 
greenish  pus.  A  similar  abscess  of  nearly  the  same  size  was  situated  a  little  ante- 
riorly, and  somewhat  deeper,  in  the  anterior  lobe.  A  third  abscess  presenting  the 
same  appearance  and  contents,  the  size  of  a  hen's  egg,  existed  in  the  centre  of  the 
left  hemisphere,  above  the  corpus  callosum,  and  about  one  quarter  of  an  inch  from 
the  surface  of  the  hemisphere.  The  walls  of  these  abscesses  were  somewhat  indurated, 
punctated  with  red  spots,  and  lined  with  a  fibrinous  matter  about  a  quarter  of  an 
inch  thick,  wliich  apparently  had  not  yet  undergone  the  purulent  transformation. 
Other  portions  of  the  brain  health}^ 

Thorax. — In  the  bronchial  glands,  and  at  the  apices  of  both  lungs,  were  several 
cretaceous  and  calcareous  tubercles,  surrounded  by  indurated  black  pulmonary 
tissue.     Other  thoracic  organs  health}'. 

Abdomen. — The  peritoneum  covering  the  intestines  presented  here  and  there 
patches  of  highly  vascular  Ij-mph,  studded  with  opaque  granular  lymph  about  the 
size  of  millet  seeds.  The  mesenteric  glands  were  enlarged  and  intiltrated  with  old 
cheesy  tubercles.  The  liver  and  spleen  also  contained  a  few  granular  yellow  deposits. 
The  uterus  was  retroverted,  the  os  oedematous,  and  the  cavity  of  fundus  filled  with 


CEREBEITIS.  331 

a  glairy  opaque  yellow  mucus.  Fallopian  tubes  obstructed  by  an  atheromatous  sub- 
stance," resembling  broken  down  and  viscid  pus.  Left  ovary  somewhat  enlarged, 
and  with  its  fellow  covered  with  Graafian  vesicles  in  dififerent  stages  of  development. 
Other  abdominal  organs  heahhy. 

Microscopic  Examixatiox.— The  pus  corpuscles  in  the  cerebral  abscesses  more 
delicate  and  clear  than  usual,  displaying  their  nuclei  without  re-agents.  They  were 
also  mingled  with,  and  surrounded  by  celloid  albuminous  deposits.  The  friable 
matter  inside  the  hniug  membrane  was  composed  of  minute  molecular  filaments, 
and  numerous  molecules  and  granules.  The  membrane  itself  also  had  a  fibrous 
basis,  involving  some  nerve  tubes,  but  no  appearance  of  fibre-cells  or  nuclei  Exter- 
nal to  the  membrane,  the  cerebral  substance,  to  the  depth  of  about  a  line,  was  com- 
posed of  disintegrated  nerve-tubes  and  granule  cells  in  great  abundance. 

Case  X* — Acute  Cerebritis — Abscesses  in  the  Brain— Pulmonary  Tubercle — Abscess  in 

Kidney. 

History.— John  Dods,  set.  19.  a  butcher— entered  the  Clinical  ward  November  9, 
18.55.  Has  been  in  weak  health  for  the  last  two  years.  A  week  ago  he  was  seized 
with  pain  in  the  upper  part  of  the  head,  not  preceded  by  shivering,  or  occasioned 
by  any  obvious  cause.  Denies  that  he  had  been  drinking.  Since  then  he  has  felt 
hot  and  feverish,  and  says  he  has  vomited  frequently,  generally  about  half  an  hour 
after  eating.  The  pain  has  continued,  accompanied  with  ringing  in  the  ears,  up  to 
the  present  time. 

Symptoms  ox  Admissiox. — On  admission,  he  complains  of  racking  pains  in  the 
upper  part  of  the  head,  which  have  prevented  sleep  for  the  last  two  nights.  There 
is  constant  ringing  in  the  ears ;  the  eyes  are  suftused ;  face  flushed ;  speech  confused ; 
with  difficulty  in  collecting  his  ideas.  Appetite  he  declares  to  be  good ;  no  great 
thirst ;  tongue  covered  with  a  duty  yellow  fur,  white  at  the  edges ;  no  pains  in 
stomach  ;  bowels  regular ;  complains  of  cough,  with  slight  mucous  expectoration ; 
percussion  everywhere  normal.  On  auscultation,  slight  prolongation  of  expiration 
over  left  lung  anteriorly,  and  at  right  pulmonary  apex  harsh  murmur  with  inspira- 
tion and  prolonged  expiration;  nowhere  increase  of  vocal  resonance;  pulse  64, 
feeble;  skin  moderately  warm;  body  emaciated.  Other  functions  normal.  The 
head  to  be  shaved,  and  cold  evaporating  lotions  to  be  constantly  employed. 

Progress  of  the  Case. — November  llth. — Passed  a  restless  night,  but  says  the 
cephalalgia  is  diminished.  Pulse  stUl  weak ;  has  taken  no  nourishment.  To  have  - 
beef  tea,  and  §  iij  of  wine.  Xovember  12th. — Last  evening  became  very  restless,  and 
frequently  cried  out.  This  morning  at  two  a.m.  he  screamed  out  violently,  com- 
plained of  pain  in  his  head,  and  became  incoherent,  but  when  loudly  spoken  to, 
gave  rational  answers.  Both  pupils  were  of  moderate  size,  the  right  shghtly  dilated 
more  than  the  left,  but  contracting  equally  on  exposure  to  fight.  At  four  a.m.  he 
was  seized  with  a  general  convulsion,  preceded  by  a  scream,  in  which  it  was  ob- 
served that  the  left  superior  extremity  was  more  rigidly  contracted  than  the  right. 
The  right  pupil  now  was  more  dilated  than  the  left,  and  both  contracted  only  feebly 
on  exposure  to  candle  light.  The  convulsion  lasted  five  minutes,  and  terminated  in 
complete  coma,  which  continued  up  to  the  hour  of  visit.  He  was  then  found  to  be 
perfectly  unconscious,  and  could  not  be  roused.  There  were  occasional  starlings  of 
the  limbs.  The  left  foot  and  leg  are  insensible  to  the  action  of  irritants,  which  on 
the  right  side,  however,  occasion  slight  movements.  Respiration  stertorous ;  right 
pupil  more  dilated  than  the  left;  pulse  120,  full.     To  be  cupped  at  the  nape  of  iJie 

*  Reported  by  Mr.  R.  P.  Ritchie,  Clinical  Clerk, 


832  DISEASES   OF  THE   NEEVOUS  SYSTEM. 

neck,  and  §  viij  of  hlood  extracted.  Continue  the  aj^plication  of  cold  to  the  head. 
At  eight  P.M.,  having  been  cupped,  tlie  breathing  became  easier,  but  the  coma  con- 
tinued, and  he  died  at  three  a.m.  on  the  13th. 

Sectio  Cadaveris. — Eighty-one  hours  after  death. 

Body  emaciated. 

Head. — On  removing  the  calvarium,  two  bulging  abscesses  were  seen,  one  occu- 
P3'ing  tlie  anterior  and  middle  third  of  the  right,  and  the  other  the  posterior  third  of 
the  left  cerebral  hemispliere,  immediately  below  the  dura  mater,  which  was  of  a 
greenish  hue.  On  removing  tliis  membrane,  the  abscess  on  the  right  side  was  ex- 
posed, which  was  of  roundish  form,  measuring  three  inches  in  diameter.  On  the 
left  side  the  abscess  was  not  quite  so  large,  measuring  two  and  a  half  inches  in 
diameter.  On  cutting  through  these  abscesses,  they  were  seen  to  be  embedded  in 
the  cerebral  lobes,  above  the  corpus  callosum.  They  consisted  of  several  excava- 
tions, varying  in  size  from  a  pea  to  that  of  a  hazel  nut,  all  communicating  with  one 
another,  and  filled  with  greenish  pus.  Their  margins  presented  a  smooth,  abrupt 
border,  which  was  considerably  indurated  to  the  depth  of  one-eighth  of  an  inch, 
with  points  of  blood  here  and  there  scattered  through  it.  The  ventricles  and  all 
other  parts  of  the  brain  were  healthy. 

Thorax. — In  the  apex  of  right  lung  were  about  half  a  dozen  miliary  tubercles, 
and  the  pleuraa  over  these  were  firmly  united  by  dense  chronic  adhesions.  The 
upper  portion  of  the  middle  lobe  of  the  right  lung,  and  the  inferior  portion  of  upper 
lobe  of  left  lung,  contained  condensed  portions  of  a  red  brick  colour,  partly  oedema- 
tous,  and  partly  pneumonic,  evidently  of  recent  formation.  The  anterior  surface  of 
the  left  lung  very  emphysematou.s. 

Abdomex. — Abdominal  organs  health}',  with  the  exception  of  an  abscess  the  size 
of  a  hazel  nut,  in  the  cortical  substance  of  the  left  kidney. 

Microscopic  Examination. — The  pus  in  the  cerebral  abscesses  contained  pus 
cells,  with  delicate  walls,  floating  in  a  liquor  puris  crowded  with  molecules.  The 
indurated  margin  of  the  abscesses  was  composed  of  a  dense  aggregation  of  minute 
molecules  of  a  light  brownish  colour,  gradually  diminishing  towards  the  healthy  por- 
tion of  the  cerebral  texture,  where  they  were  seen  to  be  infiltrated  among  the  tubes. 

Commentary.  —  In  tliese  two  cases,  abscesses  were  found  in  both 
hemispheres,  and  it  will  be  observed  that  the  symptoms  were  of  the 
same  general  character  as  those  of  meningitis  formerly  given.  The  only 
differences  observable  are  the  more  decided  convulsions  and  paralysis, 
and  the  less  degree  of  delirium,  somnolence,  and  stupor.  Indeed,  it  may 
be  said  to  be  impossible  to  distinguish,  with  anything  like  certainty,  in 
individual  cases,  acute  exudations  poured  into  the  substance  of  the  brain, 
from  those  affecting  the  meninges  or  ventricles.  The  reason  will  be 
obvious  when  we  reflect  that  the  phenomena,  in  everv  instance,  are  in 
fact  attributable  to  pressure  on  the  encephalon,  and  that,  if  this  be  rapid 
and  general,  it  can  matter  little  whether  it  originate  from  the  meninges 
or  the  centre  of  the  cerebral  lobe.  In  the  latter  case,  liowever,  as  the 
disease  progresses,  there  is  more  liability  of  the  cranial  ganglia,  con- 
nected with  motion,  to  become  affected,  and  hence  probably  the  greater 
amount  of  convulsion  and  paralysis. 

Lebert,*  in  an  elaborate  Memoir  on  Cerebral  Abscesses,  in  which  he 
has  carefully  analysed  the  histories  of  80  cases,  has  come  to  the  con- 

*  Virchow's  Archiv.  fiir  Patholog.  Anat.     Band  x. 


CEREBRITIS.  333 

elusion,  that  what  debilitates  the  individual,  causes  a  predisposition  to 
this  afltection.  Such  is  also  my  own  opinion,  as  most  of  the  cases  I 
have  seen  have  been  in  scrofulous  subjects,  and  more  especially  such  as 
have  laboured  under  some  form  of  otitis,  connected  with  caries  of  the 
temporal  bone.  In  the  two  cases  recorded,  eftete  tubercle  was  found  in 
the  luno;s,  and  the  general  health  was  much  deteriorated.  Very  little 
benefitcan  therefore  be  expected  from  depleting  remedies.  Hitherto, 
indeed,  almost  all  these  cases  have  been  vaguely  ascribed  to  meningitis 
or  apoplexy.  But  as  regards  diagnosis,  we  are  exactly  in  the  same 
condition  now  in  reference  to  meningitis  and  cerebritis,  as  medical  men 
were  in,  during  the  days  of  CuUen,  as  to  pleuritis  and  pneumonitis;  that 
is,  w^e  cannot  separate  them  by  the  aid  of  their  symptoms.  Hence  the 
following  summary  from  Lebert's  memoir,  as  it  comprises  all  that  is 
known  with  regard  to  the  symptoms  in  80  cases,  is  deserving  attention  : 
"  Sudden  headache  is  the  symptom  which  most  frequently  first  excites 
attention ;  it  is  generally  accompanied  by  febrile  symptoms,  vomiting, 
difficult  articulation,  and  convulsive  attacks  may  supervene ;  the  patients 
become  heavy  and  morose,  and  show  delirium,  contraction  of  pupils, 
photophobia ;  numbness  and  formication  may  supervene,  and  apoplectic 
symptoms  may  occur;  but  all  these  symptoms  vary  much  in  different 
cases.  The  intellect  suffers  comparatively  little ;  sensibility  suffers  more 
frequently ;  the  headache  is  more  or  less  intense,  generally  diffuse  at  first, 
and  subsequently  unilateral.  Coma  occurs  frequently,  but  often  only 
temporarily.  Paralytic  states  were  observed  in  almost  one  half  of  the 
cases;  they  were  generally  local,  but  showed  themselves  also  in  the  form 
of  general  muscular  debility.  Diminished  articulating  power  was  ob- 
served in  10  cases.  In  regard  to  the  special  senses,  only  the  affection 
of  the  ears  presents  any  points  of  impoilance.  No  special  symptoms 
are  observed  in  reference  to  the  vascular  or  respiratory  system.  Dis- 
turbance of  the  digestive  organs  showed  itself  in  the  form  of  vomiting  in 
20  cases ;  involuntary  defsecation  occurred  towards  the  fatal  termination 
of  1 1  cases.  The  duration  of  the  disease  appears  to  fluctuate  from  two 
or  three  weeks  to  two  months ;  there  is  necessarily  a  difficulty  in  deter- 
mining the  point,  as  the  commencement  can  only  be  approximately 
fixed.  It  occurs  at  all  ages;  but  the  greatest  frequency  prevails  between 
the  sixteenth  and  thirtieth  years."* 


Case  XI. f — Chronic  Cerebritis;  Epile2)tiform  Convulsions;   Hemiplegia  of  the  Right 
Side;  Loss  of  Smell;  Blindness  of  the  Left  Eye;  Amyloid  Bodies  in  the  Brain. 

History. — John  Bookless,  set.  48,  a  plasterer,  admitted  January  7,  1855.  He 
bad  enjoyed  good  health  until  two  years  ago,  when  he  first  complained  of  giddiness 
and  gradual  impairment  of  sight,  and  of  smell.  Twelve  months  ago  he  was  attacked 
with  "  fits,"  three  or  four  appearing  in  the  course  of  the  first  night.  They  have 
occurred  occasionally,  at  considerable  but  irregular  intervals,  ever  since.  His  general 
health  had  remained  good,  until  the  3d  instant,  when,  about  12  o'clock  at  night,  a 
violent  "  fit  "  appeared,  which  was  repeated  from  eighteen  to  twenty  times  before 

*  British  and  Foreign  Med.-Chir.  Review.     April,  1857. 
■j-  Reported  by  Mr.  W.  Gilfillan,  Clinical  Clerk. 


33-1  DISEASES   OF   THE   XERYOUS   SYSTEM. 

six  o'clock  on  the  following  morning.  Ou  the  4th  and  5th  he  was  comparatively 
free  from  them ;  but,  on  the  6th,  during  the  night,  they  recurred  more  frequently. 
On  the  morning  of  the  7th,  it  was  observed  that  the  right  arm  and  leg  were  para- 
lysed, and  he  was  sent  into  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  it  was  observed  that  the  body  was 
tolerabh-  robust ;  that  he  was  hemiplegic  on  the  right  side ;  that  the  head  was  ob- 
stinately kept  turned  towards  the  right  side ;  that  speech  was  slow  and  thick  ;  and 
that  although  conscious,  he  was  some  time  in  framing  an  answer  to  a  question.  To 
have  5j  o/  castor  oil.  Careful  investigation  on  the  following  day  elicited  the  fol- 
lowing facts,  viz.,  complete  blindness  of  the  left  eye — sight  in  the  right  eye  perfect — 
smell  absent — cephalalgia— frequently  applies  his  left  hand  to  the  left  side  of  the 
head — other  special  senses  normal — loss  of  voluntary  motion  over  riglit  side,  with 
considerable  impairment,  but  not  absence  of  sensibihty — left  side  normal — pulse  96, 
full — other  functions  healthy.  Bowels  have  been  freely  open,  from  the  action  of  the 
castor  oil.  WhiLst  I  was  examining  the  patient,  he  passed  through  two  attacks  of 
an  epileptic  character — there  was  no  scream,  only  a  sliglit  groan — the  muscles  of 
all  the  limbs  became  rigid — the  toes  and  fingers  incurvated — the  face  flushed,  and  the 
head  tetanically  twisted  towards  the  right  side — the  mouth  was  drawn  somewhat 
to  the  left — the  left  arm  and  leg  convulsed,  tlie  right  arm  and  leg  rigid  and  trembling ; 
there  was  complete  loss  of  consciousness.  This  state  continued  about  one  minute 
when  the  face  became  pale,  tliere  was  foaming  at  the  moulli,  the  rigidity  and  convul- 
sions subsided,  and  in  another  minute  he  was  again  conscious  and  fullj'^  restored 
to  his  former  condition.  To  be  cupped  in  the  neck  to  the  extent  of  8  oz. — ice  to  he  applied 
to  the  head. 

Progress  of  the  C.\se. — From  this  period  he  lay,  in  the  intervals  of  the 
attacks,  tolerabl v  tranquil ;  the  evacuations  were  passed  involuntarily ;  took  nourish- 
ment without  difficulty.  The  whole  of  the  12th  he  was  free  from  convulsive  attacks, 
but  on  the  13th  they  returned;  pulse  106,  soft.  A  Ulster  to  the  neck,  and  §  iv  o/ 
xoine.  On  the  14th  the  epileptic  attacks  retvu-ned  every  ten  minutes,  until  one 
o'clock  in  the  morning  of  the  15th.  From  this  time  he  remained  free  from  them. 
At  the  visit  he  was  stLU  conscious,  slowly  answered  questions,  put  out  his  tongue, 
etc.  The  respirations,  however,  were  slightly  laboured,  and  gradually  became  more 
so,  until  he  sank,  at  9  p.m.,  on  the  16th. 

Sectio  Cadaveris. — Fifteen  hours  after  death. 

Head. — On  removing  the  calvarium,  the  subarachnoid  cellular  tissue  was  infil- 
trated with  serum,  which  elevated  the  arachnoid  in  some  places  above  the  level  of 
the  convolutions.  On  slicing  the  brain  from  above  downwards,  its  substance  was 
healthy.  Both  lateral  ventricles  were  distended  with  clear  serum,  which,  on  being 
carefully  removed  with  a  pipette,  measured  1  oz.  and  7  drachms.  The  ventricles  were 
somewhat  enlarged,  but  their  lining  walls  healthy.  The  foramen  of  Monro  was 
the  size  of  a  fourpenny  piece,  its  edges  very  thin.  "\Yhite  substance  of  the  fornix 
and  central  portion  of  the  brain  healthy.  The  left  corpus  striatum  atrophied  and 
shrunk  throughout,  externally  of  a  dull  mahogany  colour,  and,  on  section,  com- 
posed of  a  diffluent  fawn-coloured  substance,  which  flowed  out,  leaving  an  irregular 
cavity  the  size  of  a  hazel  nut.  Below  the  left  corpus  striatum,  the  optic  thalamus 
presented,  on  section,  a  cribriform  appearance,  over  a  space  the  size  of  a  shilling, 
dependent  on  chronic  enlargement  and  thickening  of  small  vessels,  the  open  mouths 
of  which,  on  being  cut,  were  retracted  into  its  substance.  In  the  anterior  portion 
of  the  right  corpus  striatum  there  was  also  a  diffluent  softening,  occupying  a  space 
about  the  size  of  a  pea.     On  removing  the  cerebral  lobes  from  the  cranium,  a  dense 


CEREBRITIS.  335 

chronic  adhesion,  which  it  was  necessary  to  cut  through,  existed  between  tlie  in- 
ferior surface  of  the  left  anterior  lobe  and  tlie  dura  mater.  It  involved  the  optic 
and  olfactory  nerves  of  that  side,  and  extended  so  far  on  the  right  side  as  to  include 
also  the  right  olfactory  nerve.  The  portion  of  brain  in  immediate  connection  with 
this  adhesion  was  unusually  indurated  to  the  feel  throughout  a  portion  of  substance 
in  the  left  lobe,  about  the  size  of  a  nutmeg;  but,  in  the  right,  confined  to  a  thin  layer 
of  cerebral  substance  externally,  aboilt  an  eighth  of  an  inch  in  thickness,  and  about 
the  size  of  a  shilling  in  its  area.  On  cutting  through  the  indurated  substance  on 
the  left  side,  it  felt  like  soft  bee's-wax  under  the  knife,  was  of  a  very  pale  straw 
colour,  gradually  disappearing,  as  did  the  induration,  into  the  healthy  structure, 
without  any  obvious  limit  whatever.  About  another  oz.  of  sanguineous  serum  was 
found  collected  in  the  depending  portions  of  the  cranial  cavity  after  the  brain  was 
removed.     The  other  portions  of  the  brain  were  healthy. 

Thoracic  and  abdominal  viscera  healthy. 

Microscopic  Examination. — The  fawn-coloured  softenings  in  the  corpora  striata 
consisted  of  numerous  molecules,  granules,  granular  masses  and  cells,  mingled  with 
vessels  coated  with  granular  exudation,  and  fragments 
of  the  tubes  of  the  cerebral  substance.  In  and  around 
the  cribriform  alteration  of  the  left  optic  thalamus, 
numerous  round  colourless  transparent  bodies  were 
observed  which  refracted  light  strongly,  and  were  appa- 
rently solid.  They  varied  in  size,  from  the  1-lOOUth 
to  the  l-500th  of  an  inch  in  diameter.  Some  con- 
tained an  included  globular  body,  around  which  feint 
concentric  circles  were  discernible.  On  the  addition 
of  diluted  sulphuric  acid  and  iodine,  they  did  not  give 

the  reaction  of  starch  or  cellulose.  They  were  unaffected  by  water,  acetic  and  nitric 
acids.  Here  and  there  they  seemed  to  split  up,  not  unlike  starch  bodies.  The 
indurated  portion  of  brain  in  the  anterior  lobes  presented  an  obscure  amorphous 
appearance,  consisting  apparently  of  the  normal  elements,  infiltrated  with  a  brownish, 
exceedingly  fine,  molecular  substance.  Tlie  serum  of  the  ventricles  only  contained 
a  few  epithelial  cells,  distended  witli  water  by  endosmose. 

Commentary. — The  symptoms  observed  during  the  life  of  this  man 
■were  all  clearly  explained  by  the  inorbi'l  changes  demonstrated  after 
death.  Before  the  post-mortem  examination  took  place,  I  ventured  to 
diagnose  chronic  softening  of  the  left  corpus  striatum,  with  a  tumour  so 
situated  below  it  as  to  press  upon  the  left  optic  nerve,  and  both  olfactoiy 
nerves.  Such  Avere  the  principal  lesions  discovered,  as  the  indurated 
brain  and  dense  adhesion  may  in  one  sense  be  looked  upon  as  a  tumour, 
producing  the  destruction  of  the  special  nerves,  whilst  the  extensive 
lesion  of  the  left  corpus  striatum  sufhciently  explained  the  hemiplegia 
on  the  right  side  of  the  body.  Two  other  lesions,  however,  were  dis- 
covered, viz.,  1st,  The  limited  disease  in  the  right  striated  body  ;  and, 
2dly,  The  etfusion  of  serum  into  the  lateral  ventricles  and  subarachnoid 
cavity.  To  the  first  of  these  lesions  may  probably  be  ascribed  the  con- 
vulsions which  more  especially  attacked  the  left  side  of  the  body, 
although  alone  this  would  be  insufficient  to  account  for  its  paroxysmal 


Fig.  386.  Amyloid  bodies  with  fragments  of  nerve-tubes,  in  the  cribriform  sub- 
stance of  the  optic  thalamus.  250  diam. 


336  DISEASES   OF   THE   NERVOUS   SYSTEM. 

character — a  phenomenon  which,  as  I  have  elsewhere  endeavoured  to 
explain,  can  only  be  referred  to  congestions  within  the  cranium.*  As 
to  the  effusion  of  serum,  I  am  inclined  to  consider  it  as  having  occurred 
during  the  last  few  hours  of  life ; — 1st,  Because  he  was  conscious  within 
twelve  hours  of  his  death,  and  was  free  from  delirium  and  stupor;  2dly, 
Because,  after  death,  little  imbibition  of  serum  had  taken  place  into 
the  central  white  substance  of  the  brain,  and  there  was  consequently  no 
softenini;  from  maceration. 


Case  XII. f — Chronic  Meningo- CerebriUs — Sudden  Convulsions — Hemiplegia  of  Left 
Side — Softening  of  Anterior  Lobe  of  Right  Cerebral  Hemisphere — Adhesions  of 
Arachnoid. 

History. — TV'illiam  M'Donald,  set.  38,  wTiter's  clerk — admitted  November  22, 
1852.  from  the  account  given  of  him  by  his  friends,  it  would  seem  that  his  habits 
have  been  of  rather  a  dissipated  nature  for  several  years  back.  He  was  never  known 
to  have  delirium  tremens,  but  about  ten  months  ago  was  seized  with  cephalalgia, 
unusual  movements  of  the  shoulders,  and  inability  to  speak  or  write,  which  symptoms, 
it  is  said,  soon  disappeared.  For  the  last  six  months  also,  he  has  been  out  of  employ- 
ment, and  not  eaten  more  than  one  meal  in  the  day.  On  the  morning  of  the  19th, 
he  was  seized  with  a  fit,  which  w-as  succeeded  by  profound  sleep  for  some  hours.  The 
next  day  he  was  so  far  recovered  as  to  be  able  to  walk  about,  and  in  the  evening  he 
went  to  the  theatre  with  one  of  his  friends,  who,  on  being  interrogated,  says  that  he 
did  not  consider  him  at  that  time  in  his  right  mind.  On  the  21st  he  had  another  fit, 
and  on  the  22d  several  others,  which  succeeded  one  another  at  intervals  of  ten 
minutes. 

Symptoms  ox  Admission. — On  admission,  is  still  labouring  under  convulsive 
paroxysms,  with  loss  of  consciousness,  and  foaming  at  the  mouth.  These  are  always 
present,  with  the  exception  of  intervals,  varying  in  duration  from  ten  minutes  to 
half  an  hour,  during  which  the  consciousness  returns,  and  he  answers  questions  cor- 
rectly. When  a  paroxysm  begins,  he  generally  utters  a  short  groan ;  the  mouth 
becomes  twisted,  and  pulled  to  the  left  side ;  the  eye-balls  incline  to  the  left  side. 
During  the  fit  the  pupils  are  slightly  dilated,  and  insensible  to  light ;  the  left  arm  is 
thrown  into  violent  clonic  convulsions ;  the  left  foot  is  extended  and  rigid,  and  the 
right  one  firmly  flexed.  Towards  the  end  of  the  paroxysm  there  is  foaming  at  the 
mouth ;  respiration  is  somewhat  restrained,  not  stertorous  ;  there  is  no  appearance  of 
suffocation,  nor  any  marked  lividity  of  the  countenance.  As  the  fit  passes  off,  the 
respiration  graduahy  becomes  more  free  and  natural ;  during  expiration,  the  right 
cheek  is  puffed  out  like  a  flaccid  bag.  After  recovermg  consciousness,  he  can  move 
the  right  arm  and  leg  voluntarily,  but  the  extremities  of  the  left  side  are  quite  power- 
less and  insensible.  Pulse  98,  full,  but  not  strong.  Tongue  is  moist  and  clean,  and 
the  edges  marked  with  indentations  fi-om  the  teeth.  On  being  protruded,  it  is  turned 
tow^ards  the  left  side ;  no  distortion  of  the  face  during  the  intervals ;  urine  during  the 
fits  is  passed  involuntarily ;  bowels  open.  In  all  other  respects  the  bodily  functions 
are  normal  Four  leeches  to  be  applied  to  each  temple.  The  head  to  be  shaved, 
aiid  cold  constantly  apjdied  to  the  scalp.  To  take  ten  grains  of  Dover's  powder  at 
bed-time. 

*  See  Articles  by  the  writer  on  Apoplexy,  Epilepsy,  etc.,  in  the  second  volume 
of  the  Library  of  Medicme. 

■f-  Keported  by  Mr.  Alex.  T.  M'Arthur,  Clinical  Clerk. 


CEREBRITIS.  337 

Progress  op  the  Case. — November  23,  7  a.m. — During  the  night  has  had  frequent 
convulsive  paroxysms,  such  as  have  been  previously  described  (66  were  coiinted). 
The  skin  never  is  hot,  but  moist.  Pulse  100,  full  and  firm  ;  otherwise  the  same. 
To  he  cupped  on  the  temples,  and  12  oz.  of  Mood  abstracted.  To  have  immediately 
afterwards  an  opiate  enema.  At  the  visit  the  convulsions  are  almost  continuous, 
with  perhaps  a  minute  of  interval,  and  then  another  minute  of  violent  struggles  and 
clonic  spasms.  Pulse  120,  strong  and  bounding,  increasing  in  frequency  and  tensity 
during  the  attack.  To  he  hied  to  15  oz.  and  the  cold  douche  app)Ued  to  the  head.  3  p.m. 
— Is  now  unconscious  during  the  intervals.  Pulse  160,  soft.  The  fits,  which  became 
less  frequent  after  the  bleeding,  are  now  as  numerous  as  at  the  visit.  To  apply  Liq. 
Ammonias,  with  a  view  of  producing  vesication,  to  the  occiput.  To  have  a  table- 
spoonful  of  brandy  every  half  hour.  Sinapisins  to  be  apjdied  to  the  calves  of  the  legs. 
7  o'clock  P.M. — Consciousness  returned  after  the  first  dose  of  the  brandy.  The  ammonia 
has  only  caused  redness  of  the  integument.  Pulse  120,  small  and  weak.  On  aus- 
cultation of  chest  a  loud  moist  rale  is  heard  over  whole  anterior  surface  of  chest. 
Paroxysms  as  frequent  as  before.  Continue  brandy  at  intervals  of  two  hours,  with 
beef-tea.  November  24. — During  the  night  the  fits  became  less  frequent,  there  being 
often  intervals  of  a  quarter  of  an  hour.  At  7  a.m.  they  ceased  entirely,  when  the 
breathing  became  stertorous,  and  stupor  came  on,  from  which,  however,  he  could  be 
roused  until  half  an  hour  preceding  death,  which  occurred  at  9  a.m. 

Sectio  Cadaver  is. —  Twenty/seven  hours  after  death. 

Body  moderately  robust,  face  and  surface  somewhat  livid. 

Head  and  Spine. — Dura  mater  rather  thicker  than  usual,  especially  so  over  both 
anterior  hemispheres,  but  in  texture  healthy.  There  was  a  firm  adhesion  between 
the  dura  mater  lining  the  frontal  bone  and  the  arachnoid  covering  the  anterior  lobe 
of  right  hemisphere,  over  a  space  f  ths  of  an  inch  in  diameter.  The  arachnoid  mem- 
brane everywhere  moist.  Ventricles  do  not  contain  above  3  ss  of  serum.  Pia  mater 
and  choroid  plexuses  healthy.  The  substance  of  the  brain  everywhere  normal,  except 
at  the  place  in  the  anterior  right  lobe,  immediately  below  the  adhesion  formerly 
noticed.  Here  the  cerebral  substance  is  softened  to  an  extent  about  the  size  of  a 
hen's  egg.  The  grey  and  white  substance  cannot  be  distinguished;  and,  on  section, 
the  morbid  portion  is  of  a  grey  or  dirty  white  colour,  of  pultaceous  consistence,  readily 
disappearing  under  a  fine  stream  of  water.  Frontal  bone  healthy.  The  sjiinal  cord 
and  its  membranes  healthy.     The  other  organs  could  not  be  examined. 

Microscopic  Examination. — Numerous  fatty  granules,  granular  masses  and 
cells,  both  loose  and  accumulated  round  the  blood-vessels  of  the  cerebral  softening, 
were  visible.     The  tubular  substance  also  was  greatly  disintegrated  and  broken  up. 

Commcntari/. — In  this  case,  after  sufferinoj  from  cephalal«;ia  more 
or  less  contiimous,  commencing  ten  months  before  admission,  followed 
by  various  signs  of  perversion  of  intelligence  and  motion,  caused  appa- 
rently by  drinking,  the  patient  was  suddenly  seized  with  convulsions  on 
the  19th  of  November,  followed  by  sopor.  From  this  he  rallied  next 
day,  and  was  so  well  as  to  go  to  the  theatre,  although  still  labourino-  under 
a  certain  confusion  of  the  mind.  On  the  21st  the  convulsions  returned, 
and  at  length  became  almost  continuous  and  of  an  epileptic  character,  and 
were  followed  by  hemiplegia  of  the  left  side.  They  so  exhausted  him 
that  lie  sank. 

When  I  first  saw  this  man  he  appeared  to  me  to  be  in  an  epileptic  con- 
vulsion, but  the  history  of  the  case,  and  the  short  duration  of  the  inter- 
vals of  consciousness,  during  which  he  was  composed  and  answered  ques- 

22 


338  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tions,  pointed  to  an  organic  lesion  of  the  brain.  The  pulse,  though  fiill, 
was  not  very  strong.  Hence  eight  leeches  were  applied  to  the  temples, 
the  head  was  shaved,  and  ice  applied.  This  treatment  in  no  way  alle- 
viated the  symptoms.  Next  day  the  pulse  was  100,  full  and  firm.  He 
was  now  cupped  over  the  temples,  and  12  oz.  of  blood  extracted  from 
the  arm,  followed  by  an  opiate  enema,  but  without  benefit.  Next  day 
the  pulse  was  120,  strong  and  bounding.  He  was  now  bled  to  15 
oz.,  and  the  cold  douche  applied  to  the  head,  with  the  result  of  making 
him  much  worse,  forshoilly  afterwards  he  became  insensible  even  during 
the  intervals.  In  the  evening,  therefore,  I  at  once  changed  the  treatment, 
and  gave  brandy  in  table-spoonful  doses,  with  the  efiect  of  causing  imme- 
diate restoration  of  consciousness  and  a  marked  improvement.  Sti- 
mulants with  nutrients  were  perseveringly  continued,  but  in  vain.  Post- 
mortem examination  demonstrated  the  existence  of  a  chronic  grey  soft- 
ening in  the  anterior  lobe  of  the  right  cerebral  hemisphere,  with  old 
dense  adhesions  of  the  membranes  over  it.  The  cephalalgia  and  obscure 
cerebral  symptoms  during  a  period  of  ten  months,  were  evidently  owing  to 
these  combined  lesions  advancing  slowly  or  at  intervals.  The  history 
informs  us,  that  during  the  last  six  months  he  had  been  out  of  employ- 
ment and  insutficiently  nourished,  a  condition  highly  favourable  to  the 
disintegrating  process  in  the  brain,  which  at  length  arrived  at  such  a 
point  as,  probably  combined  with  an  unaccustomed  congestion,  to  pro- 
duce violent  irritation  of  the  motor  nerves,  together  with  such  disor- 
ganisation and  pressure  as  to  occasion  hemiplegia. 

If  this  be  the  correct  theory  of  the  case,  an  antiphlogistic  and 
lowering  system  of  treatment  could  not  be  supposed  very  well  adapted 
to  remedy  the  mischief,  to  prolong  life,  or  even  to  alleviate  symp- 
toms. The  indication  generally  laid  down  in  practical  works  on  this 
subject,  viz.,  to  bleed  when  the  pulse  is  strong  and  full,  was  here  carried 
out,  and  failed  in  the  most  signal  manner.  Indeed,  the  most  approved 
practice  was  actively  followed,  with  the  result  of  making  the  patient 
worse  in  every  particular.  "When,  however,  at  length  antiphlogistics 
wei'e  abandoned  and  stimulants  administered,  then,  and  then  only,  he 
rallied,  and  showed  for  a  little,  signs  of  amendment.  In  no  case  I  ever 
met  with  have  I  been  so  impressed  with  the  inutility  of  antiphlogistics, 
even  when  the  symptoms  seemed,  from  all  our  past  notions,  loudly  to 
demand  them.  Nor  after  the  uselessness  of  these  had  been  demonstrated, 
and  the  patient  reduced  without  benefit,  could  the  value  of  an  opposite 
practice  have  been  better  exhibited.  We  shall  afterwards  point  out 
how  unreasonable  such  lowering  practice  is  in  all  organic  diseases  of  the 
brain. — (See  Cerebral  Hemorrhage.) 


Case  XIII.* — Chronic  Cerehritis  of  the  Bight  Hemisphere — Cancerous   Ulcer  of  the 
(Esophagus  and  neighlouring  Glands — Fatty  Heart. 

Hlstory. — Robert  Millar,  .tt.  72,  married — saddler — admitted  October  6,  1856. 
Patient  states  tliat,  for  the  last  month,  he  has  suflered  from  pain  in  the  epigastrium 
and  from  vomiting,  ibr  which  he  was  in  the  habit  of  using  Gregory's  powder.  For 
a  week  past  had  vertigo,  accompanied  by  a  staggering  gait.     On  the  evening  of  the 

*  Reported  by  Mr.  H.  N.  Maclaurin,  Clinical  Clerk. 


CEREBRITIS.  339 

5tli,  his  feet  were  so  cold,  that  he  was  obhgcd  to  use  a  hot  brick  in  bed  ;  on  the  morn- 
ing of  the  Gtli,  he  found  himself  deprived  of  the  use  of  his  legs,  and  was  accordingly 
brought  to  the  hospital.  According  to  the  account  of  his  wife,  he  has  experienced 
considerable  anxiety  of  late ;  and  she  thinks  that  his  mental  faculties  have  been 
slight!)^  impaired  in  consequence. 

Symptoms  on  Admission. — It  is  with  great  ditEculty  that  the  patient  can  be  made 
to  understand  a  simple  question  ;  and  his  answers  are  often  contradictory.  He  does 
what  he  is  bid;  speech  is  slow;  there  is  slight  confusion  of  memory,  and  want  of 
concatenation  of  ideas.  Sensibility  appears  to  be  present  in  all  parts  of  the  body 
except  in  tlie  inferior  extremities,  where  the  patient  states  he  feels  numbness.  He 
has  no  feeling  of  prickling  or  itching.  Special  sensation  appears  normal ;  but  he  does 
not  see  so  well  as  formerly.  Complains  of  tenderness  over  the  spines  of  the  sacrum, 
on  pressure  and  motion.  Has  not  the  power  of  moving  the  left  inferior  extremity ; 
and  some  difficulty  in  moving  the  right.  The  left  arm  is  somewhat  stiff",  and  he  is 
unal)le  to  raise  Jiimself  in  bed.  With  the  exception  of  an  unusual  jog  with  the 
impulse  of  the  heart,  it  appears  to  be  healthy.  Pulse  50,  of  good  strength.  Tongue 
covered  with  a  whitish-grey  fur,  but  red  at  the  edges.  Protruded  straight,  but  some- 
times spasmodically  jerked  to  the  sides.  Passes  his  urine  involuntarily ;  which  is 
brown,  opaque,  with  a  flocculent  white  sediment ;  alkaline.  Habitually  constipated. 
Face  is  thin  and  pinched  ;  skin  dry,  somewhat  cool,  especially  at  the  feet.  Patient 
states  that  he  has  observed  himself  becoming  thinner  during  the  last  month.  Other 
functions  normal.     Habeat  Pil.  Colocynih.  Co.  ij  pro  re  naia. 

Progress  of  the  Case. —  October  Sih. — Power  of  flexing  the  left  leg  has  returned 
to  a  certain  extent,  but  he  is  still  quite  unable  to  extend  it.  He  can  flex  and 
extend  the  left  forearm,  but  has  no  power  of  raising  the  upper  arm  on  the  same  side. 
Bowels  quite  open ;  is  only  able  to  swallow  fluids,  and  even  these  in  very  small 
quantities ;  it  would  appear  that  matters  ingested  pass  only  a  certain  extent  down 
the  oesophagus,  and  then  regurgitate.  October  25th. — Since  last  report  has  continued 
much  the  same.  Vomiting  still  continues  to  such  an  extent,  that  everything  swal- 
lowed is  rejected  immediately.  There  is  tenderness  on  pressure  in  the  epigastrium 
An  inch  below,  and  to  the  right  side  of  the  umbilicus,  a  tumour  of  the  size  of  alien's 
egg  is  now  felt,  which  communicates  to  the  hand  an  impulse  synchronous  with  the 
arterial  pulse  ;  it  can,  by  careful  manipulation,  be  moved  to  the  middle  line,  or  even 
to  the  left  of  it.  IJ .  Bismuth.  Alb.  3  j ;  Pulv.  Opii  gr.  iij ;  Ext.  Gentian  Liq.  q.  s.  ft. 
massa  in  pil.  xxiv.  dividenda.  Two  to  be  taken  thrice  a  day.  Habeat  enema  domesti- 
cum.  November  I8th. — After  taking  the  pills  the  vomiting  was  much  alleviated  and 
has  now  ceased.  Otherwise  he  has  been  in  much  the  same  condition  as  at  last  report. 
The  bowels  have  required  to  be  moved  by  means  of  enemata  and  purgatives. 
December  2,d. — This  morning  he  expresses  himself  as  greatly  relieved,  and  states  that 
his  appetite  is  much  improved.  The  nervous  system  now  presents  phenomena  some- 
what different  from  those  on  admission.  He  answers  questions  slowly,  and  is 
occasionally  suVjject  to  optical  delusions.  There  is  scarcely  any  perceptible  difference 
between  the  left  arm  and  the  right ;  the  former  being  used  almost  as  freely  as  the 
latter,  and  presenting  little  or  no  appearance  of  stiffness.  He  can  also  move  all  the 
joints  of  the  left  leg,  but  with  difficulty ;  stating  that  it  is  stiff",  and  that  he  has  not 
so  great  command  over  it  as  over  the  right.  Feels  a  sensation  of  prickling,  which  he 
refers  to  the  affected  limb.-  Is  occasionally  subject  to  mental  aberration.  December 
ith. — Has  been  very  violent,  and  quite  delirious  all  night.  This  morning  there 
appears  to  be  still  some  aberration  of  intellect,  and  occasional  optical  delusions.  He 
understands,  however,  what  is  said  to  him,  and  answers  intelligently,  though  slowly. 
Pupils  very  much  contracted,  and  when  a  light  is  brought  close  to  the  eyes,  they  do 
not  contract  further.     December  1th. — Again  vomits  his  food  usually  shortly  after 


340  DISEASES   OF   THE   XEEYOUS   SYSTEM. 

taking  it.  Emaciation  great ;  face  pinched,  with  anxious  expression  and  staring 
eyes.  Repetantur  pU.  Bismtdhi  cum  Qpio,  habeat  Vini  %  iv  indies.  Decemher  2\st. 
— Has  not  vomited  since  taking  the  pills.  The  delirium  and  excitement  subsided 
shortly  after  the  last  report.  He  again  took  food  and  rallied  somewhat,  and 
continued  in  the  same  state  with  occasional  attacks  of  excitement  towards  evening. 
During  the  last  three  days,  however,  his  strength  has  been  gradually  diminisliing  ,• 
there  has  been  sopor,  and  latterly  coma,  and  he  died  this  morning  at  7  a.m. 

Sectio  Cadaveris. — Fifty-four  hours  after  death. 

Head. — On  removing  the  calvarium  and  dura  mater,  a  considerable  amount  of 
clear  serous  fluid  was  seen  to  exist  in  the  subarachnoid  space,  elevating  the  arachnoid 
above  the  level  of  the  convolutions.  On  slicing  the  right  cerebral  hemisphere  several 
small  patches  of  softening  were  observed.  These  were  met  with  chiefly  in  the  white 
matter  of  the  hemisphere,  but  one  or  two  were  seen  in  the  grey  matter  of  the 
convolutions.  The  softening  was  most  distinct  in  the  upper  part  of  the  hemisphere ; 
and  disappeared  towards  the  upper  wall  of  the  lateral  ventricle.  The  softened  portions 
were  of  a  pulpy  consistence,  and  of  a  white  colour,  with  here  and  there  a  slight  tinge 
of  red  or  yellov^^  Xo  such  condition  existed  in  the  left  cerebral  hemisphere. 
Each  lateral  ventricle  was  dilated,  and  contained  about  an  ounce  of  clear  serous  fluid. 
The  parts  within  the  ventricles  were  natural,  as  well  as  the  rest  of  the  bram  and  the 
cerebellum.  The  arteries  at  the  base  of  the  brain  were  generally  opaque,  and  in 
some  places  rigid,  from  the  presence  of  atheromatous  and  a  little  calcareous  matter. 

Chest. — On  removing  the  heart  the  coronary  arteries  appeared  unusually  pro- 
minent, and  felt  hard.  The  muscular  substance  was  soft  and  of  a  fawn  colour.  The 
aortic  valves  were  competent,  although  a  Httle  calcareous  matter  was  deposited  at 
the  base  of  two  of  them.  There  were  one  or  two  minute  vegetations  on  the  free 
margin  of  the  mitral  valve.  The  whole  organ  weighed  11  oz.  On  microscopic 
examination  the  muscular  fibres  had  in  great  part  lost  their  sharply  striated  appear- 
ance, and  appeared  fatty.  The  lungs  were  somewhat  emphysematous  superiorly  and 
anteriorly,  with  one  or  two  slight  puckerings  at  both  apices.  On  cutting  into  the 
pulmonary  tissue,  a  Uttle  old  tubercular  matter  and  one  or  two  minute  cretaceous 
concretions  were  found. 

Abdomex. — The  lower  part  of  the  oesophagus  felt  firm  and  thickened  externally, 
and  on  passing  the  forefinger  into  its  interior,  a  stricture  was  found  to  exist  at  the 
cardia,  through  which  it  could  with  diflBculty  be  passed.  On  laying  open  the 
oesophagus  an  ulcer  was  found  occupying  nearly  the  whole  of  the  mucous  surface 
immediately  above  the  cardia.  When  spread  out,  this  ulcer  was  seen  to  be  of  an 
almost  regularly  circular  form,  having  a  diameter  of  about  an  inch  and  a  half.  The 
face  of  the  ulcer  was  depressed ;  the  margins  prominent  and  hard.  The  base  was  on 
the  whole  smooth,  except  that  from  its  centre  projected  a  sort  of  ridge,  about  half 
an  inch  in  length  (running  parallel  to  the  length  of  the  tube),  of  white  glLstening 
appearance,  and  of  almost  cartilaginous  hardness.  This  ulcer  was  quite  limited  to 
the  oesophagus ;  and  its  surface  was  of  a  duty  greenish  colour.  The  extex'nal  parts 
were  firmly  matted  to  the  portion  of  the  oesophagus  corresponding  to  the  ulceration. 
Two  or  three  enlarged  lymphatic  glands  were  here  met  with.  On  section  of  the 
largest,  which  was  about  the  size  of  a  hazel  nut,  it  was  found  to  be  of  firm 
consistence  externally ;  while  internally  it  consisted  almost  entirely  of  a  glairy 
juice  of  a  slightly  reddish  colour.  The  mucous  membrane  of  the  stomach  and 
intestinal  canal  was  healthy.  The  other  organs,  with  the  exception  of  a  slight 
degeneration  of  the  kidneys,  were  healthy. 

Arterial  System. — Many  of  the  arteries  had  their  coats  loaded  with  athero- 
matous and  calcareous  matter.     This  was  especially  noted  in  the  case  of  the  cerebral 


CEREBRITIS.  841 

and  coronary  arteries ;    and  the  right  common  iliac  artery  was  swollen  out  into  a 
saccular  dilatation,  more  than  an  inch  and  a  half  long. 

Microscopic  Examination. — The  softened  portion  of  the  right  cerebral  hemisphere 
was  composed  of  fragments  of  nerve-tubes,  with  innumerable  granular  corpuscles, 
and  granular  masses  coating  the  vessels.  The  muscular  fasciculi  of  the  heart 
presented  various  stages  of  fatty  degeneration.  The  ulcers  in  the  oesophagus  were 
composed  externally  of  granular  matter,  in  which  a  few  cells  in  various  stages  of 
degeneration  were  observable.  The  nature  of  these  was  determined  by  those 
contained  in  the, neighbouring  glands,  which  abounded  in  cancer  corpuscles,  in  all 
stao-es  of  their  development.  The  atheromatous  matter  in  the  arteries  consisted  of 
numerous  fatty  molecules  and  granules,  associated  with  a  few  granule  cells,  numerous 
crystals  of  cholesterine,  and  masses  of  earthy  salts. 

Commentary. — When  I  first  saw  this  man  he  presented  the  usual  symp- 
toms of  chronic  softening  of  the  brain,  including  failure  of  memory, 
confusion  of  ideas,  and  diminution  of  motor  power  on  one  side  of  the 
body,  with  rigidity.  The  leading  symptoms,  however,  were  constant 
vomiting,  from  an  obstruction  at  the  cardia,  and  consequent  emaciation 
and  weakness.  At  first,  nourishment  was  carefully  regulated  and  given 
in  small  quantities.  Subsequently,  pills  of  bismuth  and  opium  seemed 
to  alleviate  the  vomiting,  which  gradually  ceased.  He  then  rallied 
considerably,  was  enabled  to  take  food  more  fi-eely,  and  became  much 
stronger.  The  paralysis  and  rigidity  of  the  affected  limbs  disappeared, 
and  he  walked  about  the  wards  affirming  that  he  was  quite  well. 
Indeed  he  several  times  desired  to  leave  the  house.  His  mental  faculties, 
however,  remained  confused,  he  became  garrulous,  and  was  subject  to 
optical  delasions  and  intellectual  aberration.  In  this  state  he  continued 
about  three  weeks,  when  he  began  to  wander  at  night,  and  became 
delirious  ;  then  symptoms  of  effusion  within  the  cranium  manifested 
themselves,  and  the  vomiting  returned.  Again  the  pills  ^vith  wine 
caused  him  to  rally  a  little,  but  his  strength  gradually  diminished,  and 
he  sunk.  On  post-mortem  examination,  chronic  softening  of  the  right 
hemisphere  was  found,  explaining  the  effects  produced  on  the  left  side 
of  the  body.  The  old  cancerous  ulcer  of  the  oesophagus  was  indurated, 
and  evidently  in  the  act  of  healing  up  by  cicatrization,  a  fact  which  will 
be  subsequently  alluded  to. — (See  Stricture  of  the  (Esophagus.)  The 
subarachnoid  cavity  and  ventricles  were  distended  with  serum,  explaining 
the  delirium  and  sopor  which  preceded  death. 

The  effects  of  treatment  in  this  case  oft'er  a  marked  contrast  to  what 
was  observed  in  the  last  one.  It  was  quite  remarkable  to  observe  how 
there  follow^ed,  on  cessation  of  vomiting  and  improved  nutrition,  so 
marked  an  abatement  in  all  his  symptoms.  Even  the  paralysed  and 
riffid  limbs  recovered  their  tone,  and  he  moved  about,  as  if  well.  On 
the  return  of  the  vomiting,  the  prostration  and  nervous  symptoms  came 
back,  and  he  again  rallied  on  checking  the  vomiting  and  giving  wine. 
Xo  better  ar'^ument  could  be  furnished  that  delirium,  or  other  evidence 
of  supposed  nervous  excitement,  is  in  fact  a  proof  of  weakness,  and 
requires  for  its  treatment  nutrients  and  stimulants. 


342  DISEASES   OF   THE   NERVOUS   SYSTEM. 


Case  XIT.* — Paralysis  of  the  Ahducens  Oculi  and  Auditory  Nerves — Exophthalmia 
— Tumour  at  the  Base  of  the  Craniura — Partial  Recovery. 

History.— John  "Wright,  set.  30,  typefounder— admitted  Novemlier  20.  1850. 
Suites  that  four  years  ago  he  had  a  severe  attack  of  rheumatism,  soon  after  which 
he  experienced  considerable  pain  in  tlie  right  side  of  the  head.  His  right  eyeball 
then  became  painful,  and  began  to  protrude.  Hearing  also  on  the  same  side  was  at 
first  dull  and  then  abohshed.  Ten  months  after  the  commencement  of  the  headache, 
it  abated  on  the  right  side,  but  became  violent  on  the  left,  where  it  has  continued 
ever  since.  He  was  treated  with  mercury  and  iodide  of  potassium.  Two  years 
since,  he  was  attacked  with  spasms  and  grinding  of  the  jaws,  and  on  two  occasions, 
the  convulsions  were  pretty  general  and  attended  with  loss  of  consciousness.  His 
vision  was  quite  perfect,  till  about  a  fortnight  ago,  when  he  began  to  see  double. 
He  continued  to  work  until  the  23d  inst.,  when,  owing  to  the  imperfection  of  his 
sight,  he  was  obliged  to  desist. 

Symptoms  ox  Admission'. — On  admission,  complains  of  cephalalgia,  most  severe 
on  the  left  side.  There  is  complete  deafiiess  on  the  right  side.  The  right  ej-eball  is 
very  prominent ;  can  be  turned  inwards  but  not  outwards.  Vision  is  perfect  in  the 
two  eyes,  but  from  the  axis  of  both  not  being  alike,  is  double.  He  cannot  lay  hold 
of  an  object  at  once,  and  in  attempting  to  grasp  it  his  hand  is  at  first  directed  to  one 
side.     There  is  no  other  form  of  paralysis,  and  the  other  functions  are  healthy. 

Progress  of  the  Case. — Since  admission,  this  man  has  presented  considerable 
alternations  in  his  s}'mptoms,  the  headache  being  sometimes  more  severe  than  at 
others ;  and  on  such  occasions,  there  was  considerable  stupor,  loss  of  memory,  and 
confusion  of  ideas.  His  treatment  consisted  of  the  internal  ?<•<?  of  the  iodide  of  potas- 
sium and  purgatives,  tvith  counter-irritants  externally.  On  the  ^1h  of  Fehruary,  it  was 
noticed  tliat  the  right  eyeball  was  less  prominent.  On  the  25th  it  was  ascertained, 
on  careful  examination,  that  he  was  not  perfectly  deaf  on  the  right  side,  and  that  the 
right  eyeball  could  be  everted  more  than  formerly.  On  the  \st  of  March  the 
prominence  of  the  right  eyeball  was  comparatively  slight.  He  could  abduct  it  fully, 
and  vision  was  then  single.  The  pain  in  tlie  head  was  unabated,  but  more  erratic. 
By  the  Ibth  of  March,  the  cephalalgia  had  greatly  abated.  There  was  a  marked 
improvement  in  his  general  health.  Movements  of  the  right  eyeball  normal — 
deafness  on  the  right  side  considerable.  Blisters  to  the  temples  and  neck,  and  a 
variety  of  remedies  have  been  tried,  to  cause  sleep,  and  diminish  the  pain  :  of  which 
M.  xij  of  the  Tr.  of  Cannabis  Indica,  appeared  to  be  the  most  beneficial.  T\'ith  the 
exception  of  deafness,  he  was  dismissed  May  22,  quite  well. 

Commentary. — In  this  case,  the  deep-rooted  cephalaljyia,  the  exoph- 
thalmia, the  paralysis  of  the  sixth  and  auditory  nerves  on  the  riojht 
side,  clearly  indicated  the  existence  of  a  solid  body  pushing  out  the  eye, 
and  pressing  on  the  affected  nerves.  At  one  period,  also,  irritation  of 
the  motor  branch  of  the  fifth  pair  was  exhibited  by  spasms  of  the  jaws, 
with  other  cerebral  derangements.  The  tumour,  however,  latterly 
diminished  much  in  size,  as  indicated  bv  the  following  facts: — First, 
return  of  the  eyeball  within  the  orbit;  secondly,  recovery  of  the 
functions  of  the  right  abdncens  ocnli ;  and  lastly,  improvement  of 
hearing,  with  diminution,  and  then  absence  of  the  cephalalgia.  The 
nature  of  the  growth  in  this  case  cannot  be  stated  with  certainty,  but  as 

*  Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


CEREBRITIS. 


543 


it  was  not  likely  to  be  a  cancerous,  and  there  was  no  evidence  of  its 
beino-  a  tubercular  formation,  so  it  was  more  probably  a  simple  exudation. 

Acute  cerebritis  is  distinguished  pathologically  by  tbe  exudation  of 
liquor  sanguinis  into  the  substance  of  the  brain,  which,  if  it  be  poured  out 
in  quantity,  is  transformed  into  pus ;  if  slowly  or  to  a  limited  extent,  it 
usualiv  passes  into  granules  and  granular  cells,  and  becomes  chronic.  In 
the  latter  case  it  constitutes  one  of  the  forms  of  softening  previously  de- 
scribed as  exudative  softening  (p.  305).  I  have  already  alluded  to  the  opi- 
nion of  those  who  consider  this  to  be  a  form  of  fatty  degeneration,  and 
have  shown  how  this  doctrine  fails  to  explain  the  occurrence  of  new  cell 
formation,  in  the  white  substance  of  the  brain,  where  no  nerve-cells  exist 
wdiich  could  undergo  the  fatty  transformation  (p.  222).  Besides,  posi- 
tive research  has  convinced  me,  that  however  fatty  a  true  inHannnatory 
softening  may  ultimately  become,  this  is  only  the  result  of  a  transforma- 
tion of  the  exuded  blood-plasma.  Fig.  113  (p.  132)  represents  this  plasma 
on  the  exterior  of  a  blood-vessel  from  the  spinal  cord,  in  which  a 
formative  process  is  going  on,  and  1  have  seen  other  cases  causing  rapid 
death,  where,  on  examination  of  the  brain  afterwards,  the  coagulated 
liquor  sano-uinis  has  been  observed  in  an  earlier  stage  of  formation. 
Thus,  in  1843,  I  recorded  the  case  of  a  child,  John  Smith,  aged  three 
years,  who  on  the  3d  of  February  18-12  awoke  from  his  sleep,  with  a 
loud  scream  ;  on  the  following  day  he  vomited  repeatedly,  and  on  his 
admission  into  the  Clinical  ward  under  Dr.  Traill,  February  12th, 
presented  as  symptoms  intense  headache,  constant  rolling  of  the  head 
contracted  pupils,  quick  and  sharp  pulse,  considerable  tremor  of  the 
limbs,  great  restlessness,  especially  at  night,  but  without  convulsion. 
He  died  the  same  night,  and  on  examination,  there  was  no  meningitis, 
no  softening,  nor  serous  effusion  into  the  ventricles.  The  blood-vessels, 
however,  of  the  fornix  and  central 
medullary  parts  were  coated  with 
a  fine  molecular  exudation  (Figs. 
387,  388),  at  many  points  two 
and  even  three  times  thicker 
than  the  vessel  to  which  it  was 
attached ;  the  exudation  con- 
tained clear  round  granules,  ex- 
actly similar  to  the  nuclei  of  the 


cells  figured  p.  131.     To  argue  Bj-      ,-. 
that  such  matter  is  the  result  of  %". 
a  fatty  degeneiation  of  the  vas- 
cular wall,  appears  to  me  opposed  ,'. 
to   all    our   positive  knowledge,  |, 
whereas  its  being  a  recent  coa-  ?;.  ^__^ 
gulation    of  the    exuded    liquor  lE^^-'^ 
sanguinis,  and  produced   coinci- 


%i> 


Fig.  38T. 


dently  with  the  violent  symptoms,  is  consistent  with  every  known  fact 


Fig.  387.  A  blood-vessel  from  the  central  substance  of  the  brain,  coated  with  a 
molecular  exudation,  and  with  nuclei  forming  in  it. 

Fig.  388.  Another  blood-vessel,  with  masses  of  recently  coagulated  exudation 
attached  to  it.  "  250  diam. 


344  DISEASES   OF   THE   NERVOUS   SYSTEM. 

another  boy,  H.  B.,  two  and  a  half  years  old,  whom  I  saw  in  private  practice, 
who  was  previously  in  good  health,  the  same  fact  was  observable.  On  the 
6th  of  July  1 848,  he  could  not  eat  his  breakfast ;  at  1  p.  m.  he  vomited  ;  at 
4  P.M.  febrile  symptoms  appeared ;  dui-ing  the  niglit  there  was  great 
restlessness  with  occasional  screaming;  on  the  morning  of  the  Vth  there 
were  general  convulsions,  but  principally  on  left  side,  and  he  died  at  half- 
past  six.  The  examination  was  peifoimed  by  Mr.  Goodsir.  "With  the 
exception  of  3iss  of  slightly  turbid  serum  in  the  ventricles,  nothing  was 
found  in  the  brain  but  a  yellow  discoloration  the  size  of  a  sixpence  on  the 
surface  of  the  right  corpus  striatum.  On  microscopic  examination,  this 
was  seen  to  consist  of  the  same  molecular  matter  surrounding  the  blood- 
vessels, as  is  represented  Fig.  387.  These  and  many  other  observations, 
therefore,  appear  to  me  a  sufficient  proof  that  there  is  a  form  of  acute 
cerebritis,  consisting  of  the  exudation  of  liquor  sanguinis  and  the 
coagulation  of  the  fibrin  around  the  vessels,  which  may  prove  fatal  very 
rapidh',  especially  in  children,  but  that  when  such  changes  occur  in  the 
adult  or  in  aged  persons,  it  has  a  tendency  to  become  chronic,  and  leads 
to  Avhat  may  be  called  exudative  softening.     See  p.  305. 

Chronic  cerebritis  so  occasioned  can  only  be  distinguished  with 
certainty  by  a  microscopic  examination.  It  may  present  various  shades 
of  colour — white,  grey,  yellow,  or  fawn-coloured.  I  have  seen  white 
softening's  which  to  the  naked  eye  exactly  resemble  such  as  are  caused 
by  imbibition  after  death,  but  which  show  under  the  microscope 
numerous  granule  cells  in  all  stages  of  formation,  proving  that  an 
exudation  and  a  new  growth  must  have  been 
established  before  death.  In  the  same  way  a 
diffluent  grey  softening  of  the  white  cerebral 
substance,  which  has  been  i-egarded  by  some 
as  atrophic,  I  have  shown  by  its  structure  to 
have  originated  in  an  exudation  (Fig.  389). 
The  yellow  and  fawn-coloured  softenings  gene- 
rally owe  their  colour  to  an  admixture  of  blood 
to  a  greater  or  less  extent,  but  are  otherwise 
essentially  the  same.  Hence,  as  previously 
'^"  ^"^  stated,  I  regard  the  microscopic  examination 

of  such  lesions  to  be  absolutely  necessarj'  to  ascertain  their  nature, 
and  the  existence  of  granule  cells  in  the  white  substance  of  the  brain  as 
a  positive  proof  of  exudation. 

We  have  previously  seen  that  it  is  a  matter  of  great  difficulty  to  dis- 
tinguish in  the  living  subject  acute  cerebritis  from  meningitis.  Neither 
is  it  always  easy  to  separate  chronic  cerebritis  from  many  cases  of  soft- 
ening resulting  li-om  hemorrhage,  or  from  fatty  degeneration  resulting  from 
arterial  obstruction.  The  cause  of  this  is  obvious,  inasmuch  as  all  these 
lesions,  consisting  of  more  or  less  destruction  of  the  nervous  tissue,  may 
be  expected  to  affect  the  brain  in  the  same  manner.  In  their  mode  of 
onset,  however,  they  exhibit  a  difference.  Thus,  as  a  general  rule,  hemor- 
rhage is  indicated  by  suddenness  of  attack,  whilst  uncomplicated  chronic 

Fig.  389.  Structure  of  a  chronic  grey  softening  of  the  cerebral  hemisphere,  resem- 
bling chalky  milk,  entirely  composed  of  exudation,  transformed  into  granules  and 
cells.  250  diam. 


CEREBRAL   DISEASE   FROM   OBSTRUCTION   OF   ARTERIES.    345 

cerebritis  o-raduallr  affects  the  mental  and  motor  functions  in  various  ways 
and  deo-rees  according  to  the  portion  of  the  brain  affected.  But  it  must 
not  be 'overlooked,  th'at  an  intiammatory,  a  hemon-hagic,  and  a  primary 
fattv  softening  mav  occur  together  in  one  individual,  as  the  conditions 
which  occasion  one  are  also  "favourable  to  the  production  of  the  others. 
Hence  I  must  refer  the  reader  to  the  considerations  on  this  point  under 
the  head  of  Cerebral  Hemorrhage. 

Great  discussion  has  taken  ptace  as  to  whether  a  chronic  inflamma- 
tory softening  ever  undergoes  a  cure.  Durand-Fardel  thinks  that  the 
curability  of  cerebral  softening  is  a  fact  of  which  we  can  no  more  entertain 
disbelief  in  the  present  day,  than  we  can  of  the  curability  of  pulmonary 
tubercle.  Most  certainly"the  observations  of  Rostan,  Cruveilhier,  Sims,^ 
Dechambre,  and  Durand-Fardel  have  fully  established  the  possibility  of 
this  occurrence.  Besides,  why  should  not  a  coagulated  exudation  of 
blood-plasma  into  the  brain,  in  consequence  of  the  changes  whereby  it  is 
broken  down  and  disintegrated,  be  ultimately  absorbed  in  that  organ  as 
well  as  in  any  other?  It  appears  to  me,  however,  that  the  anatomical 
appearances,  by  means  of  which  pathologists  have  endeavoured  to  demon- 
strate the  curability  of  a  softening,  are  not  to  be  depended  on.  Durand- 
Fardel  points  to  the  softening  resembling  chalky  milk  as  a  proof  of  the 
passage  of  the  lesion  into  a  state  of  cure,  and  Dr.  Sims  described  fawn- 
coloured  cavities  as  evincing  the  same  fact.  Xow  I  have  seen  cases  where 
the  o-rev  milky  softening  was  associated  with  hemiplegia  of  long  standing, 
but  which  presented,  on  microscopic  examination,  the  appearance  repre- 
sented Fio-.  389,  which  although  undoubtedly  evincing  great  disorga- 
nization, cannot  be  said  to  show  signs  of  healing.  The  fawn-coloured 
cavities  of  Dr.  Sims  I  have  not  onfy  seen  to  be  tilled  with  granule  cells 
in  all  stao;es  of  formation,  but  associated  with  intense  recent  contraction 
on  the  opposite  side  of  the  body.  Neither  of  these  lesions,  therefore, 
appears  to  me  to  present  anatomical  proofs  ot  a  cured  softening.  Dr. 
Todd  also  believes  in  the  cicatrization  of  chronic  softenings,  and  even 
considers  that  the  rigidity  which  occasionally  comes  on  late  in  paralysed 
muscles,  is  attributable  to  the  irritation  which  the  contraction  produces 
on  the  neighbouring  healthy  cerebral  substance.  Whether  the  yellowish 
or  fawn-coloured  indurated  spots,  which  are  very  rarely  observed  in  the 
brain-substance,  are  proofs  of  cured  softening,  it  is  very  difficult  to  say, 
for  I  have  seen  such  indurations  crowded  with  granule  cells.  (See  Case 
XVII.)  Hence  the  morbid  anatomy  of  cured  cerebral  softenings  is  a 
subject  still  demanding  careful  investigation. 

The  ireneral  diagnosis  and  treatment  of  chronic  cerebritis  will  be 
considered  under  the  head  of  Cerebral  Hemorrhage,  with  which  it  is  often 
associated. 

CEREBRAL  DISEASE  FROM  OBSTRUCTIOX  OF  ARTERIES. 

Case  XV.* — Paralysis  rapidly  becoming  general — Old  Ajjoj^ledic  Cyst  in  right 
Corpus  Striatum — Softening  of  Pons  Varolii — Clot  obstructing  Basilar  Artery — 
Pneumonia  of  Left  Lung. 

History. — Alexander  "talker,  a;t.  50 — a  pensioner — admitted  December  3,  1855. 

*  Reported  by  ilr.  John  Glen,  Clinical  Clerk. 


346  DISEASES   OF  THE   NERVOUS   SYSTEM. 

According  to  the  account  of  the  patient's  brother,  he  has  been  long  subject  to  vertigo, 
both  when  at  home  and  as  a  soldier  in  India.  For  this  complaint  he  has  been  bled 
fifteen  times,  and  always  with  temporary  relief.  He  has  been  of  temperate  habits, 
and  has  lately  been  working  in  a  printer's  office,  where  he  was  accustomed  to  carry 
heavy  weights  oii  his  head.  Yesterday,  having  undergone  unusual  bodily  fatigue  and 
great  mental  anxiety  in  consequence  of  his  sister's  death,  he  was  suddenly  seized,  about 
4  P.M.,  with  a  feeling  of  pricking  and  numbness  in  his  left  arm,  which  commenced 
at  the  fingers.  Siiortly  after,  there  occurred  thickness  of  speech,  which  rapidly 
increa.sed.  During  the  night  he  became  speechles.s,  but  could  make  signs,  and 
appeared  conscious.     In  the  morning  he  was  conveyed  to  the  Infirmary. 

Symptoms  ox  Admission. — On  admission,  there  is  no  sensibility  in  the  left  arm — 
on  being  flexed  it  appears  peculiarly  rigid,  though  not  retracted.  On  stimulating  the 
left  leg,  there  is  evidence  of  only  slight  sensibility,  and  feeble  reflex  movements. 
Right  arm  moves  readily  on  the  application  of  stimuli,  but  the  right  leg,  though 
somewhat  retracted,  is  partially  paralysed.  Left  pupQ  somewhat  more  contracted 
than  the  right  one.  Face  pale,  without  distortion  of  the  features.  Cannot  speak  or 
protrude  the  tongue,  but  is  evidently  conscious,  listening  and  watching  movements 
with  an  anxious  expression  of  countenance.  Cardiac  sounds  inaudible ;  pulse  88, 
of  good  strength;  inspirations  deep,  expirations  accompanied  with  snoring  rales. 
Skin  warm  and  dry.  Bowels  constipated  ;  bladder  distended.  To  have  a  turpentine 
enema.  The  urine  to  he  drawn  off  by  a  catheter.  Iced-ioater  to  be  constantly  applied  to 
tlie  scalp  (tlie  man's  head  was  bald),  and  the  following  bolus  to  be  carefully  placed  on 
the  posterior  third  of  the  dorsum  of  the  tongue^  so  as  to  ensure  deglutition.  R.  Olei 
Crotonis  gait,  j ;  Puiv.  Jalap.    Co.   3i ;    Confect.  Sennce,  q.  s.  ft.  bolus. 

Progress  of  the  Case. — December  Uh. — 30  oz.  of  healthy  urine  were  drawn  off 
yesterday  by  the  catheter.  This  morning  both  foeces  and  urine  were  passed  invo- 
luntarily in  bed.  Both  arras  and  legs  are  now  completely  paralysed,  and  do  not 
move  on  the  application  of  strong  stimuli.  Respiration  is  more  laboured ;  pulse  120. 
week ;  still  conscious.  To  nourish  the  patient  as  much  as  possible  by  the  mouth,  and 
if  necessary,  i)er  anum,  with  strong  beef  tea.  December  oth. — Respirations  still  more 
laboured,  and  the  chest  does  not  expand.  The  loud  snoring  with  expiration  masks 
the  pulmonary  sounds,  and  his  position  on  the  back  cannot  be  changed  to  admit  of 
examination  of  tlie  lungs.  In  other  respects  is  in  the  same  state,  but  weaker;  pulse 
120,  weak.  Is  motionless,  speechless,  with  the  lips  slightly  separated.  On  attempt- 
ing to  introduce  nourishment  by  the  mouth,  the  jaws  are  firmly  closed,  and  matters 
which  are  taken  cannot  be  swallowed,  although  he  makes  efforts  to  do  so.  The 
water  has  been  drawn  off  regularly  by  catheter,  and  nutritive  enemata.  witli  brandy, 
administered.  He  is  still  evidently  conscious.  December  Qth. — Since  yesterday  has 
been  gradually  sinking ;  tlie  cheeks  are  distinctly  paralysed,  and  distended  at  each 
expiration.  This  morning  the  left  pupil  became  much  more  contracted  than  the 
right ;  the  corneae  became  dim,  and  the  respirations  40  in  the  minute ;  the  pulse 
fluttering;  coma  supervened ;  and  he  died  at  2  p.m.  on  the  7th. 

Sectio  Cadaveris. —  Twenty-three  hours  after  death. 

Head. — Surfaces  of  the  arachnoid  moist;  slight  serous  effusion  between  the 
sulci  of  the  cerebral  convolutions.  On  .slicing  tlie  hemispheres,  their  substance  exhi- 
bits a  greater  number  of  bloody  points  than  usual.  They  are  symmetrical ;  the 
right  lateral  ventricle  somewhat  smaller  than  the  left.  The  two  contained  3  iij  of 
transparent  serum.  The  right  optic  thalamus  was  decidedly  larger  than  the  left  one, 
and  at  its  base,  near  the  corpus  striatum,  presented  on  section  a  well  marked  cribri- 
form appearance.  In  the  posterior  fourth  of  the  left  substance  of  the  corpus  striatum 
was  a  diffluent  mass  the  size  of  a  pea,  which  flowed  out  on  section,  having  a  small 


CEREBRAL   DISEASE   FROM   OBSTRUCTION   OF   ARTERIES.    347 

cavity  with  the  walls  of  a  fawn  colour.  Both  choroid  plexuses  contained  simple  cysts, 
the  greater  number  on  the  left  side.  On  cutting  through  the  pons  varolii,  its  centre 
vi'as  found  softened,  and  of  a  pulpy  consistence,  the  upper  half  more  than  the  lower, 
and  the  right  more  than  the  left  side.  The  whole  softened  portion  was  gradually 
washed  away  by  a  thin  stream  of  water,  showing  a  distinct  irregular  margin,  inclosing 
a  cavity  about  the  size  of  a  hazel  nut.  The  basilar  artery,  throughout  its  whole 
course,  was  opaque,  its  coats  loaded  with  calcareous  and  atheromatous  matter,  and 
obstructed  by  a  colourless  clot,  which  at  one  point  was  transformed  into  mineral 
matter. 

Spinal  Cord. — The  spinal  cord  was  carefully  examined,  and  found  to  be  healthy. 

Chest. — The  inferior  lobe  of  left  lung  hepatized,  of  a  dirty  grey  colour,  and  in  the 
upper  lobe  two  masses  of  pneumonic  condensation  about  the  size  of  walnuts.  Mar- 
gins of  both  lungs  emphysematous.     Heart  healthy. 

All  the  other  organs  were  healthy. 

Microscopic  Examination. — The  contents  of  the  old  apoplectic  cyst  in  right  cor- 
pus striatum  had  disappeared,  but  the  indurated  walls  consisted  of  a  dense  aggrega- 
tion of  brownish  opaque  molecules,  which  gradually  diminished  externallj',  and  were 
gradually  lost  among  the  tubular  and  granular  substance  of  the  striated  body.  The 
softened  portion  of  the  pons  varolii  was  entirely  composed  of  the  disintegrated 
tubular  and  vesicular  structure  of  this  portion  of  the  encephalou.  There  -nere  no 
granule  cells  or  granule  masses,  such  as  are  found  in  softening  from  an  exudation. 
But  the  nerve-cells  contained  an  unusual  number  of  minute  brownish  granules,  and 
floated  about  isolated  in  the  softened  substance,  as  seen  in  Fig.  364.  The  clot  in  the 
basilar  artery  contained  irregular  masses  of  phosphate  of  lime,  which  at  one  point 
were  so  closely  aggregated  together  as  in  themselves  completely  to  block  up  the  ves- 
sel. The  hepatization  of  the  left  lung  presented  all  tlie  stages  of  the  congestive, 
exudative,  and  suppurative  stages  of  pneumonia.  These  were  remarkably  well  seen 
in  the  two  masses  in  the  upper  lobe,  in  which  the  centres  were  soft  and  purulent, 
the  air  vesicles  filled  with  pus,  and  the  surrounding  mass  indurated,  exhibiting  dif- 
ferent stages  of  the  transformation  of  an  amorphous  exudation  into  cells.  (See  Fig. 
357,  p.  242,  which  was  drawn  from  a  demonstration  made  from  one  of  these  masses.) 

Commmtan/ — After  vertigo  and  other  head  symptoms  for  many 
years,  for  wliich  he  was  in  the  habit  of  being  bled,  this  man,  in  conse- 
quence of  unusual  bodily  exertion  and  mental  anxiety,  was  suddenly 
seized  with  paralysis  in  the  left  arm  without  loss  of  consciousness.  This 
was  followed  by  paralysis  of  speech,  and  of  the  other  limbs,  inability  to 
pass  urine  or  retain  the  foeces,  and  spasmodic  closure  of  the  jaws.  These 
symptoms  indicated  a  lesion  of  the  central  parts  of  the  brain,  which, 
from  the  suddenness  of  their  occurrence,  1  supposed  would  be  a  hemor- 
rhage either  in  or  pressing  upon  the  pons  varolii.  But  on  examination 
there  was  found  an  old  apoplectic  cyst  in  the  left  corpus  striatum,  which 
did  not  appear  to  have  caused  any  of  his  recent  symptoms,  and  is  not 
accounted  for  in  his  history.  The  general  paralysis  was  evidently  owing 
to  the  softening  of  the  pons  varolii,  and  this  in  its  turn  was  certainly 
not  dependent  on  an  exudation  from  the  bloodvessels,  a  fact  which  I 
ascertained  by  careful  and  prolonged  microscopical  examination,  I 
could  not  therefore  resist  the  conclusion,  that  the  disorganization  of  the 
nervous  substance  was  attributable  to  the  obstruction  in  the  basilar  artery, 
and  a  peculiar  fattv  degeneration  commencing  in  the  nerve  cells.  Of 
this  lesion  we  shall  be  able  to  form  a  better  idea  after  examining  the 
facts  of  the  followinof  case : — 


848  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Case  XVI.* — Apophxij — Hemiplegia  of  Left  Side — Convulsive  Attacks — Cardiac  and 
Renal  Disease — Old  Clot  in  the  right  Cerebral  Hemisphere,  loith  surrounding  softening. 

History.  —Elizabeth  Ross,  set.  26,  married — admitted  May  23,  1853.  States 
that  about  -i^  years  ago  she  suffered  from  acute  rlieumatism,  on  recovering  from 
which  she  frequently  experienced  palpitations,  and  during  the  last  18  months  there 
has  l^een  occasional  epistaxis,  preceded  by  giddiness,  dimness  of  vision,  and  muscje 
volitantes.  Last  January,  when  quietl_y  sitting  in  a  chair,  she  suddenly  fell  to  the 
ground  insensible,  in  which  condition  she  remained  48  hours.  On  recovering  her 
consciousness,  she  could  not  speak ;  the  left  half  of  the  body  and  face  was  deprived 
of  motion  and  sensibility.  Five  weeks  afterwards  she  began  to  regain  her  speech 
and  the  command  of  the  left  arm  and  leg,  but  observed  at  the  same  time  an  oedema- 
tous  state  of  the  feet  and  legs,  and  that  this  gradually  spread  over  the  whole  body. 
Three  weeks  ago  she  again  became  suddenly  insensible,  and  continued  so  1|  hours, 
during  which  time  she  was  much  convulsed.  Slie  had  three  similar  fits  during  the 
succeeding  ten  days,  which  were  preceded  by  a  choking  sensation  in  the  throat,  pal- 
pitation and  uneasiness  in  the  precordial  region. 

Symptoms  on  Admissiox. — On  admission  there  is  still  partial  paralysis  of  the 
left  side  of  the  body,  which  is  much  colder  than  the  right  side.  On  attempting  to 
walk  she  cannot  raise  her  left  foot  completelj^  from  the  ground,  but  drags  it  behind 
her.  She  cannot  bend  her  left  wrist  or  arm,  or  raise  them  so  readily  as  she  can 
those  of  the  right  side.  Her  mouth  is  slightly  drawn  to  the  right  side,  and  the 
tongue  when  protruded  appears  to  be  somewhat  to  the  left  of  the  mesial  line.  The 
sensibility  over  the  whole  left  side  is  somewhat  impaired.  She  complains  of  uneasi- 
ness in  the  precordial  region.  Action  of  heart  strong,  but  rhythm  regular.  Apex 
beats  between  the  5th  and  6tli  ribs,  about  half  an  inch  to  the  outer  side  of  the  nipple. 
Transverse  cardiac  dulness  3|-  inches.  A  blowing  murmur  is  heard  with  the  first 
sound  at  the  apex,  and  a  double  blowing  murmur  at  the  base,  of  which  that  with 
the  second  sound  is  the  loudest  and  longest,  and  is  distinctl}^  audible  in  both  infra- 
clavicular spaces.  Immediately  above  the  right  sterno-clavicular  articulation  con- 
siderable pulsation  is  visible  to  the  eye,  but  no  tumour  can  be  defined  upon  mani- 
pulation. Over  this  part  a  harsh  single  blowing  murmur  is  audible,  and  fremitus  is 
very  perceptible  to  the  finger.  No  venous  pulsation.  Radial  pulse  87  per  minute, 
strong  and  hard,  communicating  a  jerking  sensation  to  the  finger.  The  voice  is 
weak,  and  articulation  diflBcult  and  indistinct.  Respirations  irregular  and  spasmodic. 
20  per  minute.  No  dyspnoea.  Cough  short;  expectoration  scanty.  Chest  resonant 
everywhere  on  percussion,  and  the  only  abnormal  sound  audible  is  a  fine  moist 
rattle  with  inspiration  over  the  two  lower  thirds  of  left  lung  posteriorly.  Tongue  is 
red  and  drj- :  appetite  very  bed,  and  dysphagia  to  such  a  degree  that  she  can  only 
take  liquid  food.  Slight  epigastric  tenderness.  Bowels  costive.  Micturition  diffi- 
cult, painful,  and  frequent.  Urine  of  pale  colour,  neutral  reaction,  sp.  gr.  1010,  with 
deposit  of  triple  phosphate  on  coohng ;  quantity  passed  small,  and  deposits  when 
heated  a  considerable  coagulum.  There  is  general  oedema  of  the  whole  surfiice  of  the 
body,  but  especially  of  the  inferior  extremities.  R  Pil.  Scillce  et  Digitalis,  vj  :  Sumat 
unam  his  in  die.  ^  Pil.  Opii,  gr.  i.  hora  somni  sumend.  Habeat  Elect.  Laxans 
3  i  j ;  et  repetatur  post  horas  sex  si  opus  sit. 

Progress  of  the  Case. — May  25ih. — Sleeps  better.  Bowels  relieved.  (Edema 
of  upper  part  of  body  diminished.  Urine  still  in  small  quantity,  highly  coagulable, 
and  containing  waxy  and  fatty  casts.  Heart's  action  not  so  strong.  June  6th. — 
Since  last  report  has  been  gradually  improving.     She  can  use  the  extremities  of 

*  Reported  by  Mr.  Joseph  Johnson,  Clinical  Clerk. 


CEREBRAL   DISEASE   FROM    OBSTRUCTION   OF   ARTERIES.    349 

left  side  more  freely,  and  the  sensibility  is  more  acute.     Can  rise  and  return  to  bed 
■without  assistance.     Speech   more  distinct.     Impulse   and   murmur   over  sternum 
greatly  diminished.     Heart's  impulse  more  feeble  and  blowing  sounds  not  so  loud. 
Pulse  90,  still  jerking.      Complains  of  pain,  but  without  tenderness  in  right  lumbar 
region.     (Edema  of  lower  limbs  stiU  considerable,   though  diminished.     Digestive 
fuuctions  normal.     Renal  symptoms  the   same.     Has  been  taking  half  a  grain  of  the 
proto-iodide  of  inercury  every  night,  tvith  mild   diuretics   and  occasional    laxatives. 
June  lih. — Yesterday  afternoon,  at  4  p.m.,  she  became   giddy,  and  soon  fell  into  an 
unconscious  state,    accompanied   with  convulsions   equally   strong   in  the  limbs  of 
both  sides;  screams  and  moaning.     The  pupils  were  dilated  and  the  eyeballs  turned 
outwards  and  upwards.     She  had  no  foaming  at  the  mouth,  but  frequently  shut  her 
jaws  with  great  violence,  so  that  her  tongue  could  -with  great  difficulty  be  kept  from 
being  injured.     The  attack  lasted  ten  minutes.     During  the  evening,  she  had  lour 
other  attacks  of  about  the  same  duration.     After  each  fit  she  remains  for  some  time 
in  a  drowsy  condition,  and  cannot  answer  questions  perfectly.     After  the  first  attack 
six  leeches  were  applied  to  the  temples,  and   a  turpentine  enema  given.     In  the 
evening  a  blister  was  applied  to  the  head.     To-day  is  much  better.     June  9th. — Had 
another  slight  attack  yesterday  morning,   and  a  third  last  night.      Paralysis  not 
Increased;    other  symptoms  the  same.     Jmie   I9th. — Since  last  report  has  been  com- 
plaining of  wandering  pains,  more  especially  in  right  hypochondrium.     The  gums 
on  the  l-ith  became  slightly  tender,  when  the  proto-ipdide  of  mercury  was  omitted 
Since  the  10th  there  has  been  diarrhoea,  the  bowels  havmg  been  opened  6  or  7  times 
daily,  notwithstanding   the  employment  of  various  astringents  with  opium  by  the 
mouth  and  rectum.     About  4  p.m.,   without  any  precursory  symptoms,   she  sud- 
denly became  unconscious  and  convulsed.     She  strained  and  struggled  violently  for 
about  fifteen  minutes ;    the  convulsions  at  first  being  equally  severe  on  both  sides, 
although  latterly   they  were  entirely  confined   to  the   left  side.     Her  mouth  was 
drawn  towards  the  right,  and  the  lower  jaw  was  incessantly  carried  from  one  side 
to  the  other,  with  a  semi-rotatory  motion,  as  in  grinding  food.     The  eyelids  remained 
permanently  open,  and  the  eyeballs  were  carried  in  an  upward  and  outward  direction, 
in  which  position  they  remained  during  the  continuance  of  the  fit.     The  breathing 
became   slow,    sometimes  interrupted  and  irregular,  attended  with  stertor   during 
inspiration,  and  a  putfing  out  of  the  cheeks  during  expiration.    There  was  also  foaming 
at  the  mouth.     These  phenomena  soon  subsided,  and  the  patient  was  left  in  a  coma- 
tose condition.     Two    hours   thereafter   these  phenomena   recurred  twice,  without 
the  patient  in  the  intervals  regaining  the  slightest  degree  of  consciousness.     The 
foeces  and  urine  were  pa.ssed  involuntarily.     During  the  last  attack  the  inhalation  of 
chloroform  was  tried,  but  the  breathing  becoming  more  stertorous  and  hurried,  and 
the  pul.se  intermitting  and  almost  imperceptible,  it  was  instantly  stopped.     Ahradatur 
Cajnllitiuyn;   Applicetur  Capiti  Emp.  Caniharid  {4:  x  6).     June  20th. — Became  con- 
scious  last  night  about  8  o'clock,  when  she  could  answer  questions  correctly,  but 
slowly,  and  in  an  inarticulate  manner.     She  complains,  when  interrogated,  of  great 
exhaustion  and  severe  frontal  headache.      Diarrhoea  continues  and  is  involuntary. 
Pulse  90.  weak,  almost  imperceptible.    Stupor  at  intervals.     Habeat  Vini  §  ij.     June 
2lst. — Xo  return  of  convulsions.    Stools  not  passed  involuntarily  as  formerly.     No 
pain  in  head,  and  says  she  is  free  from  suflering.     Countenance  dull  and   stupid ; 
pupUs  natural;    expression  of  eye  sluggish.     Respiration  slow  and  snoring.     Over 
both  sides  of  chest  anteriorly,  loud  moist  rales  are  audible.      Pulse  90,  very  weak. 
Other  symptoms  unaltered.      Haheai  Vini  5  iv  indies.     Nutritive  food   and  drinks. 
Towards   evening  the  mucous  rattle  in  chest  became  very  loud,  and  the  breathing 
snoring,  and  occasionally  interrupted ;  no  pain  anywhere.     Could  with  difiBculty  be 
roused  to  answer  questions.     Died  at  1.30  a.m. 


350  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Sectio  Cadaveris. — Thirty-Jive  hours  after  death. 

Body  pale,  not  emaciated ;  lower  extremities  very  oedematous. 

Head. — The  arachnoid  membrane  presents  its  natural  degree  of  moisture.  On 
section  of  the  right  hemisphere  of  the  brain,  a  softened  portion  is  situated  above  and 
to  the  outer  side  of  the  corpus  striatum.  It  measured  I^  by  1  inch,  and  extends 
externally  close  to  the  cerebral  convolutions.  In  its  centre  there  is  a  hard  round 
nodule,  about  the  size  of  a  small  hazel  nut,  of  a  dark-red  colour,  with  a  zone  of 
bright  yeUow,  extenduig  about  a  quarter  of  an  inch  into  the  softened  cerebral  sub- 
stance. This  is  of  friable  consistence,  and  of  a  yellowish  hue  in  the  centre,  becom- 
ing of  an  ash-grey  tint,  and  of  almost  diflBuent  consistence  towards  the  circumfer- 
ence. Externally  the  diseased  substance  gradually  passes  into  the  healthy  cerebral 
structure.     Arteries  healthy. 

Chest. — Pericardium  distended,  containing  3J-  oz.  of  pale  straw-coloured  fluid. 
Left  ventricle  firm,  its  cavity  dUated.  The  mitral  orifice  admits  the  entrance  of  two 
fingers ;  but  the  anterior  segment  of  its  valve  has  on  its  external  surface  a  few 
scattered  fibrinous  granules,  wliile  its  posterior-inferior  angle  is  thickened  and 
covered  with  small  masses  of  fibrui,  which  extend  along  the  shortened  chordae  ten- 
dinea;,  giving  them  a  fringed  appearance.  The  aortic  valves  are  much  thickened, 
hard  and  inelastic,  especially  at  their  free  borders,  upon  "ivhich  also  a  few  aggrega- 
tions of  fibrinous  granulations  are  seen  simQar  to  those  upon  the  mitral  valve.  They 
contain  in  their  interior  a  small  amount  of  atheroma,  which  extends  into  the  aorta 
for  about  three  quarters  of  an  inch.  Tiiey  admit  the  passage  of  water  tlirough  them 
rapidly,  on  its  being  poured  upon  them  fi-om  above.  The  pleurae  on  both  sides  are 
partially  adherent  by  long  bands  of  chronic  lymph.  The  right  pleural  cavity  con- 
tains about  six.  and  the  left  about  three  ounces  of  serum.  The  lungs  are  slightly 
collapsed,  flaccid,  and  imperfectly  crepitant.  In  several  places  are  indurated  masses, 
varving  in  size  from  a  pea  to  a  hazel  nut,  composed  of  infiltrated  blood.  Other  por- 
tions of  the  lungs  pour  out,  from  their  cut  squeezed  surfaces,  a  small  quantity  of 
turbid  serum,  with  pus  from  the  smaller  bronchi. 

Abdomen*. — Cavity  of  the  peritoneum  contains  a  considerable  quantity  of  serum. 
Liver  of  natural  size,  but  the  colour  dark  from  venous  congestion.  Spleen  of  firm 
consistence,  7  inches  long  by  4  broad.  Both  kidneys  slightly  larger  than  usual,  of 
firm  consistence,  puckered  surface,  and  stellate  irregular  vascularity.  On  section, 
they  present  the  usual  characters  of  the  waxy  degeneration.  Other  abdominal 
organs  healthy.     Xo  leucocythemia. 

Microscopic  Exajiixatiox. — The  central  portion  of  the  diseased  cerebral  struc- 
ture is  principally  composed  of  fibre  cells,  distinctly  nucleated,  infiltrated,  however, 
w^th  sanguineous  colouring  matter,  in  various  stages  of  degeneration,  and  mingled 
with  purple  and  ruby  crystals  of  hematoidine.  The  more  external  yellow  and  grey 
softenings  present  granules  and  granular  masses  in  great  abundance,  mingled  with 
reddish  and  yellow  portions  of  disintegrated  blood ;  the  latter  with  a  few  crystals  of 
hematoidine,  are  most  abundant  towards  the  centre.  Externally  the  softening  is 
principally  composed  of  disintegrated  nerve-tubes,  presenting  various  forms  with 
double  lines. 

Commentari/. — In  this  young  woman  vascular  disease  of  the  heart 
had  supervened  upon  acute  rheumatism,  and  vegetations  had  formed 
upon  the  sui-faces  of  the  mitral  and  aortic  valves.  These  vegetations,  as 
we  shall  subsequently  see,  are  deposits  of  the  fibrin  in  the  blood  which 
niav  become  detached,  and  be  carried  by  the  circulation  into  more  dis- 
tant   and    smaller  vessels.     Four  months  previous  to  admission,  when 


CEREBRAL   DISEASE    FROM   OBSTRUCTION   OF   ARTERIES.    351 

quietly  sitting  in  her  chair,  she  became  suddenly  apoplectic;  and  on 
recoverino-  her  consciousness  laboured  under  hemiplen-ia  of  the  left  side 
and  paraivsis  of  speech.  Five  weeks  subsequently  syniptouis  of  renal 
disease  manifested  themselves ;  then  there  supervened  another  attack  of 
apoplexy,  followed  by  a  long  train  of  nervous  phenomena,  which  exhausted 
her  streiioth  and  caused  death.  I  took  charge  of  the  case  in  the  middle 
of  June,  bv  which  time  she  was  so  reduced  that  wine  and  nutrients  failed 
to  rallv  her.  On  post-mortem  examination  the  arteries  of  the  brain 
were  healthv,  but  evidence  of  an  old  hemorrhage  existed,  and  the  ques- 
tion tliat  arises  is,  whether  or  not  this  had  been  caused  by  obstruction  of 
the  middle  cerebral  artery,  from  one  of  the  clots  derived  from  the  heart? 
Though  this  cannot  be  affirmed,  it  appears  to  be  very  probable.  The 
lesion" so  produced  by  its  irritating  action  in  the  surrounding  brain  tissue, 
conjoined  with  occasional  congestions,  is  quite  sufficient  to  explain  all 
the  nervous  phenomena  which  followed. 


Case  XYIL* — Tico  sudden  attacks  of  Apoplexy — Hemiplegia — Cardiac  Disease — 
Persistent  Albuminuria — Enlarged  and  diseased  Spleen — Cerebral  Softening — 
Anasarca — Atheroma  of  Arteries — Obstruction  of  the  left  middle  Cerebral 
Artery. 

History.— James  Balfour,  set.  38,  a  smith — admitted  April  13, 1857.  The  patient 
has  been  a  man  of  temperate  habits,  accustomed  to  good  diet,  and  in  the  enjoyment 
of  excellent  health  for  the  greater  part  of  his  life.  For  nearly  a  twelvemonth  before 
admission,  his  wife  had  noticed  that  he  was  not  looking  so  weU  as  formerly,  but  he 
liimself  had  no  feeling  of  Qlness,  and  continued  to  follow  his  usual  occupation  until 
three  months  ago.  At  that  time,  one  day,  while  engaged  at  his  work,  he  was  sud- 
denly seized  with  headache  and  vertigo,  the  pain  being  so  severe  as  to  compel  him  to 
return  home  and  go  to  bed.  He  became  insensible,  and  remained  comatose  for  three 
days.  On  recovering  from  this  state,  he  found  he  had  lost  the  power  of  his  right 
side,  and  that  his  features  were  drawn  to  the  left.  His  speech  was  not  affected. 
From  this  state  he  gradually  recovered,  and  in  four  weeks  was  able  to  return  to 
work.  Three  weeks  subsequently,  while  in  the  act  of  shoeing  a  horse,  he  again  .sud- 
denly lost  to  a  considerable  extent  the  power  of  his  right  side,  and  his  speech  now 
became  affected.  Since  the  second  attack  he  has  never  been  able  to  resume  his 
work;  for,  although  he  has  recovered  the  power  of  his  right  side  almost  entirely,  he 
has  gradually  become  weaker.  For  the  last  five  or  six  weeks  his  legs  have  swollen 
towards  night,  and  during  the  same  period  there  has  been  slight  diarrhoea,  which 
has  increased  considerably  d\u-ing  the  last  ten  days,  but  which  causes  no  pain.  Two 
weeks  ago  he  was  attacked  with  severe  vomiting,  the  matters  ejected  being  appa- 
rently bilious,  and  since  then  he  has  suffered  from  pain  in  the  splenic  region,  espe- 
cialh'  when  he  stands  or  moves  about. 

Symptoms  ox  Admission. — On  admission,  the  patient  talks  in  a  loud  monotonous 
tone,  indistinctly,  and  with  stammering;  he  cannot  whisper,  though  he  can  speak  in 
lower  tones  than  usual.  When  speaking,  the  voice  often  becomes  whining;  he  cries 
and  sheds  tears  without  any  obvious  cause.  The  sensibility  of  both  sides  of  face,  of 
the  trunk,  and  limbs,  seems  unimpaired,  tongue  slightly  protruded  to  the  riglit 
side,  while  the  mouth  is  drawn  to  the  left ;  when  the  patient  eats,  the  food  lodges  in 
the  right  cheek ;  he  tastes  and  feels  as  well  on  the  right  side  of  the  tongue  as  on  the 

*  Reported  by  Mr.  T.  J.  Walker,  Clinical  Clerk. 


352  DISEASES   OF   THE   NERVOUS   SYSTEM. 

left.  The  grasp  of  the  right  hand  is  as  firm  as  that  of  the  left,  and  the  patient  walks 
without  a  hmp,  but  there  seems  a  want  of  certainty  in  planting  the  right  foot,  and  he 
staggers  slightly  on  turning  quickly  round.  His  intelligence  and  memory  are  unim- 
paired. He  cannot  write  now  as  well  as  formerly,  being  unable  to  form  the  letters ; 
but  he  can  read  WTiting  and  printing.  On  percussion,  the  transverse  dulness  of  the 
heart  is  found  to  be  3i  inches,  and  for  an  inch  external  to  this  the  note  is  flat.  On 
auscultation  at  the  apex,  a  blowing  murmur  is  heard  with  the  first  sound,  and  the 
second  is  somewhat  lengthened.  At  the  base  there  is  a  blowing  murmur  with  both 
fii-st  and  second  sounds.  This  double  murmur  is  propagated  along  the  great  vessels, 
and  is  heard  most  distmctly  along  the  sternum  and  in  the  epigastrium.  The  pulse  is 
76  per  minute,  soft  and  weak.  Tongue  has  a  dark  coat  in  the  centre,  and  is  furred 
round  the  edges ;  appetite  small ;  food  neither  causes  pain  nor  inconvenience,  and  is 
not  vomited.  There  is  considerable  tenderness  on  pressure  all  over  the  left  side. 
Has  painless  diarrhoea,  with  frequent  watery  stools  of  a  dark-brown  colour,  and  foecal 
odour.  Hepatic  dulness  is  not  easily  determined,  but  appears  about  -i^  inches  verti- 
cally. In  the  splenic  region  there  is  a  large  area  of  dulness  extending  into  the  abdo- 
men, where  a  tumour  is  felt.  The  dulness  commences  at  the  seventh  rib,  an  inch 
and  a  half  below  the  level  of  the  nipple,  and  extends  vertically  for  8  inches.  On 
pressure  over  the  enlarged  spleen  the  patient  complains  of  pain.  When  he  lies  on 
right  side,  the  upper  margin  of  the  dulness  is  found  to  be  lower  than  when  he  lies  on 
the  back :  the  anterior  limit  does  not  change.  Urine  slightly  albuminous ;  contains 
a  sediment,  consisting  of  mucus,  squamous  epithelial  scales  and  numerous  tube  casts, 
chiefiy  granular,  but  a  few  waxy,  containing  one  or  two  epithelial  scales.  There  is 
slight  pitting  on  pressure  over  the  feet  and  ankles.  Respiratory  system  normal. 
Ordered  an  a-stringeni  iwwder  to  he  taken  at  bed-time. 

Progress  of  the  Case. — The  treatment  for  the  diarrhoea  by  astringent  powders 
was  continued  until  the  20th  April  with  no  good  result,  but  the  pain  in  the  splenic 
region  was  considerably  relieved  by  the  exliibition  of  a  terebiuthinate  followed  by 
an  opiate  epithem.  Astringents  succeeded  in  arresthig  the  diarrhoea  on  the  24th,  and 
it  did  not  recur  throughout  the  progress  of  the  case.  The  amount  of  urine  passed 
during  the  week  diminished  from  62  to  23  ounces,  and  again  increased  to  43  ounces 
daily.  From  the  24:th  April  until  May  6(h,  the  physical  signs  and  symptoms 
continued  much  the  same,  but  diu-ing  this  period  the  urine  diminished,  the  anasarca 
increased,  the  aspect  became  more  heavy,  the  weakness  more  marked,  the  articulation 
more  embarrassed,  and  the  ideas  seemed  to  be  formed  slowly  although  correctly. 
No  leucocythemia.  On  May  1th  there  was  marked  tenderness  on  pressure  in  both 
hypochondria.  At  the  apex  of  the  heart  a  long  blowing  murmur  srachronous  with 
both  soimds  still  audible,  and  at  the  base  a  double  blowing  murmur.  Great  dyspnoea 
and  prostration.     Coma.     He  died  the  following  morning. 

Sectio  Cadaveris. —  Seventy-Jive  hours  after  death. 

Head. — Surface  of  brain  was  natural;  but  the  ventricles  contained  2|  ounces  of 
clear  serum,  and  their  lining  membrane  was  tough,  thickened,  and  almost  of  a 
leathery  feeL  On  the  surface  of  the  right  corpus  striatum  there  occurred  two  patches 
(the  larger  being  2  lines  by  1,  and  the  smaller  being  half  that  size)  of  an  opaque 
yellow  colour — slightly  depressed — quite  superficial — not  softer,  but  rather  tougher 
than  usual  On  the  surface  of  the  left  corpus  striatum,  a  similar  patch,  not  larger 
than  a  hemp  seed,  occurred.  On  the  inner  surface  of  the  lower  part  of  the  descending 
comu  of  the  left  ventricle,  there  was  observed  a  mass,  the  size  of  a  small  pea. 
consisting  of  gritty  matter,  embedded  in  a  membranous  cyst,  and  surrounded  by  a  soft 
substance  of  a  dark,  reddish-brown  colour.  The  choroid  plexuses  and  other  portions 
of  the  brain  healthv.     The  middle  cerebral  arterv  on  the  right  side,  in  the  fissure  of 


CEREBRAL   DISEASE    FROM   OBSTRUCTIOX   OF   ARTERIES.    353 

Sj'lvius,  close  to  its  division  into  two  branches,  looked  opaque  and  felt  firm,  being 
obstructed  over  the  last  two  lines  of  its  course  by  a  yellowish  mass,  which  also 
extended  one  line  along  the  larger  of  the  two  branches.  The  other  arteries  of  the 
brain  and  both  carotids  were  healthy,  presenting  the  merest  trace  of  atheroma  at  the 
division  of  the  common  carotids. 

THOR.A.X. — Heart  weighed  19  ounces.  On  the  anterior  flap  of  the  mitral  valve 
numerous  small  vegetations  occurred  in  the  left  ventricle.  The  aorta  at  its  origin 
was  almost  completely  obstructed  by  a  mass  of  vegetations,  some  the  size  of  a  pin's 
head,  others  about  the  size  of  a  small  pea,  and  one  nearly  as  large  as  a  filbert. 
They  .were  clustered  on  the  ventricular  surface  of  the  right  and  left  semi-lunar  valves, 
and  on  the  margin  of  lacerations  in  then"  vicinity  which  occurred  in  the  endocardium. 
There  was  no  posterior  semi-lunar  valve,  its  substance  having  apparently  been  broken 
away,  leaving  only  a  ragged,  soft,  atheromatous  edge  close  to  the  aorta.  The  endo- 
cardium was  thickened  and  opaque  over  the  ventricle.  The  mitral  valves  were  much 
thickened  at  their  edges,  with  noJular  swellings  projecting  towards  tlie  auricles. 
The  pleurie  contained  each  two  pints  of  clear,  rather  dark-coloured  serum ;  the  lungs 
were  collapsed  posteriorh-,  and  a  little  emphj-sematous  anteriorh',  but  everj-where 
crepitant. 

Abdomes. — The  peritoneum  contained  more  than  a  quart  of  dark-coloured  clear 
serum.  In  the  intestines  there  was  no  trace  of  ulceration,  but  the  mucous  membrane 
of  the  colon  and  of  the  lower  part  of  the  ileum  was  congested.  The  liver  weighed 
4  lb.  7  oz.,  presented  congestion  of  the  hepatic  veins,  but  in  structure  was  normal. 
The  spleen  measured  7^  inches,  weighed  2  lb.  2  oz.,  and  on  section  presented  one- 
thu"d  of  its  area  normal  in  colour,  consistence,  and  minute  structure ;  but  the  other 
two-thirds  were  of  a  fawn  yellow  colour,  of  firm  consistence,  without  trace  of 
vascularity.  The  kidneys  weighed  14  oz.,  were  of  smooth  surface,  but  on  section 
presented  portions  of  a  dark  red,  and  others  of  a  yellowish-grey  colour.  The  dark 
red  colour  was  due  to  the  extravasation  of  a  thin  layer  of  blood. 

Microscopic  Examixatiox. — The  serum  in  the  ventricles  contained  a  few 
epithelial  cells.  The  superficial  indurated  patches  on  the  surface  of  the  corpora 
striata  were  chiefly  composed  of  numerous  granules  and  molecules,  containing  many 
granule  cells,  closely  aggregated  together  and  apparently  in  a  state  of  disintegration. 
The  gritty  matter  in  the  centre  of  the  old  apoplectic  clot  dissolved  with  eflervescence 
in  sulphuric  acid  (carbonate  of  lime).  The  brown  matter  surrounding  it  consisted 
of  numerous  oily  granules,  mingled  with  masses  of  yellow  and  brown  pigment. 
The  vegetations  covering  the  aortic  valves  consisted  entirely  of  granular  matter, 
evident!}-  undergoing  the  fatty  degeneration.  The  yellow  portion  of  the  spleen 
consisted  of  a  translucent  substance,  in  which  the  normal  elements  of  the  organ 
appeared  shrunk  and  decayed.  The  kidneys  presented  the  usual  aj^pearance 
of  partial  fatty  degeneration  of  those  organs. 

Commenfari/. — On  the  entrance  of  this  man  into  the  house,  it  was 
recognised  that  he  laboured  under  obstructive  disease  of  both  valves  ; 
and  it  is  observable  that  the  history  says  nothing  of  his  having  ever 
been  atfected  with  rheumatism.  He  had  previously  experienced  two 
attacks  of  apoplexy,  followed  by  hemiplegia  on  the  left  side,  and  when 
he  came  into  the  house  there  were  superadded  symptoms  of  cerebral 
softening,  of  Bright's  disease,  and  of  enlargement  of  the  spleen.  I 
subsequently  determined  that  there  was  no  leucocythemia.  On  jjost- 
mortem  examination,  organic  alterations  of  the  heart,  brain,  spleen,  and 
kidneys,  were  discovered.  The  slight  indurations  in  the  corpora  striata 
were  curious.     They  were  composed  structurally  of  numerous  granules 

23 


Soi  DISEASES   OF   THE   NERVOUS   SY5TE:M. 

and  o;ranule  cells,  and  it  may  be  asked  wlictlier  they  were  the  results  of 
previous  heraorrhas^ic  extravasations,  or  of  exudations.  I  think  the  latter, 
as  they  appear  to  have  been  very  chronic  in  their  nature,  and  not  to  have 
been  connected  with  any  recent  symptoms.  The  apoplectic  attacks  and 
hemiplegia  on  the  right  side  seem  to  have  depended  on  the  limited 
hemorrhage,  on  the  inner  surface  of  the  descending  cornu  of  the  left 
ventricle.  ^  It  is  true,  we  have  historically  an  account  of  two  apoplectic 
attacks  with  hemiplegia,  and  only  the  trace  of  one  hemorrhage.  It  is 
observable,  however,  that  the  centre  of  this  old  clot  presented  a  different 
structure  from  its  circumference,  and  that,  consequently,  the  blood  of 
which  it  was  composed  may  have  been  thrown  out  at  different  times. 
This,  however,  is  a  matter  of  opinion,  and  did  not  admit  of  demon- 
stration. It  should  also  be  noticed  that  the  clot  found  in  the  artery  of 
the  Svh-ian  fissure  on  the  right  side  did  not  appear  to  have  occasioned 
anv  svmptoms,  or  to  have  produced  other  structural  alteration.  These 
chronic  cerebral  lesions  seemed  ultimately  so  to  have  affected  the  circula- 
tion within  the  craniiun,  as  to  have  caused  effusion,  the  two  ventricles 
beinsr  o-reatlv  distended  with  serum,  to  which  the  coma  preceding  death 
was  probably  attributable. 

The  three  cases  now  given  appear  to  me  to  afford  evidence  of  disease 
of  the  brain,  being  occasioned  by  obstruction  of  the  arteries,  an  idea  that 
was  distiuctlv  put"" forth  by  Carswell  and  Bright,  but  the  confirmation  of 
which,  based  on  combined  pathological  and  clinical  observations,  was 
reserved  for  more  recent  observers,  and  especially  for  Yirchow,  Kirkes, 
Tiifnell,  and  others.  This  obstruction  may  arise  in  two  ways, — Iv^,  From 
disease  of  an  arterv,  causing  coagulation  of  the  blood,  and  obstruction 
immediately  within  the  portion  olf  vessel  aftected.  2d,  In  consequence 
of  coagula  from  the  heart  becoming  loosened,  then  carried  in  the  course 
of  the'circulation,  and  subsequently  arrested  in  some  distant  and  sraaller 
arterv.  An  example  of  cerebral  disease  produced  in  the  first  way  is  ob- 
served in  Case  XV.,  and  illustrations  of  the  second  mode  are  given  in 
Cases  XVI.  and  XVII. 

Galliver  was  the  first  to  demonstrate  that  the  so-called  ossification 
of  arteries,  commonly  observed  in  old  persons,  was  in  fact  a  fatty  dege- 
neration of  the  vessels,  consisting  of  numerous  oil  granules  and  crystals 
of  cholesterine,  accumulated  between  their  coats,  and  frequently  asso- 
ciated with  deposits  of  earthy  salts.  This  disease  of  the  arteries, 
however,  is  a  true  arteritis  (Donders  and  Jansen),  originating  in  an  exu- 
dation between  their  coats,  from  the  vessels  which  supply  them,  which 
exudation  subsequently  undergoes  the  fatty  degeneration.  This  l^^ion 
induces  slight  constriction  of  the  vascular  calibre,  thickening  of  the 
arterial  wall,  and  occasional  roughness  of  the  internal  surface — circum- 
stances which  favour  coagulation  of  the  blood  at  the  part,  and  cause 
more  or  less  obstruction.  In  chronic  cases  the  vessel  becomes  brittle, 
and  hence,  on  any  unaccustomed  exertion,  it  gives  way,  and  occasions 
hemorrhage.  These  obstructions  and  ruptures  of  the  vessels  from  chronic 
arteritis,  are  the  most  common  causes  of  chronic  cerebritis  and  hemor- 
rhagic apoplexy.  The  case  of  Walker,  however,  (Case  XV.)  demon- 
strates another'mode  in  which  softening  may  be  occasioned.  Here  ob- 
structiou  of  the  basilar  artery  had  occurred,  occasioned  by  a  local  arteritis, 


CEREBRAL   DISEASE   FROM    OBSTRUCTION   OF   ARTERIES.    355 

and  subsequent  mineral  degeneration  of  the  clot.  The  result  was  a  pecu- 
liar kind  of  softening,  which,  as  the  sole  lesion  of  the  cerebral  substance, 
I  observed  in  this  man  for  the  first  time.  In  the  pons  varolii  the  tubes 
and  nerve  cells  were  loosened  and  easily  broken  down,  without  any  exu- 
dation from  the  vessels,  granules,  or  granule  cells,  such  as  are  observed 
in  chronic  cerebritis.  The  nerve  cells,  however,  were  enlarged,  and  con- 
tained an  unusual  number  of  small  fatty  molecules,  forming  masses  of 
various  sizes,  so  as  to  constitute  a  partial  mould  of  their  interior.  Many 
of  these  masses  were  naked,  and  swam  about  in  the  liuid,  but  were  easily 
recognised  by  their  shape  to  have  originally  been  formed  in  the  interior 
of  cells  (Fig.  364).  I  have  fi-equently  seen  this  alteration  associated 
with  exudative  and  hemorrhagic  softenings ;  but  as  constituting  the  sole 
lesion,  and  occasioning  an  extensive  softening,  producing  such  undoubted 
symptoms  in  the  living  body,  this  is  the  only  case,  so  far  as  I  am  aware, 
in  which  it  has  been  clearly  described.  It  appears  to  me  to  consist  of  a 
primary  fatty  degeneration  of  the  nerve  cells,  and  to  depend  upon  altered 
nutrition  of  the  part;  a  condition  hypothetically  put  forth  as  a  cause  of 
softening  by  Delaberge  and  Monneret,  but  now  for  the  first  time  demon- 
strated. 

That  foreign  solid  bodies  floating  in  the  blood  would  obstruct  the 
smaller  vessels  and  occasion  exudations,  was  first  shown  by  the  experi- 
ments of  Magendie,  Cruveilhier,  Gaspard,  and  others,  who  injected  starch, 
quicksilver,  and  various  substances  into  the  blood,  with  the  etfect  of  pro- 
ducing fatal  inflammations.  Cases  by  Virchow,  Kirkes, Tufnell,  and  others, 
have  further  shown  the  probability  that  the  coagula  and  so-called  vege- 
tations formed  in  the  interior  of  the  heart,  may  in  like  manner  be  oc- 
casionally loosened,  carried  by  the  blood  to  a  distant  part,  such  as  the 
brain,  lungs,  or  extremities,  and  become  impacted  in  a  distant  artery. 
If  so,  they  may,  by  causing  obstruction,  induce  hemorrhage,  exudation, 
and  perhaps  the  kind  of  lesion  from  diminished  nutrition  of  which  I  have 
just  spoken.  Many  cases  are  now  on  record,  and  Cases  XVI.  and  XVII. 
are  good  examples  of  them,  where,  in  conjunction  with  valvular  vege- 
tations in  the  heart,  clots  have  been  found  in  the  arteries  leading  to  im- 
portant organs,  causing  in  the  same  individual  cerebritis,  pneumonia, 
nephritis,  splenitis,  etc.  etc.  But  although  it  is  certain  that  solid  plugs 
may  block  up  arteries  and  occasion  serious  results,  it  is  by  no  means 
clear  that  all  the  instances  of  disease  which  have  been  cited  as  proof  of 
this  in  the  living  body  really  depend  on  arterial  obstruction,  or  because 
cerebral  hemorrhage  and  softening  or  pneumonia  are,  as  is  well  known, 
common  sequelae  of  diseased  heart,  that  therefore  plugs  of  coagulated 
fibrin,  derived  from  the  last-named  organ,  should  originate  these  secon- 
dary lesions.  I  need  scarcely  point  out  that  increased  or  diminished 
impulse  of  the  heart  itself,  arising  from  hypertrophy  or  fatty  degene- 
ration of  its  fasciculi,  are  equally  powerful  causes  of  cerebral  disease, 
and  that  this  in  its  turn  very  commonly  occasions  pneumonia  by  its  para- 
lysing influence  on  the  vagi  nerves.  Besides,  although  clots  are  often 
found  in  arteries,  associated  with  cardiac  vegetations,  I  am  not  aware 
of  any  facts  which  demonstrate  that  the  clot  originating  in  one  place 
is  the  identical  clot  which  has  been  found  in  another.  Much  stress  has 
been  laid  upon  the  form  of  the  clot,  the  broken-oft-lookiug  appearance 
of  its  ends,  its  structure,  etc.  etc.     It  has  been  supposed  that  whilst  spou- 


356  DISEASES   OF  THE  XERVOUS  SYSTEM. 

taneous  coagulations,  or  such  as  are  induced  by  arteritis,  are  gradually 
converted  into  fibrous  tissue,  those  coming  from  one  place  and  impacted 
in  a  vessel  at  a  distance  break  down  and  undergo  a  disintegrating  pro- 
cess. Attempts  even  have  been  made  to  show  that  the  broken  ends 
of  impacted  coagula  correspond  with  and  fit  the  surfaces  of  other  coagula 
in  the  heart,  or  on  the  cardiac  valves  from  which  they  have  been  sup- 
posed to  originate.  All  I  shall  say  with  regard  to  such  arguments  is, 
that  numerous  investigations  into  the  structure  of  coagula  under  a 
varietv  of  circumstances  have  convinced  me  that  we  possess  no  certain 
means  of  distinguishing  one  clot  from  another,  and  that  all  such  state- 
ments should  be  received  with  great  caution.  Otherwise,  every  case  of 
apoplexy  and  softening  will  have  to  be  ascribed  to  wandering  coagula. 
At  the  same  time  the  probability  of  this  occurrence  is  so  great,  and  its 
explanation  of  certain  facts  so  simple,  that  it  has  every  claim  to  be 
entertained  in  practical  medicine.  Thus  cases  have  occurred  where  the 
pulse  of  an  artery  has  suddenly  stopped,  followed  by  more  or  less  numb- 
ness and  coldness  of  the  parts  to  which  it  led.  Tying  arteries  has  pro- 
duced similar  effects.  Fragments  separated  from  the  aortic  valves  would 
readily  pass  into  the  carotids  or  vertebrals,  especially  the  former,  and 
become  impacted  in  the  cerebral  arteries.  Hence  local  congestions, 
causing  headache  arad  other  symptoms,  followed  by  exudations  and  he- 
morrhan-es,  producing  convulsions  or  paralysis.  In  the  same  manner, 
coawulaformed  in  the  right  side  of  the  heart  may  pass  into  the  branches 
of  the  pulmonary  artery,  causing  pneumonia  more  or  less  extensive. 
Spontaneous  coagulations  also  may  occur.  Thus,  in  the  spring  of  1856, 
Professor  Miller  asked  me  to  examine  a  clot  which  formed  a  mould  of 
the  pulmonaiy  artery,  and  was  unusually  firm  and  fibrous.  It  had 
apparently  occurred  during  life,  in  an  elderly  gentleman,  who  was  sud- 
denlv  seized,  when  in  a  warm  bath,  with  symptoms  of  oppression  in  the 
chest  and  dyspnoea,  and  shortly  after  died.  On  examination  no  other 
lesion  could  be  discovered  but  the  clot  referred  to.  Similar  cases  of  sud- 
den death  owing  to  a  like  cause  have  been  recorded  by  Paget,  Virchow, 
and  others.  The  true  lesion  in  all  these  cases  is  obstruction  of  the 
vessels,  however  produced,  whether  by  coagulation  of  the  blood  from 
unknown  causes,  by  arteritis  or  aneurisms  causing  clots  to  form  within 
the  vessel,  or  by  such  clots  travelling  from  one  place  to  another,  which, 
however,  I  am' disposed  to  think  has  very  rarely  been  demonstrated, 
^'irchow  has  sought  to  elevate  this  simple  matter  into  pathological  doc- 
trines, under  the  names  of  Thrombosis  and  EmhoUsmus. 

CEREBRAL  HEMORRHAGE. 

Case  'KXlll.*— Apoplexy,  followed  by  Hemiplegia  of  Left  Side — Recovery. 

HiSTOET. — Andrew  Bryce,  fet.  72,  tailor — admitted  Jan.  29,  1851.  He  states 
that  on  the  9th  October  last,  while  walking  up  Dundas  Street,  he  suddenly  felt  very 
dizzy,  and  was  obliged  to  sit  down.  He  lost  his  senses  completely  for  several  min- 
utes, and  when  he  again  became  conscious  he  found  he  could  not  waUc.  He  was 
assisted  home,  and  on  the  afternoon  of  the  same  day  admitted  into  Xo.  10  of  the 

*  Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


CEREBRAL   HEMORRHAGE.  357 

Royal  Infirmary.  He  was  freelj'  purged,  aud  has  been  confined  to  bed  ever  since. 
Since  his  admission  he  has  been  gradually  gaining  power  in  the  paralysed  side. 

Symptoms  on  Admission. — At  present  he  complains  of  occasional  frontal  headache, 
increased  during  cold  weather.  His  intelligence  is  unaffected.  The  special  senses 
also  normal.  He  cannot  raise  himself  into  a  sitting  posture.  He  can  move  the 
left  hantl,  but  is  unable  to  direct  it  steadily  to  a  distant  object;  neither  can 
he  place  it  on  the  top  of  his  head.  WhUe  m  bed  the  left  leg  moves  as  perfectly  as 
the  right,  but  he  cannot  stand  upon  it.  The  sensibility  of  the  left  leg  appears  to  be 
at  present  normal,  but  that  of  the  left  arm  is  slightly  impaired.  There  is  also  a 
little  rigidity  of  the  left  arm.  The  tongue  is  protruded  in  the  median  line.  On 
laughing,  the  mouth  is  drawn  slightlj-  towards  the  right  side.  Sensibility  of  the  face 
unimpaired.  The  pulse  88;  is  of  natural  strength.  The  urine  is  not  so  copious  as 
formerly,  and  is  made  in  a  smaller  stream  and  more  frequently.  He  has  sometimes 
passed  gravel,  and  observed  his  urine  of  a  high  colour — sp.  gr.  1023 — non-albuminous 
— a  copious  dejDOsit  of  phosphates. 

Progress  of  the  Case. — This  man  remained  a  few  days  in  the  ward,  during  which 
no  change  occurred  in  the  symptoms,  and  on  Feb.  7th  he  returned  to  Xo.  10,  from 
which  he  was  dismissed  with  the  power  of  the  left  side  nearly  restored,  ilaj'  13,  1851. 

Case  XIX.* — Apoplexy,  followed  by  Hemiplegia  of  the  Eight  Side — Recovery. 

History. — Anthony  Caron,  hairdresser,  a  Frenchman — admitted  Feb.  6,  1851,  in  a 
state  of  coma,  in  which  condition  he  was  found  lying  on  the  Grantou  road,  and  was 
immediately  brought  to  the  Infirmary. 

Symptoms  on  Admission. — When  first  examined,  he  appeared  to  be  about  fifty 
years  of  age,  and  of  robust  habit  of  body.  He  was  perfectl\'  unconscious  of  sur- 
rounding objects,  and  as  if  in  a  deep  sleep — the  surface  pale,  the  countenance  calm, 
and  respirations  natural.  The  mouth  was  slightly  drawn  to  the  left  side.  The 
right  arm,  allowed  to  fall  down  after  being  raised,  sank  rapidly  like  an  inert  mass — 
the  left,  similarly  treated,  fell  slowly.  Pricking  the  right  leg  and  foot  caused  no 
shrinking  of  the  limbs ;  but  the  left  limbs  when  pricked  were  rapidly  withdrawn. 
Pulse  60,  rather  full,  but,  considering  his  habit  of  body,  probably  of  natural  strength. 
On  returning  to  him  an  hour  after  the  first  examination,  consciousness  had  to  a  con- 
siderable extent  returned.  He  opened  the  mouth  when  asked  to  do  so,  and  the  tongue 
was  ascertained  to  be  covered  with  a  white  fur.  He  also  raised  the  left  arm  and  leg 
readily,  but  could  not  move  the  limbs  on  the  right  side.  The  pulse  remained  the 
same.  In  consequence  of  this  change  in  his  condition,  the  full  bleeding  which  was 
previously  determined  on  from  his  arm,  was  changed  into  the  removal  of  §  xij  of 
blood,  by  means  of  cupping,  from  the  nape  of  the  neck.  He  was  ordered  a  pill  con- 
taining 01.  Crotonis  min  i,  and  ext.  colocynth,  gr.  v,  to  be  taken  every  four  hours 
until  the  bowels  were  freely  moved.  Cold  was  to  be  applied  to  the  head,  and  the 
most  perfect  quietude  enjoined. 

Progress  of  the  Case. — The  following  daj'  he  was  much  better — consciousness 
had  returned,  and  from  this  time  he  gradually  improved,  and  was  dismissed  May  17, 
the  arm  having  somewhat  recovered  its  motion,  but  with  the  leg  still  lame  aud 
paralysed. 

Cotnmentary. — The  term  apoplexy  has  been  used  in  two  senses. 
By  the  older  writers  and  clinical  observers,  it  was  used  to  denote  a 
sudden  loss  of   consciousness    and  volition,  independent  of  the  various 

*  Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


358  DISEASES   OF   THE   NERVOUS   STSTET,!. 

morbid  lesions  wliich  may  occasion  these  symptoms.  By  the  followers 
of  the  French  school  of  pathoKogy,  the  same  word  has  been  applied  to 
an  extravasation  of  blood  into  an  organ  ;  and  hence  the  terms  apoplexy 
of  the  Inng,  apoplexy  of  the  spinal  cord,  apoplexy  of  the  kidney,  etc. 
Ecchymosis  of  the  skin,  the  residt  of  a  contusion — such  as  is  present  in 
what  is  commonly  called  a  "  black  eye  " — is  in  this  sense  an  apoplexy. 
I  believe  it  better  to  adhere  to  the  meaning  of  our  ancestors,  the  more 
so  as  it  is  not  always  possible  to  determine  when  a  cerebral  hemorrhage 
is  present.  Hence  the  two  cases  which  have  been  given,  characterised 
by  sudden  loss  ot  consciousness  and  volition,  coming  on  spontaneously, 
are  called  apoplexy.  But  should  such  cases  prove  fatal,  and  Ave  are  ena- 
bled to  speak  positively  as  to  the  cause  of  the  apoplexy  from  post- 
mortem examination,  then  we  may  denominate  them  with  more  propriety 
cerebral  hemorrhage,  softening,  etc.  etc.,  according  to  circumstances. 

In  the  two  cases  before  us  there  is  great  similitude — both  were 
seized  suddenly  with  apoplexy  while  walking.  In  the  first  case,  however, 
the  apoplectic  state  was  of  a  few  minutes'  duration  ;  in  the  second,  it  con- 
tinued several  hours.  The  one  case  occurred  between  three  and  four 
months  before  it  came  under  our  observation  ;  in  the  other,  he  was  seen 
in  the  apoplectic  condition,  or  immediately  after  he  emerged  h-om  it. 
In  both  there  was  perfect  hemiplegia  ;  but  in  the  one  case  there  has  been 
complete  recovery  of  sensation  and  partial  recovery  of  motion,  as  regards 
the  afi'ected  side.  In  the  other,  both  sensibility  and  motion  are  still 
completely  lost. 

On  examining  Case  XIX.,  the  practical  question  to  decide  on  was 
whether  he  should  be  bled  ?  But  the  patient  shortly  after  exhibited  signs 
of  coming  out  of  the  apoplectic  condition,  and  it  was  clear,  therefore,  that 
the  pressure  on  the  brain  was  spontaneously  diminishing,  the  pulse  was 
steady  and  of  natural  strength.  How  could  a  bleeding  have  benefited 
him  I  The  chief  point  here,  therefore,  was  not  to  interfere  with  the 
operations  of  nature,  but  assist  her  as  much  as  possible  in  the  operation 
she  had  next  to  perform — that  is,  causing  absorption  of  the  clot.  Tliis 
I  presume  to  be  best  accomplished  by  quietude,  by  the  avoidance  of  all 
circumstances  which  could  excite  the  heart's  action,  regularity  of  the 
excretions,  and  moderate  diet.  These  are,  therefore,  the  measures 
Avhich  were  adopted,  and  his  recovery,  though  slow,  was  satisfactory. 


Case  XX.* — Palsy — Ileriiipliijia  of  Left  Side — Recovery. 

History. —  Jessie  Fleming,  set.  45,  single,  milliner — admitted  Xov.  27,  1856. 
Since  last  May  the  mind  of  patient  has  been  in  an  unsettled  state ;  previously  she 
eujoj'ed  good  health.  During  last  summer  her  digestion  was  much  impaired,  and 
she  suffered  from  severe  cramps  in  the  left  leg,  especiallj-  during  the  night.  On  Friday 
last,  Nov.  21st,  while  engaged  at  her  work,  she  suddenly  fell  down,  and  though  retain- 
ing her  senses,  felt  unable  to  rise  without  assistance ;  shortly  after  she  quite  lost 
the  use  of  the  left  side.  When  put  to  bed,  she  experienced  great  pain  in  the  head, 
for  which  she  was  cupped  over  the  back  of  the  neck,  to  the  amount  of  13  ounces; 
and  next  day  a  large  blister  was  applied  to  the  same  part;  two  pills  were  taken 
every  three  hours  till  her  bowels  were  freely  moved.     On  the  23d  of  November, 

*  Reported  by  Mr.  M 'Arthur,  Clinical  Clerk. 


CEEEBRAL   HEMOREHAGE.  359 

some  leeches  were  applied  to  the  temples,  and  on  the  24th  she  was  removed  to  the 
infirmary. 

Symptoms  ox  Admission. — Great  pain  is  felt  over  the  top  of  the  head,  which  is 
constant,  and  prevents  the  patient  from  stooping.  Speech  thick  and  imperfect. 
The  muscles  of  the  left  superior  extremity  are  completely  paralysed,  and  do  not 
admit  of  extension;  the  muscles  of  the  head  and  face  are  not  afifected,  nor  is  sensi- 
bUity  impaired.  Cannot  move  the  left  leg,  but  on  applying  an  irritant  to  the  sole  of 
the  "foot  tlie  limb  is  at  once  retracted.  Pulse  120,  of  good  strength;  other  symptoms 
normal.  The  head  to  he  shaved,  and  ice  to  be  applied  to  the  scalp.  To  have  a 
purgative  bolus. 

Progress  op  the  Case. — On  the  following  day  the  pain  in  the  head  was  much 
reheved.  and  from  this  time  she  slowly  regained  the  use  of  her  arm  and  leg.  Her 
recovery,  however,  was  retarded  by  a  carbuncle  which  formed  over  the  right  inter- 
scapular region,  and  subsequently  by  an  exantheraatous  eruption,  accompanied  by 
considerable  fever.  She  was  dismissed  April  8th,  when  she  could  walk  witli  the  aid 
of  slight  assistance,  and  move  the  arm  of  the  affected  side  without  difficulty. 

Commentanj. — In  this  case  sudden  lieniiplegia  occurred  without  loss 
of  consciousness,  when  the  individual  was  wide  awake  and  performing 
ber  household  duties,  a  fact  which  was  established  by  frequent  inter- 
rogation and  bv  the  accounts  of  others.  It  may  be  presumed  that  a 
vessel  had  suddenly  given  away,  causing  hemorrhage  into  the  right  cere- 
bral hemisphere.  Tlie  clot  must  have  been  larger  than  in  the  last  case, 
not  only  because  the  paralysis  was  more  extensive,  but  from  the  longer 
time  necessary  for  recovery. 


Case  XXI.* — Sudden  Paralysis  of  Face  and  Left  Arm — Pneumonia — Bright' s  Disease 

— Recovery. 

History. — Christina  Hutchinson,  tel.  40,  married,  a  sempstress — admitted  Xo- 
vember  7,  1854.  She  states  that  on  the  5th  inst.,  at  half-past  1  o'clock  A.M.,  on 
waking  from  sleep,  she  found  that  she  was  unable  to  lift  the  left  arm,  and  that  she 
had  lost  the  power  of  speech.  She  also  experienced  intense  general  headache,  as 
well  as  great  pain  in  the  right  side  of  the  face,  which  was  greatly  swollen.  She 
does  not  know  whether  she  was  insensible  previously.  On  the  preceding  evening 
she  had  gone  to  bed  healthy  and  strong,  though  with  a  sense  of  fulness  in  head.  - 
Though  habitually  enjoying  good  health,  she  has  occasionally  had  palpitations,  with 
dizziness  of  the  head,  dimness  of  sight  and  tinnitus  aurium,  especially  brought  on  by 
stoopin?.     Seventeen  months  ago  she  had  an  attack  of  acute  rheumatism. 

Symptoms  ox  Admissiox. — Her  speech  is  somewhat  embarrassed,  and  her  intelU- 
gence  dull,  though  she  is  quite  conscious  of  surrounding  objects.  Hearing  perfect. 
Sees  dimly.  Left  pupil  does  not  contract  so  readily  on  exposure  to  light  as  the  right. 
The  face  is  dragged  to  the  right  side.  Cannot  lift  up  the  left  arm,  though  she  can 
move  it  slightly  by  a  strong  effort  of  volition ;  neither  can  she  grasp  an  object  firmly 
with  the  left  hand.  Sensibility  of  the  limb  much  dimmished,  but  not  lost.  The  left 
leo'  and  side  unaffected.  Tongue  when  protruded  seen  to  be  loaded  and  apparently 
turned  to  the  left,  although  this  is  really  owing  to  dragging  of  the  mouth  to  the  right 
side.  Deglutition,  especially  of  liquids,  difficult.  Bowels  constipated.  Sliglit  pain 
in  the  loms.     Urine  slightly  coagulable,  sp.  gr.  1014.     Pulse  86,  small  and  weak. 

*  Reported  by  Mr.  0.  Beaugeard,  Clinical  Clerk. 


860  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Heart  normal.     Other  symptoms  healtbj.     A  hlister  to  be  apiAied  to  the  nape  of  the 
neck.     To  have  01.  Ricini  §  ss.     Quietude  and  rest  enjoined. 

Progress  of  the  Case. — November  14. — Since  admission  has  gradually  recovered 
her  intelligence  and  power  of  speech,  the  features  of  the  face  are  less  distorted,  and 
the  sensibility  in  the  left  arm  has  been  augmented.  There  has  been  constipation, 
whicli  required  pills  of  colocynth  and  croton  oil  to  overcome.  To-day  complains  of  a 
sharp  pain  in  the  left  lateral  region  of  the  mamma,  increased  on  deep  inspiration. 
The  dulness  on  percussion  but  slight;  sibilatiou  audible  on  auscultation.  Xovember 
28th. — Since  last  report,  has  had  an  attack  of  pneumonia,  involving  two-thirds  of  the 
left  lung,  and  characterised  by  all  the  signs  and  sj^mptoms  of  that  disease.  (See  Pneu" 
monia.)  To- day  she  has  completely  recovered,  the  pulmonary  disease  has  passed 
through  its  usual  course,  leaving  her,  however,  weak  and  thin.  The  appetite  is  now 
good,  the  strength  improving.  The  sensibihty  and  power  of  motion  in  the  left  arm 
nearly  restored.  Dragging  of  the  mouth  ncarh- disappeared.  December  Wth — Since 
last  report  all  trace  of  the  pulmonarj^  disease  has  disappeared.  A  week  ago,  however, 
she  experienced  considerable  pain  in  the  lumbar  region,  and  on  examining  tlie  urine 
it  was  found  that  the  albumen  had  greath^  increased.  To-day  microscopic  examina- 
tion demonstrates  in  addition  numerous  fatty  and  waxy  casts  of  tlie  tubes.  Urine 
pale,  passed  in  good  quantity,  sp.  gr.  1010.  She  states  that  tlie  ankles  swell  towards 
evening.  Habeat  Potass.  Biiart  3j  ttr  die.  Jaiiuary  \st. — Has  been  gradually 
gaining  strength ;  all  trace  of  the  paralytic  attack  has  now  left  the  face  and  arm. 
Careful  examination  of  the  left  lung  can  detect  no  remains  of  the  pneumonia.  The 
urine  is  still  coagulable  on  the  addition  of  heat,  but  much  le.?s  so  than  formerlj'. 
But  it  contains  no  casts  of  the  tubes,  is  passed  in  good  quantity,  and  the  oedema  of 
the  feet  has  disappeared.     Dismissed  at  her  own  request. 

Commentary. — The  peculiarity  in  this  case  was  the  sudden  occurrence 
of  palsy  in  the  left  arm  and  left  side  of  the  face  during  sleep.  This  was 
most  probably  owing  to  a  limited  hemorrhage  compressing  the  origin  of 
those  nervous  filaments  more  immediately  in  relation  with  the  nerves 
supplying  those  parts.  Such  hemorrhage  was  not  likely  to  have  been 
extensive,  as  we  may  assume  that  recovery  followed  on  the  gradual  ab- 
sorption of  the  clot.  It  is  worthy  of  observation,  that  this  woman  had 
formerly  sntlered  fi-ora  an  attack  of  acute  rheumatism,  and  was  liable  to 
palpitations  of  the  heart.  On  admission,  no  valvular  lesion  could  be  dis- 
covered, and  yet  there  supervened  many  of  those  phenomena  supposed 
.  to  result  from  coagula  in  the  blood,  causing  first  cerebral  hemorrhage, 
then  pneumonia  on  the  left  side,  tlien  renal  disorder.  The  occurrence 
and  o-radual  recovery  from  each  of  these  diseases  in  succession  is  rarely 
observed. 

Case  XXII.* — Apoplexy — Extravasation  of  Blood  into  the  Left  Corpus  Striatum — 
Pneumonia — Arrested  Tubercle  of  Lung. 

History. — Isabella  Bain,  set.  59 — admitted  May  20,  1855.  She  was  brought  to 
the  Infirmary  by  some  policemen,  who  had  found  her  insensible  in  a  common  stair. 
They  supposed  she  was  in  a  state  of  intoxication.  Her  daughter,  however,  said 
this  was  impossible,  as  she  was  a  very  sober  woman,  and  had  always  been  quite 
healthy,  and  had  left  her  house  only  a  quarter  of  an  hour  previous  to  the  time  she 
was  discovered  insensible. 

*  Reported  by  Mr.  D.  Macgregor,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE.  361 

Symptojis  ox  Admission.— On  admission  slie  was  completely  comatose;  the 
breathing  stertorous;  pupils  contracted;  countenance  pale;  pulse  120,  weak  and 
irregular.  One  drop  of  croton  oil  was  administered  immediately  on  a  piece  of  sugar, 
and  afterwards  a  turpentine  enema. 

Progress  of  the  Case.— May  21.s<.— Coma  continues.  The  enema  brought  away 
some  scybalous  foeces,  and  slie  has  since  had  several  loose  stools,  which  were  passed 
in  bed.  There  is  now  complete  paralysis  of  the  right  side,  and  the  mouth  is  strongly 
drawn  to  the  left  side.  Head  to  be  shaved,  and  cold  constantly  applied.  May  23rf. 
—Has  continued  insensible.  She  now  breathes  wiih  diflBculty,  and  with  heaving  of 
the  chest.  There  is  marked  dulness  over  inferior  two-thirds  of  right  lung,  but  no 
murmurs  are  audible  there,  in  consequence  of  the  stertor.  May  24^7i.— Slight  occa- 
sional movements  have  been  observed  in  left  arm.  In  other  respects  the  same. 
Paralysis  of  right  side  of  face  well  marked.  Loud  moist  rattles  are  now  audible 
over  right  side  of  chest.  Dy.spnoea  more  urgent.  Blister  to  the  head.  Died  at  two 
A.M.  on  the  25th. 

Sectio  Cadaveris. —  Thirty-four  hours  after  death. 

Head. — The  arachnoid  membrane  covering  the  convolutioES,  considerably  elevated 
above  the  sulci,  in  consequence  of  fluid  in  the  subarachnoid  cavity.  The  veins  cov- 
ering the  hemispheres  everywhere  turgid  with  blood.  On  slicing  the  left  hemisphere 
from  above  downwards,  the  knife  passed  through  a  clot  of  blood  in  its  centre,  about 
the  size  of  a  walnut.  The  left  lateral  ventricle  was  also  filled  with  recent  coagu- 
lated blood  and  sanguineous  fluid.  On  removing  the  brain,  and  cutting  through  the 
diseased  parts,  it  was  seen  that  the  seat  of  extravasation  was  the  left  corpus  striatum, 
the  posterior  third  of  which  was  broken  up,  and  reduced  to  a  pulpy  consistence  of  a 
red  colour.  It  was  surrounded  by  a  zone  of  hemorrhagic  purple  spots  closely  aggre- 
gated together,  extending  half  an  inch  into  the  surrounding  white  substance,  and 
this  again  surrounded  by  another  zone  of  a  gamboge  yellow  colour,  gradually  dj-ing 
away  into  the  healthy  white  structure  of  the  cerebrum.  The  choroid  plexuses  both 
contained  several  cysts,  one  or  two  of  which  were  the  size  of  large  peas,  and  filled 
with  an  opaque  yeflov*-  fluid.  The  vessels  in  the  Sylvian  fossae  were  unusually  large, 
thick,  and  rigid,  from  atheromatous  deposit.  The  right  hemisphere  was  normal.  Some 
of  the  more  fluid  portion  of  the  clot  on  the  left  side  had  infiltrated  itself  below  the 
cerebellar  arachnoid,  and  was  accumulated  in  a  thin  layer  over  the  convex  margin 
of  the  cerebellum  on  both  sides. 

Thorax. — A  few  atheromatous  patches  on  the  lining  membrane  of  aorta  and  of 
the  mitral  and  aortic  valves.  The  heart  was  healthy.  The  pleurae  on  the  right 
side  were  everywhere  united  by  chronic  adhesions.  The  two  inferior  lobes  of  the 
right  lung  were  hepatized,  readily  sinking  in  water,  with  a  few  scattered  tubercles. 
The  apex  was  oedematous  and  spongy.  The  apex  of  right  lung  was  indurated, 
strongly  puckered,  of  blackish  colour,  and  contained  several  cretaceous  and  calcare- 
ous concretions,  varying  in  size  from  a  pin's  head  to  that  of  a  small  walnut.  The 
rest  of  the  lung  was  spongj^  but  at  the  base  were  two  or  three  masses  of  clironic 
tubercle  the  size  of  filberts,  surrounded  by  a  dark  ring  of  pneumonic  condensation. 

Abdomen. — Abdominal  organs  health3\ 

Microscopic  Examination. — The  sofl;ened  portion  of  cerebral  substance  sur- 
rounding the  clot  consisted  of  disintegrated  nerve-tubes  and  blood  globules,  and 
contained  no  granule  cells.  The  opaque  fluid  in  the  cysts  of  the  choroid  plexus 
contained  numerous  delicate  cells,  globular  in  form,  and  varying  in  size  from  the 
l-2000th  to  l-500th  of  an  inch  in  diameter.  They  contained  a  single  nucleus,  also 
varying  in  size,  sometimes  clear,  at  others  containing  numerous  granules.  There 
were  also  numerous  irregular  masses  of  granules  and  mineral  bodies,  which,  on  the 
addition  of  nitric  acid,  were  rendered  very  transparent,  whUst  the  larger  ones  pre- 


362  DISEASES   OF  THE   NERVOUS  SYSTEM. 

sented  a  series  of  concentric  rings  surrounding  a  nucleus.     Tliey  resembled  the 
amyloid  bodies  so  commonly  found  in  the  choroid  plexus.     (See  Fig.  370.) 

Commentary. — This  case  is  an  example  of  death  from  pi'imarv 
hemorrhage  into  the  left  ventricle  and  corpus  striatum,  the  result  of 
chronic  arteritis.  She  died  five  days  subsequent  to  the  attack,  during 
which  period  a  pneumonia  had  been  developed  in  the  right  lung,  one  of 
the  most  common  sequela?  of  severe  lesion  at  the  base  of  tlie  brain.  The 
woman  was  apparently  in  good  health  previous  to  the  attack,  which  was 
induced  bv  ascendino-  a  stair. 


Case  XXIII.* — Apoplexy — Hemiplegia  of  left  side — Hemorrhage  into  right  Cerebral 
Hemisphere — Diseased  Heart — Pneumonia. 

History. — Margaret  Wales,  tet.  55,  married,  admitted  January  10,  1849.  On 
the  1st  instant  patient  and  her  husband  left  their  home  quite  well,  and  walked  about 
the  streets  for  about  two  hours,  when  feeling  cold,  they  entered  a  spirit  shop  and 
drank  each  a  glass  of  whisky.  On  leaving  the  shop  she  suddenly  fell  down  on  the 
left  side,  insensible.  Next  morning  she  began  gradually  to  revive,  being  evidently 
conscious,  though  not  speaking.  Her  friends  say  that  she  remained  quiet  in  bed, 
with  the  eyes  mostly  closed.  There  was  no  distortion  of  the  face.  The  right  arm 
and  left  leg  felt  ver^^  cold,  but  were  frequently  moved.  The  left  arm  and  leg  of 
natural  temperature,  but  completely'  paralysed.  On  the  evening  of  the  4th  she 
became  delirious,  muttering  and  roaring  out.  This  continued  until  the  7th.  During 
this  time  she  was  seen  frequently  to  move  the  right  arm  and  leg,  but  not  the  left. 
On  the  8tli  was  somewhat  drowsy,  but  so  far  conscious  as  to  speak  when  roused. 
On  one  occasion  asked  for  a  glass  of  whisky,  but  had  some  tea  given  her.  In  the 
evening  of  this  day  again  became  comatose,  and  has  continued  in  this  state  until 
admission.  Has  had  no  medical  attendance,  and  the  bowels,  it  is  said,  have  not 
been  relieved  since  the  attack. 

St.mptous  o>j  Admission. — On  admission  the  face,  hands,  and  feet  are  cold,  and 
of  bluish  aspect,  not  unlike  that  of  cholera.  The  trunk  moderately  warm ;  eyelids 
closed ;  pupils  slightlj^  contracted,  and  insensible  to  light.  She  is  quite  insensible, 
the  strongest  stimuli  failing  to  rouse  her.  There  is  considerable  dj-spnoea  (respira- 
tions 40  in  the  minute);  no  stertor,  but  some  tracheal  rales;  pulse  100,  soft  and 
small.  Bronchial  moist  rales  are  very  general  on  auscultation  over  anterior  surface 
of  chest,  which  is  also  resonant  on  percussion,  with  the  exception  of  lower  half  of 
right  chest,  where  there  is  comparative  dulness.  Heart's  sounds  are  weak,  and 
masked  by  bronchial  rales.  The  right  arm  and  leg,  on  being  pinched,  move  slightly, 
but  the  left  arm  and  leg  are  completely  paralysed.  The  left  side  of  face  also  com- 
pletely paralysed,  but  no  distortion ;  slight  movement  of  facial  muscles  on  the  right 
side  when  they  are  pricked  with  a  pointed  instrument.  The  bowels  are  said  not  to 
have  been  opened  since  the  attack,  a  period  of  ten  days.  No  injury  of  scalp  or 
cranium  can  be  detected,  'fy  Olei  croionis  guft.  ij ;  Extr.  colocynth.  comp.  q.  s.  ft.  pit. 
to  he  taken  imraediately.  A  large  sinapism  to  he  applied  to  each  leg.  Head  to  he  shaved, 
and  a  blister  applied  to  the  occiput. 

Progress  of  the  Case. — January  llth. — Continues  in  the  same  condition. 
Bowels  not  open.  To  have  a  pill  ivith  ol.  crotonis  gutt.  iv.  A  ptiece  of  lint  3  inches 
square  to  he  d'qyped  in  strong  aqua  ammonice,  and  aj)p)lied  to  the  vertex.  Jamuiry  12th. 
— No  improvement,  though  the  Ijowels  have  been  opened  once  copiously.     Breathing 

*  Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE.  863 

is  more  rapid,  with  tracheal  rale.     Surface  cold,  and  covered  with  a  clammy  sweat; 
pulse  almost  imperceptible.     Died  in  the  evening. 

Sectio  Cadaveris. —  Tiventy-three  hours  after  death. 

Considerable  livor,  with  oedema  of  hands  and  feet.     Integuments  loaded  with  fat. 

Head. — On  reflecting  the  .scalp  no  wound  or  contusion  was  anywhere  visible. 
Membranes  of  the  brain  healthy.  On  slicing  the  brain  from  above  downwards,  a 
slight  prominence  was  observed  over  the  right  lateral  ventricle,  and  the  cerebral 
substance  forming  its  roof  was  softened,  and  of  a  reddish  brown  colour.  On  opening 
the  right  lateral  ventricle,  its  posterior  half  was  seen  to  be  occupied  by  a  clot  of 
blood,  which  also  infiltrated  the  .surrounding  cerebral  substance  to  the  depth  of 
several  hnes,  which  beyond  the  infiltrated  portion  was  also  softened  to  the  extent  of 
half  an  inch,  the  dark  red  gradually  passing  through  fawn-coloured  into  white  softening. 
The  left  ventricle  was  sliglitly  distended  with  sennn.  The  foramen  of  Monro  enlarged 
so  as  to  admit  a  goose  quill.     Cerebral  arteries  studded  with  patclies  of  atlieroma. 

Thorax. — Heart  slightly  hypertrophied,  otherwise  healtliy.  Aorta  healthy. 
Both  lungs  much  congested,  and  the  bronchi  filled  in  many  places  with  muco-purulent 
matter.  The  lower  half  of  the  inferior  lobe  on  the  right  side  hepatized.  On  section 
it  presents  a  dusky  red  colour,  containing  here  and  there  circumscribed  purulent- 
looking  deposits  about  the  size  of  a  millet-seed. 

Abdomen. — Liver  slightly  enlarged,  its  right  lobe  adherent  to  the  diaphragm  by 
chronic  adliesions.  Gall  bladder  greatly  distended ;  colon  loaded  with  indurated 
foeces.     Other  viscera  healthy. 

Microscopic  Examixatiox. — The  white  softening  of  the  brain  surrounding  the 
clot  externally  consisted  of  the  mechanical  breaking  up  of  the  nerve  tubes  as  figured 
Fig.  381.  The  fawn-coloured  and  reddish  portions  of  the  softening  contained  nume- 
rous granule  cells,  mixed  with  broken  down  clots  of  blood,  some  of  which  were  of  a 
bright  orange  colour,  mingled  with  numerous  crystals  of  hematoidine.     (Fig.  326.) 

Commentary. — This  case  was  very  like  the  last,  viz.,  chronic  arteritis, 
followed  by  extensive  hemorrhage  into  one  of  the  ventricles,  induced 
by  walking  about  the  streets,  after  the  excitement  of  drinking  whisky. 
Pneumonia  of  one  lung  was  also  induced.  She  rallied  somewhat  from 
the  attack,  but  again  relapsed  into  coma,  which  is  a  very  unfavourable 
sign.  The  importance  of  administering  a  pui'gative  was  here  well 
demonstrated,  the  paralysis  liaving  aftected  the  bowels,  and  caused 
constipation  for  ten  days,  which  was  with  the  greatest  difficulty  even 
imperfectly  overcome.  After  death  the  colon  was  found  loaded  with 
indurated  fceces. 


Case  XXIY.* — Apoplexy — Hemorrhage  at  i!te  base  of  the  Brain  in  a  boy  aged  14  years. 

History. — Thomas  Pitbladdo,  a-t.  14,  a  house-painter's  apprentice — admitted 
on  tlie  evening  of  June  6,  1855.  His  father  states  that  he  has  generallj^  been  a 
healthy  lad,  but  occasionally  complained  of  a  pain  in  his  head.  Tliis  morning  he  got 
up  as  usual  and  went  to  his  work.  He  ate  his  breakfast  and  dinner  at  the  usual 
times,  not  so  heartUy,  it  is  said,  as  he  was  accustomed  to  do,  but  he  made  no  com- 
plaint. Between  2  and  5  o'clock,  p.  jr.,  he  was  in  the  streets  carrying  errands  for  his 
master,  during  which  time  he  purchased  and  ate  several  partially-decayed  oranges. 
On  returning  to  the  workshop  he  was  noticed  by  the  workmen  •'  nearly  to  fall ''  from 
giddiness,  and  to  vomit  several  times,  bringing  up  the  oranges  he  had  eaten.     At 

*  Reported  by  Dr.  Wilson  Fox,  Resident  Physician. 


864  DISEASES   OF   THE  NERVOUS  SYSTEM. 

half-past  T  p.m.  his  father  was  sent  for,  and  found  him  complaining  of  pain  in  the 
head  and  abdomen.  Subsequently  he  was  observed  to  grind  his  teeth.  An  emetic 
of  ipecacuanha  was  obtained  from  a  neighbouring  druggist,  which  operated  once, 
slightly.     He  was  brought  to  the  infirmary  at  10  p.m. 

Symptoms  on  Admission  — On  admission  he  complained  of  pain  in  the  abdomen, 
on  which  he  pressed  his  hands.  Coma  was  apparently  coming  on.  Pupils  dilated. 
No  strabismus.     Pulse  natural. 

Progress  of  the  Case. — On  being  conveyed  to  bed  an  attempt  was  made  to  pass 
the  stomach-pump,  under  the  impression  that  the  case  was  one  of  poisoning.  This, 
however,  failed  in  consequence  of  the  firm  spasmodic  contraction  of  the  jaws,  accom- 
panied by  grinding  of  the  teeth.  "Warm  fomentations  also  were  applied  to  the 
abdomen.  He  now  became  completely  comatose,  and  it  was  observed  that  there 
was  strabismus  inwards  of  the  left  eye  with  contracted  pupil,  the  right  one  being 
fixed  with  dilated  pupiL  He  lay  motionless,  Avith  the  exception  of  slight  clonic 
spasms  of  the  left  hand  and  forearm.  A  purgative  enema  was  given,  which  returned 
unchanged.  He  was  then  placed  in  a  warm  bath.  The  spasmodic  contraction  of 
the  jaws  however  continued,  the  respirations  gradually  became  more  laborious,  and 
he  expired  about  one  a.m.  on  the  7th,  without  having  had  any  convulsion. 

Sectio  Cadaveris. —  Twelve  hours  after  death. 

Considerable  rigor  mortis.  Sugillation  strongly  marked;  jugular  veins  turgid  with 
fluid  blood.     The  blood  in  the  heart  and  all  the  vessels  fluid. 

Head. — No  marked  congestion  of  the  scalp.  On  raising  the  dura  mater,  both 
surfaces  of  the  arachnoid  were  observed  to  be  unusually  dry.  Substances  of  hemi- 
sphere healthy.  The  lateral  ventricles  contained  about  §  ij  of  sanguineous  serum. 
At  the  base  of  the  brain  was  a  clot  of  blood,  forming  a  round  tumour  the  size  of  a 
walnut,  situated  below  the  arachnoid,  and  breaking  up  the  cerebral  substance  sur- 
rounding the  fifth  and  third  ventricles,  and  the  inferior  portion  of  the  optic  thalami, 
between  the  pillars  of  the  fornix,  thereby  communicating  inferiorly  with  the  lateral 
ventricles.  The  sanguineous  mass  was  about  an  inch  in  depth.  Arteries  every- 
where healthy. 

TuoRAx  AND  Abdomen. — Thoracic  and  abdominal  organs  healthy,  with  the  ex- 
ception of  an  ecchymotic  circular  patch  of  a  brick-red  colour,  four  inches  in  circum- 
ference, in  the  mucous  membrane  lining  the  great  curvature  of  the  stomach. 

Microscopic  Examination. — The  clot  composed  of  recently  coagulated  blood. 
The  surrounding  softened  cerebral  substance  exhibited  the  nerve-tubes  broken  up 
to  a  remarkable  degree,  and  presenting  numerous  rounded  bodies,  with  double  out- 
lines either  isolated  or  attached  to  the  tubes.  The  varicosities  of  the  tubes  also 
could  readily  be  increased  by  pressure.  (See  Fig.  384,  which  was  drawn  from  a 
demonstration  of  the  softening  in  this  case.) 

Commentary. — Cerebral  hemorrliage  is  a  rare  idiopatbic  lesion  in 
very  young  persons,  and  tbe  canses  leading  to  its  occnrrence  in  tliis  case 
are  inexplicable.  There  was  no  heart  disease,  nor  could  coagula  be  found 
in  any  of  the  vessels.  On  receiving  the  patient  at  night,  the  house 
physician,  as  stated  in  the  report,  was  led  to  suppose  that  the  boy  had 
eaten  some  poisonous  substance,  and  the  treatment  was  founded  on  this 
supposition.  Pathologically,  it  is  interesting  to  observe  how  tlie  same 
lesion,  which  in  an  elderly  person  would  have  occasioned  coma  and 
paralysis,  in  the  boy  caused  grinding  of  the  teeth,  trismus,  and  spasms. 
Coma  subsequently  came  on,  probably  from  the  accumulation  of  serum 
in  the  ventricles. 


CEREBRAL   HEilORRHAGE.  365 


Case  XXV.* — Apoplexy,  followed  by  Delirium,  and  proving  fatal  in  eight  hours — 
Hemoirhage  into  the  Meninges  of  the  Brain, 

History. — Elizabeth  Vicars,  ait.  59,  brought  by  the  police  to  the  waiting  room 
of  the  Infirmary,  at  2.30  a.m..  May  30,  1857.  Three  and  a  half  hours  before 
admission  patient  was  seated  in  her  own  house  (Canongate)  by  the  fireside  undress- 
ing. She  is  reported  up  to  that  date  quite  healthy,  although  of  intemperate  habits, 
and  given  to  quarrelling  with  her  daughter.  She  was  not  subject  to  giddiness ; 
never  attacked  by  fits  nor  by  palsy.  Suddenly  at  11  p.m.,  29th  of  May,  she  was 
observed  to  fall  off  the  seat,  not  striking  lier  head  against  anything.  She  remained 
insensible  for  10  minutes,  and  on  emerging  from  unconsciousness,  rolled  on  the  floor 
and  shouted — "Murder — Police — I'm  mad,"  etc.,  and  could  not  be  kept  quiet. 

Symptoms  ox  Admission'. — When  seen  in  No.  X.  she  was  lying  quiet  on  her  left 
side,  as  laid  down  by  the  police ;  heart's  sounds  normal.  Respiration  not  stertorous, 
but  natural;  pulse  80,  of  ordinary  strength;  legs  rather  cold;  body  warm.  The 
jrapils  were  equal,  rather  contracted  than  dilated;  Hps  not  blanched,  face  naturally 
pale ;  the  eyelids  had  been  closed.  On  their  being  opened  the  patient  began  to  show 
restlessness,  and  this  increased  when  her  lower  garments  wevQ  being  removed.  She 
shouted  and  moved  from  side  to  side,  putting  her  legs  out  of  bed,  and  moving  both 
arms  freely. 

The  mattress  was  laid  on  the  floor.  Warm  bottles  ivere  ajjplied  to  the  fed,  and  cold  to 
the  head.  Rest  and  pierfect  quietude  enjoined.  She  was  seen  again  about  3  a.m.,  by 
the  house-physician  (Dr.  Glen);  at  that  time  she  was  lying  quiet.  She  is  reported 
to  have  had  a  spontaneous  recurrence  of  the  restlessness,  and  tendency  to  vociferate, 
again  sinking  into  apparent  repose.  At  7  a.m.  she  was  recognised  by  the  nurse  to 
be  dead. 

Seciio  Cadaveris. — Fifty-Jive  hours  after  death. 

Body  well  formed,  somewhat  emaciated 

Head. — On  removing  the  dura  mater,  a  hemorrhagic  extravasation  was  found  to 
have  occurred  below  the  arachnoid.  It  covered  nearly  the  whole  of  the  surface  of 
the  hemispheres,  and  formed  a  thin  layer,  thickest  towards  the  lateral  external 
surface  on  both  sides.  The  extravasation  was  still  more  abundant  over  the  ba.se, 
where  it  was  half  an  inch  thick ;  it  extended  from  a  little  anterior  to  the  optic  com- 
missure to  the  commencement  of  the  spinal  cord;  it  was  particularly  abundant 
around  the  medulla  oblongata.  The  blood  was  of  a  dark  colour  and  very  loosely 
coagulated.  The  fourth  ventricle  contained  a  clot  of  similar  character.  There  was 
a  cavity  filled  with  blood  in  the  anterior  portion  of  the  right  hemisphere,  communi- 
cating with  the  extravasation  into  the  meninges.  It  was  of  the  size  of  a  chestnut, 
but  did  not  extend  back  into  the  lateral  ventricle — the  parts  contained  in  which 
were  quite  normal.  The  arteries  at  the  base  of  the  brain  were  atheromatous; 
numerous  opaque  yellowish  patches  being  found  ou  nearly  all  the  branches.  JSTo 
ruptured  vessel,  however,  could  be  made  out. 

Thorax. — Heart  weighed  11 J  oz.;  the  left  ventricle  being  slightly  enlarged, 
appeared  paler  and  browner  than  usual,  being  found  on  microscopic  examination  to 
be  in  an  advanced  stage  of  flitty  degeneration.  The  valves  were  healthy.  On  the 
anterior  flap  of  the  mitral  valve,  and  on  the  endocardium  below  the  origin  of  the 
aorta,  there  occurred  several  oepaqu  atheromatous  patches.  The  surface  of  the 
aorta,   chiefly  in  the  ascending  portion,  but  also  down  to  the  bifurcation  of  the 

*  Reported  by  Dr.  John  Glen,  Resident  Physician. 


366  DISEASES   OF   THE   NERVOUS   SYSTEM. 

abdominal  aorta,  was  irregular  from  lij'pertrophj'  of  the  liuing  membrane,  with 
atheromatous  and  slight  calcareous  degenerations.  Various  of  the  branches  were 
similarly  affected,  but  to  a  less  degree.  There  were  a  few  old  adhesions  of  the 
2ileurffi,  and  slight  emphj-sema  anteriorly  of  both  lungs. 

Abdojien. — Abdominal  organs  healthy. 

Microscopic  Examixatiox. — The  coagula  of  blood  presented  nothing  unusual, 
and  the  brain  surrounding  the  extravasation  in  the  anterior  lobe  of  the  right  hemi- 
sphere was  onlj-mechanicalh'  broken  up.  The  atheromatous  patches  in  the  cerebral 
arteries  exhibited  the  usual  structure  of  that  lesion. 

Commentary. — In  this,  as  in  preceding  cases,  chronic  arteritis  had  led 
to  liemorrhage,  which,  however,  was  for  the  most  part  poured  into  the 
subarachnoid  cavity.  The  symptoms  in  consequence  presented  a  re- 
markable modification,  for  after  the  first  apoplectic  phenomena  had 
disappeared,  slie  exhibited  no  paralysis,  but  great  restlessness,  and 
deHrium  with  vocifei'ation.  These  are  exactly  the  effects  which  result 
from  any  acute  disorder  of  the  meninges,  and  indicate  how  all  lesions, 
by  affecting  the  same  parts  of  the  nervous  mass,  produce  similar  symp- 
toms.    (See  p.  120.) 


Case  XXYL* — Hemorrhage  into  the  Riijlit  Crus  Cerebri — Meningitis  at  the  Base  of 
the  Encephalon — Serous  Effusion  into  the  Loieral  Ventricles — Chronic  Pldhisis — 
Vertigo — Paralysis — Spasnis  of  the  Jaw — Delirium  and  Coma. 

History. — George  Crichton,  xt.  28,  brewer — admitted  Jan.  31,  1851.  For  tlie 
last  six  montlis  he  has  sufiered  from  a  short  dry  cougli,  and  has  sweated  profusely 
at  night.  His  appetite  lias  been  good,  and  he  considered  himself  in  good  health. 
Three  weeks  ago  he  felt  pain  in  his  head,  which  gradually  increased  in  intensity, 
although  he  continued  at  his  work.  On  the  2Gth,  feeling  the  headache  very  severe, 
he  applied  eight  leeches,  but  without  relief  On  tlie  following  day  as  he  was  going 
to  his  work,  he  had  a  severe  lit  of  coughing,  and  expectorated  a  teaspoonful  of 
florid  blood.  Immediateh'  after  he  felt  giddy  and  stupid,  being  obliged  to  support 
himself  against  a  wall.  He  says  he  never  lost  his  recollection,  recovered  himself  in 
a  few  minutes,  and  walked  home,  but  with  difficult}' ;  afterwards  he  felt  weak,  but 
had  perfect  command  over  all  his  muscles.  On  Tuesda}'  evening  he  felt  drowsy, 
and  on  awakening  from  one  of  his  short  sleeps,  he  discovered  that  the  power  of 
moving  the  left  arm  was  much  diminished.     The  left  leg  was  unaffected. 

Symptoms  on  Admission. — On  admission,  appears  weak  and  emaciated;  com- 
plains of  pain  in  the  forehead ;  most  severe  on  the  right  side ;  has  no  pain  else- 
where. His  intelligence  seems  but  little  afiected.  He  speaks  slowly,  reluctantly, 
and  with  an  eftbrt.  The  special  senses  are  unimpaired.  The  power  of  motion  in 
his  left  arm  and  leg  is  almost  entirely  gone.  He  can  neither  stretch  nor  flex  his  arm 
or  leg.  His  leg  has  become  much  more  useless  within  the  last  twenty -four  hours. 
Sensibility  of  the  parts  is  unimpaired,  and  he  feels  impressions  made  upon  them. 
His  mouth  is  very  slightly  twisted  to  the  right  side ;  tongue  protruded  straight. 
During  the  examination  before  the  class,  he  was  seized  with  spasmodic  movements 
of  the  lower  jaw,  lasting  for  a  minute  and  a  half,  unattended  with  pain.  This  was 
first  observed  on  Wednesday, — when  it  occurred  nine  times, — and  has  returned  at 
irregular  periods  since.  Pulse  60,  not  increased  in  strengtli.  Cardiac  sounds 
normal.     Appetite  good.     Tongue  clean  in  centre ;    covered  with  a  white  fur  at 

*  Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


CEREBRAL   HEMORRHAGE.  367 

edges.  Bowels  generally  costive :  not  opened  by  mediciue  last  night.  Urine  1027 
sp.  gr. — deposits  a  copious  sediment  of  mucus  and  phosphates.  Has  occasional 
slight  cough ;  there  is  dulness  on  percussion  under  left  clavicle,  with  harsh  inspira- 
tion, and  great  increase  of  vocal  resonance.  He  was  ordered  ice  to  the  head; 
quietness  to  be  maintained. 

Progress  of  the  Case. — Feb.  2.— To-day  headache  is  abated,  he  complains  of 
weakness  in  the  right  eye,  which  he  cannot  keep  open  without  an  effort.     On  frown- 
ing, the  corrugations  are  more  distinct  over  the  left  eye.     The  right  pupil  is  less 
contracted  than  the  left.     Ftb.  3.— Slept  ill  last  night,  had  a  good  deal  of  convulsive 
twitching  of  the  unaffected  side.     Is  more  confused.     Tongue  has  a  dense  white  fur 
over  it.     Bowels  costive.     5   Olei  Ricird  3  iss,  to  be  followed  by  laxative  enema,  if 
required.     Fth.  4. — Bowels  moved  after  administration  of  the  injection.     Has  had  a 
good  deal  of  muttering  delirium, — passes  his  urine  in  bed.     Appeal's  to  know  he  is 
addressed,  if  spoken  to  in  a  loud  voice,  but  gives  no  answer.     Pulse  60.     Small 
and  weak.     Twitchings  more  distinct  and  decided.     Breathing  not  laboured.     5 
Carb.  Ammon.  gr.  xij ;  MM.  Camph.   §  vj;  M.  Signa,  two  table  spoonfuls  every  third 
hour;  Aj^plicetur  Yesicat.  (3x4)  ad  Kucharn.—  Cold  to  head.     Ftb.   5. — Muttering 
dehrium  last  night:  does  not  seem  to  feel  a  prick  on  his  left  leg;  is  restless  when 
spoken  to,  but  never  speaks.     Pulse  60,  still  small  but  stronger  than  yesterday; 
has  some  dysphagia.     Feb.  6. — Quiet  during  the  night;    had   a  shght  attack  of 
general  convulsions;  bowels  opened  by  enema.     Pulse  75,  of  good  strength.     Feb. 
7. — Was  more  restle.ss  during  the  night;  picking  the  bedclothes;  no  muttering; 
respiration  is  more  hurried  and  laboured ;  there  is  puffing  of  the  left  cheek  during 
expiration ;  left  pupil  more  contracted  than  right ;   jactitation  of  the  right  ann. 
JV5  8. — Dysphagia  is  increasing.     Pulse  80.     Twelve  leeches  were  applied  to  the 
temples.     To  have  one  drop  of  croton  oil  every  four  hours.     Feb.  9. — Breathing 
more  hurried  and  laboured.     Pulse  116,  small  and  weak.     Bowels  freely  opened  by 
the  croton  oil.     Appeared  to  feel  the  bites  of  the  leeches.     This  mornuDg  he  had  a 
return  of  the  general  convulsions,  more  severe,   and  lasting  for  a  longer  period 
than  the  former,  accompanied  with  frothing  at  the  mouth.     Feb.  10. — Last  night, 
dbout  8  P.M.,  he  began  to  moan  and  cry  out,  but  no  convulsions.     The  respiration 
became  more  laboured,  and  accompanied  by  a  tracheal  rale.     At  12  p.m.,  he  died 
comatose. 

Sectio  Cadaveris. —  Thirty-six  hours  after  death. 

Head. — On  removing  the  calvarium.  the  smuses  of  the  dura  mater  were  found 
almost  empty ;  the  longitudinal  one  contained  a  small  decolorised  coagulum.  The 
cerebral  arachnoid  was  veiy  dry,  the  surfaces  of  the  hemispheres  flattened,  and  the 
convolutions  pressed  together.  The  ventricles  were  distended  by  13  drachms  of 
colourless  limpid  serum,  and  freely  communicated  with  each  other  by  means  of  the 
foramen  of  Monro,  which  was  much  enlarged.  The  fornix,  septum  lucidum,  floor 
of  the  fourth  ventricle,  and  corpus  callosum,  were  of  pultaceous  consistence,  and 
readily  broke  down  under  the  fingers.  On  removing  the  brain,  a  semi-opaque 
exudation  of  yellowish-white  colour  was  seen  in  the  subarachnoid  space  at  the  base 
of  the  brain,  extending  to  the  sylvian  fissures  laterally,  surrounding  the  chiasm 
of  the  optic  nerves  anteriorly,  and  stretching  as  far  back  as  the  fifth  pau-  poste- 
riorh\  Here,  however,  the  coagulated  exudation  was  very  thin  and  soft,  whereas 
immediately  behind  the  optic  commissure,  it  was  one-eighth  of  an  inch  thick,  and 
of  considerable  density.  On  slicing  the  optic  thalamus  from  above  downwards  on 
the  right  side,  there  was  discovered  below  that  ganglion,  in  the  eras  cerebri,  a  clot 
of  dark-red  blood  the  size  of  a  pea,  surrounded  by  several  smaller  red  spots,  the 
result  of  capillary  hemorrhage.     The  cerebral  substance  surrounding  it  was  softened 


368  DISEASES   OF   THE   jSTERVOUS   SYSTEM. 

to  the  extent  of  a  quarter  of  an  inch  all  around.  In  the  pons  varolii,  two  masses, 
the  largest  the  size  of  a  millet  seed,  of  yellowish  indurated  chronic  exudation,  were 
discovered. 

Chest. — Pleurae  of  both  lungs  were  adherent  at  the  apex,  especially  on  the  left 
side.  The  lining  membrane  of  the  bronchi  appeared  congested,  and  of  a  reddish 
colour.  The  bronchial  glands  were  loaded  with  pigment.  A  cavity  was  broken 
into,  when  separating  the  dense  adhesion  at  apex  of  left  lung,  and  a  dirty  greyish 
white,  tolerably  tenacious,  fluid  escaped.  This  cavity  was  capable  of  holding  a 
hen's  egg.  Walls  were  irregular  and  lined  by  no  distinct  membrane.  The  surround- 
ino-  texture  was  of  a  deep  red  colour,  and  displayed  on  section  numerous  j'ellowish 
hard  miliary  tubercles.  These  were  also  found  scattered  over  the  lower  part  of  the 
left  lung.  The  right  lung  was  crepitant  throughout,  and  displaj-ed  here  and  there 
on  section  the  same  bodies  as  above  described. 

Abdomen'  — Numerous  yellowish  miUary  tubercles  were  found  in  the  cortical  and 
tubular  portions  of  both  kidneys      Other  viscera  healthy. 

Microscopic  Ex.\minatiox. — The  exudation  at  tlie  base  of  the  brain  was  com- 
posed of  bands  of  molecular  fibres,  mingled  with  curled  and  spiral  elastic  filaments. 
In  tlie  softer  parts  of  the  exudation,  tlie  delicate  molecular  fibres  at  irregular  inter- 
vals contained  nuclei,  most  of  which  were  oval,  and  a  few  fusiform.  The  centre  of 
the  clot  in  the  crus  cerebri  was  composed  of  numerous  blood  corpuscles,  and  the 
surrounding  softened  cerebral  substance  contained  numerous  granules  and  granular 
cells.  The  serum  in  the  ventricles  was  structureless,  and  the  cerebral  softening  of 
the  white  substance  contained  no  granule  cells,  the  normal  structure  being  only  moi;e 
easily  separated  and  capable  of  being  broken  up  when  crushed  between  glasses. 

Commentarif. — This  is  an  instructive  characteristic  case  of  that  form 
of  apoplexy  wliicli  has  been  called  ingravescent,  commencing  with  head- 
ache, followed  by  temporary  loss  of  consciousness  and  voluntary  motion, 
then  recovery,  and,  after  a  period  varying  from  a  few  hours  to  several 
days,  gradual  return  of  the  coma,  almost  always  followed  by  death. 
Such  return  of  coma  is  usually  the  result  of  gradually  increasing  pressure 
on  the  brain,  but  the  pathological  cause  of  that  pressure  is  not  always 
easy  to  determine.  Most  commonly  it  is  the  result  of  a  hemorrhage 
slowly  increasing,  and  at  length  foi'miug  a  large  coagulum.  Occasionally 
it  is  caused  by  an  etfusion  of  serum  into  the  ventricles,  and  a  few  cases 
have  been  observed  where  it  was  the  effect  of  a  congestion  which  either 
mio-ht  or  might  not  leave  traces  after  death.  In  the  present  case  we 
found  four  lesions  of  the  nervous  structure, — 1st,  Chronic  exudation  at 
the  base  of  the  brain;  2d,  A  hemorrhagic  clot  in  the  right  ci-us  cerebri ; 
3d,  Accumulation  of  serum  in  the  lateral  ventricles;  4th,  Sottening  of 
the  central  structures  of  the  brain.  Of  these  lesions  the  three  first 
doubtless  united  in  producing  the  symptoms,  whilst  the  last  was  post- 
mortem, dependent  on  imbibition  of  the  serum  after  death.  Here  it  is 
important  to  observe,  that  the  exudation  of  the  base  was  chronic,  for  in 
structure  it  was  firm  and  fibrous,  characters  which  I  have  never  seen  in 
recent  exudations  into  the  subarachnoid  cavity,  which  are  generally 
purulent.  It  is  exceedingly  probable,  therefore,  that  the  headache  and 
premonitory  symptoms  were  occasioned  by  the  meningitis;  whilst  the 
subsequent  twitchings  and  convulsions  were  attributable  to  the  presence 
of  the  exudation,  more  especially  the  pressure  and  irritation  occasioned 
at  the  base  of  the  encephalon  by  the  subsequent  changes  through  which 
it  passed.     Then  the  apoplectic  attack  on  the  2'7th  was  entirely  owing 


CEREBRAL   HEMORRHAGE.  369 

to  tlic  liemorrhage  into  the  right  crus  cerebri.  This  hemorrhage  was 
small  in  amount,  and  the  apoplectic  condition  was  momentary.  It  pro- 
bably, however,  increased  somewhat  afterwards,  and  broke  up  the  nervous 
strnctnre  of  the  cms;  and  the  result  was  interruption  of  the  conducting 
power  between  the  brain  and  left  side  of  the  body, — in  other  words,  hemi- 
pletjia.  Lastlv,  the  exudation  and  clot  combined  must  have  exercised 
pressure  on  the  veins,  producing  dropsy  of,  or  effusion  into,  the  lateral 
ventricles,  whereby  was  produced  a  gradually  augmenting  pressure  on 
the  whole  organ,  occasioning  the  ingravescent  coma.  It  may  be  a  ques- 
tion how  far  the  spasms  of  the  jaw  were  occasioned  by  the  clot  in  the 
eras  cerebri  irritating  the  deep  origin  of  the  motor  branch  of  the  fifth,  or 
by  the  exudation  surrounding  its  superficial  origin  from  the  pons  varolii. 
I  am  inclined  to  think  the  first  theory  the  true  one,  because  both  divi- 
sions of  the  fifth  were  alike  surrounded  by  the  exudation  at  the  base, 
and  yet  spasm  only  was  caused,  and  no  pain. 

The  treatment  of  this  case  was  very  carefully  considered,  the  more 
so  as  it  was  the  evident  opinion  of  the  examining  class,  and  of  the  clerks, 
that  it  should  be  treated  actively  by  blooddetting.  The  student  and 
voung  practitioner  is  generally  an  advocate  for  active  treatment ;  and 
this  was  certainly  a  case  in  which  a  difference  of  opinion  might  be 
expected  to  exist,  even  among  the  most  experienced.  The  circum- 
stances, however,  Avhich  forbade  general  bleeding,  were,  the  condition 
of  bis  pulse,  which,  though  of  good  strength,  was  never  full  or  hard ; 
the  paleness  of  his  countenance,  and  his  general  habit  of  body,  which 
was  tar  from  robust.  The  existence  of  phthisis  did  not  influence  me  at 
the  time ;  but  I  think  it  supports  the  correctness  of  the  conclusion  I 
arrived  at.  Many  years  ago,  when  studying  the  subject,  nothing  struck 
me  more  in  carefully  analysing  the  cases  of  Abercrombie,  in  reference 
to  this  question,  than  the  fact,  that  notwithstanding  he  waited  until  the 
circulation  rallied,  and  the  pulse  rose,  the  almost  constant  statement  is, 
that  a  full  blood-letting  produced  "  no  benefit,"  "no  relief,"  "  not  the 
smallest  benefit,"  and  so  on.  And  in  such  cases,  when  pressure  is 
caused  by  a  solid  coagulum  or  local  obstruction  to  some  part  of  the 
venous  svstem,  inducing  eftusion,  how  can  bleeding  lessen  the  pressure 
when  the  heart's  action  is  not  increased  ?  We  have  already  seen  that  the 
idea  of  diminishing  the  amount  of  fluids  within  the  cranium  by  bleeding 
is  visionarv,  and  experience  fully  proves  its  uselessness,  even  in  the  hands 
of  men  who  inculcate  the  practice.  All  agree,  however,  that  you  can 
only  relieve  pressure  on  the  brain  by  influencing  the  force  of  the  heart's 
contractions.  But  in  the  present  case,  so  far  were  these  contractions 
from  being  increased,  that  they  were  normal  when  he  was  first  admitted, 
and  exhibited  a  tendency  to  diminish  in  force.  Indeed,  so  low  was  the 
pulse  on  4th  February,  that  I  administered  stimulants  under  which  he 
rallied.  Looking,  then,  retrospectively  at  this  case,  it  appears  to  me 
certain  that  bleeding,  by  diminishing  the  force  of  the  general  circulation, 
would  have  increased  the  tendency  to  effusion  in  the  lateral  ventricles, 
and  would  have  hastened  rather  than  retarded  the  fatal  result. 

24 


370  DISEASES    OF   THE  NERVOUS   SYSTEM. 


Case  XXTII.* — Apoplexy — Hemorrhage  into  right  Optic  l?ialamus,  causing  Eemi- 
pltgia  on  left  side — Progressive  Recovery — Two  months  afterwards  Hemorrhage 
into  Pons  Varolii  and  Mtmhranes  on  right  side — Death  in  seven  hov.rs. 

HiSTORT. — Margaret  Lockie,  jet.  57,  a  sempstress — admitted  on  the  evening  of 
December  8,  1854.  A  friend  who  accompanied  her,  said  that  the  patient  had  been 
very  much  addicted  to  drinking,  and  had  an  attack  of  dehrium  tremens  a  month 
ago,  for  which  she  was  treated  in  the  Infinnary,  and  dismissed  cured  after  a  week's 
treatment.  She  continued  well  until  three  days  ago,  when,  sitting  in  a  neighbour's 
house,  she  suddenly  fell  from  her  chair  insensible  This  occurred  about  five  o'clock 
P.M.,  without  any  obvious  cause,  as  at  the  time  she  was  pursuing  her  usual  employ- 
ment of  sewing. 

Symptoms  on  Admission. — On  admission  the  face  presents  its  natural  appearance, 
and  is  in  no  way  distorted.  The  intelligence  is  much  impaired,  although  she  is  so 
far  conscious,  that  when  loudly  spoken  to,  she  mutters  something,  and  with  great 
effort  can  articulate  indistinctly  "  Yes,"  and  '•  No."  The  eyes  are  suflused  and  red ; 
the  pupils  normal ;  the  right  hand  and  arm  are  paralysed,  though  the  sensibility  is 
not  absolutely  gone.  Sensibilitj'  also  is  greatly  dimiuished,  and  motion  completely 
lost  in  the  riglit  inferior  extremity.  The  left  leg  is  abruptly  retracted  on  pinching 
it ;  the  left  arm  and  hand  unaffected.  There  has  been  no  convulsion,  nor  is  there 
any  mu.scular  rigidity.  She  cannot  protrude  the  tongue.  State  of  digestive  system 
cannot  be  ascertained.  Heart  sounds  normal  in  character,  but  weak.  "Pulse  at  the 
wrist  60,  barely  perceptible.  One  drop  of  croton  oil  to  be  administered  in  the  fwm  of 
boliLS  immediately.  A  sinapism  to  be  applied  to  the  back  of  the  neck.  5  i^s  of  sherry 
wine  to  be  taken  every  tivo  hours. 

Pkogress  of  the  Case. — December  dth. — Is  more  conscious.  Urine  loaded  with 
lithates,  otherwise  healthy.  Bowels  have  not  been  relieved.  December  10th. — Has 
had  a  dose  of  castor  oil,  and  the  bowels  have  been  freely  relieved  twice.  Is  now  so 
far  conscious  that  she  attempts  to  speak  voluntarily,  and  she  can  mutter  various 
words.  On  smiling,  it  is  distinctly  seen  that  the  mouth  is  dragged  to  the  left  side, 
and  that  the  riglit  half  of  the  face  is  paralysed.  She  can  now  also  protrude  the 
tongue,  which  is  very  foul.  Skin  of  natural  temperature.  Pulse  68,  still  weak,  but 
of  better  strength.  Has  taken  nourishment.  To  have  §  iij  of  sherry  daily.  Prom 
this  time  she  rapidly  recovered  her  consciousness.  On  the  20th  she  could  readily 
answer  questions,  and  the  mind  seemed  perfect,  but  the  articulation  is  still  difficult. 
On  the  31st  articulation  is  nearly  distinct.  January  lith. — Paralysed  parts  still 
immovable,  but  their  sensibility  has  to  a  great  extent  been  restored.  January  2oth. 
— Galvanic  currents  to  be  applied  to  the  right  leg  and  arm.  February  1st. — Can 
now  move  the  right  arm  voluntarily  to  a  certain  extent.  Right  leg  still  immo- 
vable. Paralysis  of  jaw  has  disappeared.  February  12th. — Had  been  doing  well 
up  to  four  o'clock  this  morning,  when  after  having  been  assisted  out  of  bed,  she 
suddenly  began  to  moan,  and  was  seen  by  the  nurse  to  apply  her  left  hand  to  the 
head.  She  was  seen  by  the  house  physician  (Dr.  M'Laren)  ten  minutes  afterwards, 
and  was  found  to  be  quite  unconscious,  breathing  heavily.  The  left  pupil  dilated, 
the  right  contracted,  and  both  were  insensible  to  light.  All  the  limbs  were  power- 
less, and  fell  on  being  raised  like  inert  masses.  The  respirations  rapidly  became 
more  laborious  and  less  frequent,  and  she  died  at  eleven  o'clock. 

Sectio  Cadaveris. — Fifty  hours  after  death. 

Head. — On  removing  the  calvarium  and  dura  mater,  the  surface  of  the  arachnoid 

*  Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


CEREBRAL   HEMORRHAGE.  371 

was  observed  to  be  unusually  dry.  la  the  right  temporal  region  was  a  thin  extra- 
vasation of  blood,  in  the  subarachnoid  cellular  tissue.  The  lateral  ventricles  con- 
tained above  3  ij  of  sanguinolent  serum,  and  communicated  freely  with  each  other 
by  means  of  the  foramen  of  Monro,  which  was  the  size  of  a  goose's  quill.  The  right 
corpus  striatum  and  optic  thalamus  were  healthy,  but  the  left  optic  thalamus  was 
disorganized  throughout,  its  centre  being  occupied  by  a  clot  of  blood  the  size  of  a 
hazel  nut,  dark  in  the  centre,  of  a  brick  red  colour  externally,  surrounded  by 
softened  cerebral  matter  of  a  yellow  fawn  colour.  On  removing  the  brain,  the 
extravasation  formerly  noticed  on  the  right  side  was  seen  to  extend  downwards 
over  the  base  of  the  brain  on  the  right  side,  and  over  a  portion  of  each  lobe  of  the 
cerebellum,  forming  a  thin  layer  of  blood  between  the  pia  mater  and  arachnoid  mem- 
branes. The  arteries  at  the  base  of  the  brain  presented  numerous  opaque  patches  of 
atheroma.  On  cutting  into  the  pons  an  extravasation  of  blood  had  taken  place  into 
its  substance,  disintegrating  the  whole  of  it ;  it  was  of  a  dark  red  colour,  evidently 
recently  poured  out,  and  was  fluid  in  some  places,  and  loosely  coagulate  in  others. 

Chest. — With  the  exception  of  a  few  atheromatous  patches  on  the  aorta  and 
mitral  valve,  which  latter  in  no  way  impeded  efficiency,  the  thoracic  organs  were 
healthy. 

Abdomex. — Abdominal  organs  also  healthy. 

Microscopic  Examination. — The  softening  of  left  optic  thalamus  consisted  of 
disintegration  of  the  tubes;  fatty  granules  accumulated  in  the  ganglionic  cells; 
numerous  granule  cells,  several  tinted  of  an  orange  colour,  and  others  of  a  dusky 
red,  in  the  immediate  neighbourhood  of  this  clot,  mingled  with  several  crystals  of 
hematoidine,  and  masses  of  blood  varying  in  tint.  The  centre  of  the  clots  presented 
a  series  of  laminae  of  a  brownish  black  colour.  The  broken  up  pons  varolii  was 
infiltrated  with  blood  corpuscles,  and  the  tubes  were  more  or  less  disintegrated. 

Commentary. — In  this  case,  circninscribed  hemorrliage  into  the  right 
optic  thalamus  caused  apoplexy  and  hemiplegia  on  the  left  side,  from 
which  she  was  gradually  recovering,  when  an  unusual  exertion  caused  a 
secondar}^  fatal  hemorrhage  into  the  pons  varolii.  Here  the  primary 
disease  was  chronic  arteritis,  causing  brittleness  of  the  vessels.  In  all 
such  cases  too  mucli  care  cannot  be  taken  to  avoid  sudden  exertion, 
agitation  of  mind,  and  every  other  circumstance  which  is  likely  to  pro- 
duce increased  pressure  on  the  blood-vessels. 


Case  XXVIII.* — Five  years  iefore  admission,  Hemiplegia,  folhwed  by  Recovery — 
F<mr  months  before  admission.  Apoplexy,  with  Convulsions  and  Partial  Recovery — 
Pulmonary  Disease — Death  by  Asphyxia — Chronic  Softening  of  Right  Corpus 
Striatum — More  Recent  Hemx)rrhage  into  the  Pons  Varolii —  Cardiac  Hypertrophy, 
with  mitral  constriction — Hemorrhage  into  the  Lungs. 

History. — Mrs.  Macpherson,  set.  34,  admitted  December  22,  1850 — of  intemperate 
habits.  She  has  been  troubled  for  the  last  four  years  more  or  less  with  cough.  Eive 
years  ago  she  had  an  attack  of  paralysis  affecting  the  left  side  of  whole  bod}'-.  Her 
speech  was  thick.  The  left  cheek  appeared  more  prominent  than  natural ;  there 
were  twitchings  also  of  the  left  arm.  Leg  not  affected.  Intellect  unimpaired.  She 
recovered  perfectly  in  two  or  three  months.  She  continued,  however,  her  intemperate 
habits,  and  was  addicted  to  taking  laudanum.  Four  months  ago,  after  taking  a 
drachm  of  laudanum,  she  was  suddenly  seized  with  violent  convulsions,  sprang  a  little 

*  Reported  by  Mr.  Pearse,  Clinical  Clerk. 


372  DISEASES   OF  THE   NERVOUS   SYSTEM. 

distance,  and  fell  on  her  face.  She  %vas  quite  unconscious  at  the  time,  a  condition 
from  which  she  gradually  emerged,  but  her  mind  has  ever  since  been  affected,  and 
the  power  over  the  left  side  is  much  impaired.  Since  the  second  attack,  slie  has 
been  subject  to  violent  and  sudden  fits  of  coughing,  lasting  for  hours  whhout  intei'- 
mission,  which  have  latterly  increased. 

Symptoms  on  Admission. — On  admission,  she  leans  to  the  right  side  when  sitting. 
Countenance  anxious,  motions  of  chest  rapid,  with  much  elevation  of  thorax  during 
inspiration.  Dyspnoea  urgent.  Cough  constant  and  paroxysmal.  Expectoration 
copious..  On  percussion  the  anterior  portion  of  the  chest  sounds  resonant.  There  is 
dulness  over  the  infra-scapular  region  of  left  side.  On  auscultation,  the  inspiration 
is  short,  and  the  expiration  much  prolonged,  and  accompanied  with  sibilant  and 
sonorous  rales  over  the  whole  anterior  suriace  of  both  sides ;  loud  crepitating  and 
mucous  rales  over  the  inferior  portion  of  left  back,  with  distinct  crepitation  also 
inferiorly  in  right  back.  Yocal  resonance  is  increased  over  left  infra-clavicular  region. 
Heart's  sounds  normal,  distant.  Tong-ue  of  a  brown  colour,  moist.  Appetite  bad. 
Bowels  regular.  Catamenia  regular.  Has  no  pain  in  head  or  any  part  of  her  body. 
Skin  hot  and  moist. 

Progress  of  the  Case. — December  ^Oth. — She  has  been  treated  with  various 
anodyne  expectorant  mixtures,  sulphuric  and  nitric  ether,  ipecacuan  wine,  chloro- 
form, morphia,  etc ,  to  relieve  the  cough  and  ditficulty  of  breathing,  but  with  little 
benefit.  Is  weaker  to-day.  Countenance  sunk  and  anxious.  Tossing  about  of  arms. 
Breathing  short  and  rapid.  Cough  almost  ceased.  Expectoration  greatly  diminished. 
Pulse  weak,  scarcely  perceptible.  Ordered  two  ounces  of  whisky  and  one  pint  of 
porter  daily.  January  1st. — Exhaustion  still  greater.  With  difficulty  roused  to 
answer  questions;  incoherent  in  her  conversation;  sleeps  little;  breathing  rapid, 
short  and  laboured ;  paroxysmal  cough.  The  rales  formerly  noticed  still  continue; 
dulness  over  the  left  back  more  extensive  and  complete.  Pulse  small.  Sjnrit 
commun.  §  iv.  January  2d. — Since  yesterday  there  have  been  coldness  and  lividity 
of  face,  with  stupor  gradually  increasing.  Dyspnoea  very  urgent.  Expectoration 
scanty.     These  symptoms  increasing,  she  died  at  3  a.m.,  January  3d. 

Sectio  Cadaverls. — Nine  hours  after  death. 

Head. — The  dura  mater  and  arachnoid  membrane  was  healthy  in  structure,  but 
the  subarachnoid  cavity  contained  superiorly  a  small  quantity  of  serum  between  the 
sulci.  Both  lateral  ventricles  contained  about  a  drachm  of  fluid,  but  that  on  the  right 
side  was  opaque,  of  a  greyish  colour  like  dirty  milk,  while  that  on  the  left  side  was 
colourless  and  clear.  Three-fourths  of  the  right  corpus  striatum  posteriorly  was 
reduced  to  a  fawn-coloured  diffluent  pulp,  from  which  a  turbid  grey  fluid  flowed  out 
on  puncture,  similar  to  what  had  tinged  the  serum  in  the  ventricle.  The  white 
substance  external  to  the  corpus  striatum  was  not  aftected,  the  lesion  being  limited 
to  a  space  about  the  size  of  an  almond  nut.  On  cutting  through  the  softened  texture, 
a  few  bright  yellow  patches  were  observable,  about  the  size  of  a  millet  seed,  closely 
resembling  in  appearance  the  reticulum  often  seen  in  soft  cancer.  On  slicing  the 
pons  varolii,  there  was  observed  near  its  centre,  a  little  to  the  right  of  the  median 
line,  a  hemorrhagic  extravasation  the  size  of  a  small  pea,  the  centre  of  a  dark  red, 
and  the  circumference  passing  into  a  rusty  brown.  Other  portions  of  the  encephalon 
vere  healthy. 

Chest. — The  left  ventricle  of  the  heart?  was  somewhat  hypertrophied,  the  apex 
rounded,  the  mitral  orifice  was  smaller  than  usual — just  admitting  the  thumb — but 
there  was  no  thickening  or  disease  of  the  lining  membrane.  Lining  membrane  of 
the  heart  and  large  vessels  stained  of  a  claret  colour — blood  fluid.  Both  lungs 
anteriorly  emphysematous.     The  lining  membrane  of  the  Ijronchi  of  dark  mahogany 


CEREBRAL   HEMORRHAGE.  373 

colour,  and  more  or  less  filled  with  sanguiuolent  mucus.  Inferior  lobe  of  left  lung 
greatly  engorged,  containing  coagulated  masses  of  extravasated  blood,  varying  in  size 
from  a  pea  to  a  moderate  sized  orange.  Inferior  lobe  of  right  lung  also  engorged, 
with  similar  masses  of  blood,  but  not  so  numerous  nor  so  large  as  on  the  opposite  side. 

Abdominal  organs  healthy. 

Microscopic  Examin'atiox  — Tlie  turbid  fluid  in  the  right  ventricle  of  the  brain 
contained  numerous  floating  compound  granular  cells  and  masses.  The  softened 
portion  of  the  corpus  striatum  was  infiltrated  with  them  throughout,  and  the  bright 
yellow  masses  were  composed  of  an  aggregation  of  the  same  cells  and  masses  mingled 
with  innumerable  molecules  and  granules.  The  clot  in  the  pons  varolii  contained 
several  round  and  oval  cells,  varying  in  size  from  the  four  to  the  six  hundredth  of  au 
inch  in  diameter,  crowded  with  blood  corpuscles.  No  compound  granular  cells  were 
anywhere  visible  in  its  neighbourhood. 

Commentary. — The  historv  of  what  occurred  to  tliis  woman  previous 
to  her  admission,  involvino-  the  account  of  the  two  paralytic  seizures, 
was  obtained  after  her  death  from  the  linsband,  who  attended  the  post- 
mortem examination.  Durino-  the  period  she  was  under  treatment,  the 
pulmonary  symptoms  were  those  that  excited  chief  attention.  The 
weakness  stated  to  exist  on  the  left  side  of  the  body  was  certainly  very 
slight,  as,  in  the  frequent  examinations  which  occurred,  it  was  observed 
that  she  sat  up  when  desired  to  do  so,  presented  either  hand  when  bid 
to  have  the  pulse  felt,  and  frequently  got  out  of  bed  without  assistance. 
The  crepitating  and  mucous  rales,  with  the  dulness  of  percussion  and 
great  prostration  of  the  patient,  however,  left  little  hopes  from  the  first 
of  her  recovery  ;  and  of  these  symptoms  she  alone  complained,  never 
speaking  of  a  former  or  a  present  palsy.  These  facts  in  themselves  are 
very  curious,  when  compared  with  those  narrated  when  the  brain  was 
examined,  although  here  it  must  be  confessed  that  tiie  investigation  of 
the  nervous  phenomena,  from  the  dislike  to  interrogate  closely  a  woman 
evidently  dying,  was  not  very  minute.  There  can  be  little  doubt  that 
the  first  attack  was  owing  to  disease  (perhaps  a  hemorrhage  into  the 
right  corpus  striatum)  five  years  previously,  and  the  second,  four  months 
before  admission,  to  the  limited  hemorrhage  into  the  pons  varolii. 

The  predisposing  cause  of  cerebral  hemorrhage  is,  in  the  vast  majority 
of  cases,  previous  disease  and  consequent  brittleness  of  the  arteries.  It 
is  true  there  are  some  lare  instances  in  which  it  cannot  be  traced  to  this 
circumstance,  and  where  its  origin  is  obscure  (Case  XXIV.),  or  where 
in  young  persons,  or  those  of  middle  age,  it  may  originate  from  obstruc- 
tion of  the  vessels  by  clots  sent  from  a  distance,  as  previously  explained. 
Still  even  in  these,  and  in  the  great  majority  of  individuals  advanced  in 
life,  among  whom  apoplexy  and  sudden  palsy  are  common,  chronic 
cerebral  arteritis  may  be  considered  as  the  real  disease,  and  hemorrhage 
as  its  result.  Hence  why  all  those  circumstances  Avhich  induce  increased 
pressure  on  the  internal  surface  of  the  arteries  are  the  proximate  causes 
of  apoplexy  and  sudden  palsy,  such  as  violent  exertion,  constipation, 
straining  at  stool,  strong  drinks,  undue  repletion  at  meals,  mental  emo- 
tions, etc.  etc. 

The  histological  facts  ascertained  in  connection  with  the  hemorrhao-ic 
clot  are  important.  The  coloured  blood  corpuscles  at  first  aecunnilate  in 
groups,  and  some  of  them  are  subsequently  surrounded  by  a   celloid 


874 


DISEASES   OF  THE   NERVOUS  SYSTEM. 


membrane.  Under  such  circumstances  they  slowly  disintegrate ;  the 
red  colour  is  changed  into  a  brown,  which  becomes  darker  and  darker, 
and  is  ultimately  conveited  into  black.  Not  unfrcquently  crystals,  sup- 
posed to  be  of  hematine,  are  scatteied  among  the  broken  up  clots,  and 
have  been  seen  both  of  a  deep-red  and  black  colour  even  within  the 
membrane  alluded  to.  That  this  membrane  really  does  form  in  the 
manner  described — that  is,  secondarily — around  heaps  of  blood  corpus- 
cles, I  am  satisfied,  my  former  assistant,  Dr.  Sanderson,  having  proved  it 
by  direct  experiments  in  my  presence.  He  thrust  a  needle  tlirough  the 
cranium  into  the  cerebral  lobes  of  four  pigeons,  Avhich  were  killed,  and 
the  brains  inspected,  successively  on  the  third,  iiftb,  and  sixth  days. 
There  could  be  observed  in  one  case,  where  a  slight  hemori'hagic  streak 
marked  the  track  of  the  pin,  that  the  cerebral  substance,  seen  under  a 
magnifying  power  of  250  diameters  linear,  contained  groups  of  from  five 
to  twelve  oval  blood  corpuiscles,  each  surrounded  by  a  delicate  membrane. 
(See  Fig.  293,  p.  214.)  When  the  clot  is  large,  this  process  may  go  on 
through  its  entire  substance,  in  conjunction  Avith  the  formation  of  com- 
pound granular  cells.  I  examined  a  tumour  the  size  of  a  small  hen's  egg, 
brought  to  me  by  Dr.  Peddie,  in  which  the  external  layer  presented 
numerous  fibre  cells  and  fibres,  in  various  stages  of  development,  whilst 
the  interior  was  principally  composed  of  numerous  granules  and  compound 
granular  cells.  Here  and  there,  liowever,  were  patches  of  red  extravasa- 
tion, more  or  less  recent,  containing  large  delicate  vesicles  filled  with 
blood  globules.  (See  Fig.  292,  p.  214.)  In  another  tumour  sent  to  me 
for  examination  by  Dr.  Kirkwood  of  Berwick,*  whieh  was  the  size  of  a 


890. 


large  orange,  and  imbedded  in  the  right  cerebral  liemisphere,  I  found  it 
to  consist  of  a  firm  resistent  sliell  or  capsule,  about  one-eighth  of  an  inch 
thick,  containing  coagula  of  blood  of  a  brick-dust  colour"  The  capsule, 
externally,  was  of  a  straw  colour,  like  that  of  coagulable  lympli ;  but  one- 
third  of  its  thickness,  internally,  was  dark  red, "passing  into  black.  A 
small  portion  of  the  external  layer  of  the  capsule,  examined  under  a 
power  of  250  diameters  linear,  presented  apparently  a  dense  mesh-work 

*  Monthly  Journal.     March,  1851. 


Fig.  390.  Section  of  the  capsule  and  portion  of  the  coagulum,  size  of  an  orange, 
found  in  the  brain  in  Dr.  Kirkwood's  case,  a,  External  portion  of  capsule  consisting 
of  fibrinous  laminae;  b,  internal  portion  of  capsule,  rendered  dark-red,  purple,  and 
opaque,  from  condensed  blood  corpuscles ;  c,  broken-down  blood  corpuscles  in  the 
interior,  with  crystals  of  cholesteriue.  250  diam. 


CEREBRAL   HEMORRHAGE. 


375 


of  fibres,  running  in  waved  bundles,  which  in  fact  were  the  edo-es  of 
laminae.  The  thicker  internal  layer  was  composed  of  similar  fibres, 
mingled  with  masses  of  blood  corpuscles,  in  various  stages  of  disintegra- 
tion. The  internal  coagula  were  composed  of  numerous  molecules  and 
granules,  and  a  mass  of  blood  corpuscles,  diminished  in  size,  and  variously 
altered  in  shape,  but  still  presenting  their  normal  yellow  hue,  mingled 
with  numerous  crystals  of  cholesterine.  These  and  numerous  other  exami- 
nations have  convinced  me  that,  when  the  hemorrhagic  extravasation  is 
small,  it  breaks  down  and  disintegrates  in  a  period  varying  from  three  to 
six  months.  Even  then  it  may  leave  traces  of  its  existence,  especially  in 
the  form  of  a  cyst,  the  internal  membi-ane  of  which  is  of  a  bright  orange, 
or  brick-red  colour.  On  examining  this  membrane,  or  the  coloured 
softening  in  its  immediate  neighbourhood,  it  mav  be  seen  to  consist  of 
numerous  molecules  and  granules,  sometimes  associated  with  fragments 
of  the  nerve-tubes.  There  are  also  granular  corpuscles  and  masses, 
variously  tinted,  of  a  bright  orange,  brick-red,  reddish-brown,  or  dark 
brown.  The  former  are  evidently  the  celloid  bodies  formerly  described 
and  figured  (Fig.  27.5),  containing 
blood  corpuscles  in  different  stages  of 
disintegration.  There  are  also  fre- 
quently present  a  greater  or  less  num- 
ber of  crystals  of  hematoidine,  of  a 
deep  red  or  ruby  tint  (Fig.  369).  If 
the  clot  be  large,  the  period  required 
for  absorption  may  extend  to  years, 
and  then  the  external  portions  of  the 
clot  are  transformed  into  an  external 
fibrous  cyst,  within  which  the  blood  is 
very  slowly  disintegrated  and  absorb- 
ed. Most  commonly,  however,  in 
these  cases,  long  before  absorption  oc- 
curs, secondary  changes  take  place  in  the  surrounding  nervous  structure, 
or  pressure  is  exercised  on  parts  at  the  base  of  the  cranium,  whereby 
convulsions,  paralysis,  or  other  symptoms  occur,  and  life  is  destroyed. 

The  diagnosis  of  cerebral  liemorrhage  from  the  other  lesions  of 
the  brain  is  not  always  easy,  in  consequence  of  the  fact  that  a  cbronic 
cerebritis  may  proceed  imperceptibly,  and  then  induce  apoplexy  or 
sudden  palsy.  It  may  generally  be  observed,  however,  that  a  true 
exudative  cerebral  softening  is  preceded  by  more  or  less  weakness  of 
the  intellect,  and  more  especially  by  slowness  in  receiving  mental  im- 
pressions, or  framing  replies  to  questions,  frequently  combined  with  more 
or  less  headache,  confusion  of  ideas,  and  perversion  of  motion.  Much 
will  depend  upon  the  seat  of  the  lesion,  the  mind  being  disordered  most 
in  proportion  to  the  extent  and  nearness  of  the  disease  to  the  hemi- 
spherical ganglion — while  motion  is  the  more  influenced,  according  as 
the  central  and  basic  {)arts  of  the  brain  are  aflected.  Then  it  should  not 
be  forgotten  that  whilst  a  cerebral  softening  may  occasionally  lead  to  or 


Fifr.  391. 


Fig.  391.  Granular  corpuscles  and  masses,  of  a  bright  orange  and  pale  yellow 
colour,  some  of  them  passing  into  bro\Yn,  with  crystals  of  hematoidine  from  an  old 
apoplectic  clot.  250  diam. 


376  DISEASES  OF  THE  NERVOUS  SYSTEM. 

be  complicated  with  a  hemorrhage,  so  a  hemorrhage  is  one  of  the  most 
common  causes  of  a  softening.  The  distinction  between  the  two  under 
such  circumstances  becomes  very  difficult.  Still  there  can  be  no  ques- 
tion that  suddenness  of  attack^  whether  of  apoplexy  or  of  palsy,  is 
(excluding  external  injury)  the  characteristic  symptom  of  cerebral 
hemorrhage.  Occasionally,  however,  sudden  paralysis  makes  its  ap- 
pearance in  cases  of  chronic  softening,  a  result  which  Di'.  Todd  has 
attributed  to  the  rupture  or  deliquescence  of  tubes  which  had  been 
already  softened,  but  not  sufficiently  to  interrupt  their  power  as  con- 
ductors of  the  nervous  force.  AYhether  hemorrhage  be  consecutive  on 
diseased  arteries,  or  upon  their  calibres  being  obstructed  by  clots,  must 
be  determined  from  all  the  facts  of  tlie  case ;  the  fonner  being  most 
likely  in  elderly,  and  the  latter  in  younger  persons  with  diseased  hearts. 
Littlf,  however,  is  as  yet  undt-rstood  of  this  point  diagnostically  in  the 
living  subject.  For  what  is  known  with  regai-d  to  the  seat  of  cerebral 
hemorrhage  and  softening,  I  must  refer  to  page  120. 

The  intluence  of  cerebral  softening  and  hemorrhage  on  the  motor 
function  has  justly  excited  the  attention  of  physicians.  Wliilst  by  some 
more  or  less  contraction  and  rigidity  of  the  limbs  have  been  considered 
as  liighly  characteristic  of  inliammatory  softening,  others  have  main- 
tained that  it  is  altogether  incidental,  that  it  often  exists  when  no 
softening  can  be  found,  and  that  it  is  as  often  absent  when  softening 
is  present.  It  has  also  been  known  to  accompany  hemorrhages,  appa- 
rently unconnected  with  softening.  The  analysis  of  many  cases  in 
reference  to  this  subject  has  led  me  to  the  conclusion,  that  on  the  vshole 
muscular  rigidity  or  contraction  is  a  valuable  sign  of  softening,  when 
present^  but  that  as  the  softening  may  be  permanent,  whilst  the  rigidity 
is  only  temporary  and  indicative  of  the  irritating  effects  of  the  lesion, 
the  absence  of  the  one  is  no  proof  of  the  non-existence  of  the  other. 
It  should  be  remembered  that  much  of  this  discussion  took  place  for- 
merly when  no  means  were  known  of  distinguishing  histologically  between 
inflammatory,  hemorrhagic,  and  post-mortem  softenings.  Dr.  Todd 
has  especially  drawn  attention  to  the  state  of  the  muscles  in  palsied 
limbs  from  cerebral  disease,*  arranging  the  cases  into  three  classes : — 
1st,  Those  in  which  the  muscles  of  the  paralytic  limbs  are  completely 
relaxed  ;  2d,  Those  in  which  the  paralysed  muscles  exhibit  rigidity  from 
the  moment  of,  or  soon  after,  the  attack ;  3d,  Tliose  in  w  liich  rigidity 
comes  on  long  after  the  paralysis.  The  first  class  of  cases  he  considers 
usually  results  from  hemorrhage,  combined  with  previous  softening  of 
the  brain  and  rupture  of  the  tubes,  the  clot  of  blood  being  separated 
from  healthy  brain.  The  second  class  of  cases  depends  on  the  clot  of 
blood  acting  directly  on  sound  brain  at  the  point  of  implantation  of  the 
nerves  of  the  atiected  muscles;  while  the  third  class  of  cases  are  owing 
to  a  similar  irritation  from  an  attempt  at  cicatrization  of  the  brain's 
substance.  These  views  of  Dr.  Todd,  though  ingenious,  must  as  yet 
only  be  regarded  as  probable  speculations.  The  true  genei-alization 
appears  to  me  to  be,  that  complete  paralysis  indicates  such  pressure 
on  or  obstruction  of  cerebral  tissue  as  to  prevent  all  transmission  of 
nervous  influence,  whilst  rigidity,  convulsion,  and  pain  show  that  some 

*  Clinical  Lectures  on  Paralvsis,  etc.     1854. 


CEREBRAL   HEMORRHAGE.  377 

tabes  of  that  tissue  are  preternaturall}'  excited.  Both  conditions  may 
be  occasioned  by  hemorrhage,  exudation,  effusion,  tumours,  or  any  lesion 
that  affects  the  brain. 

The  treatment  of  cerebral  hemori'hage  must  refer  to  the  attack, 
and  to  the  subsequent  management  of  the  case.  At  the  moment  of 
attack,  the  steps  to  be  pursued  must  always  be  a  subject  of  anxious 
consideration.  Formerly  there  was  little  difficulty — venesection  to  a 
large  extent  being  the  established  routine  remedy.  The  advance  of 
pathological  knowledge,  however,  must  have  made  it  apparent,  that 
the  same  proceeding  is  not  likely  to  be  beneficial  in  all  cases  where 
the  nervous  centres  are  similarly  affected.  AVe  may  have  sudden  loss 
of  consciousness  and  volition  from  syncope,  as  well  as  from  coma,  the 
only  supposed  difference  between  the  two  being,  that  the  same  nervous 
phenomena  commence  in  the  heart,  with  a  weak  pulse,  in  the  one  case, 
wliilst  they  originate  in  the  brain,  and  have  a  strong  pulse,  in  the  other. 
But  careful  observation  has  sufficiently  proved  tliat  there  are  many 
cases  of  even  true  hemorrhagic  apoplexy  which  are  closely  allied  to 
syncope,  and  Avliich  have  recovered  under  the  use  of  stimulants  rather 
than  of  depletions.  It  seems  to  me  also  very  probable  that  many  of 
those  individuals  who  died  under  what  Abercrombie  called  simple 
apoplexy,  and  in  whom  no  trace  of  disease  could  be  found  in  the  brain 
after  death,  were  really  the  victims  of  one  form  of  fatty  degeneration 
of  the  heart — an  affection  in  his  day  altogether  unknown.  The  best 
rule,  therefore,  I  can  give  you,  ]s  to  judge  from  all  the  circumstances 
of  the  case.  Whenever  the  individual  is  of  vigorous  frame  of  body,  if 
the  face  be  flushed,  the  attack  recent,  and  the  pulse  strong  and  full,  a 
moderate  bleeding  may  be  beneficial.  The  extent  must  be  influenced 
by  its  effect  on  the  heart's  action ;  for,  as  we  have  seen,  the  object  of 
this  measure  is  not  to  draw  blood  from  the  brain,  which  is  impossible, 
but  to  diminish  the  pressure  on  that  organ,  by  lessening  the  force  Avitli 
which  the  heart  propels  the  blood  through  the  carotid  and  vertebral 
arteries.  On  the  other  hand,  if  the  individual  be  of  spare  habit,  the 
face  pale,  the  pulse  weak  and  irregular,  and  the  usual  symptoms  of 
shock  be  present,  wine,  brandy,  stimulants  generally,  and  restoratives 
are  demanded.  But  it  most  frequently  happens  that  when  you  are 
called  in,  neither  one  nor  the  other  indication  presents  itself.  It  will 
be  most  prudent,  under  such  circumstances,  simply  to  apply  cold  to  the 
head,  administer  an  active  purgative,  and  above  all  enjoin  quietude. 
At  the  same  time  the  patient  should  be  placed  in  the  horizontal 
position,  with  the  head  slightly  elevated,  whilst  the  cravat,  stays,  and 
all  impediments  to  the  respiratory  and  circulatory  functions  should  be 
removed. 

Should  the  individual  recover  from  the  attack,  quietude,  mental 
and  bodilv,  and  supporting  the  economy  by  good  nouiishment,  consti- 
tute the  chief  treatment.  Thus  long  conversations,  literary  labour, 
business  transactions,  the  sudden  reception  of  joyful  or  distressing  intelli- 
gence, etc.,  should  be  carefully  avoided.  Sudden  exertions,  rising  from 
bed  (See  Case  XXVII.),  constipation,  straining  at  stool,  etc.,  must  be 
o-uarded  against.  Of  all  these  I  believe  the  prevention  of  constipation 
to  be  the  most  important,  as  the  straining  at  stool  thereby  occasioned 
is  one  of  the  most  common  causes  of  secondary  attacks.     If  paralysis 


378  DISEASES   OF   THE   NERVOUS   SYSTEM. 

remain,  consi(leral)le  caution  mast  be  exercised  before  having  recourse 
to  local  stimulants,  such  as  frictions,  galvanism,  or  exercise  of  the 
affected  parts.  These  are  remedies  of  undoubted  utility,  but  never 
to  be  emploved  at  the  risk  of  causing  general  excitement,  and  ahvays 
very  gradually  applied,  and  their  increase  well  regulated.  Exactly  the 
same  management  is  required  in  cases  of  chronic  cerebritis,  or  where 
there  is  reason  to  suspect  that  coagula  from  the  heart  constitute  the 
cause  of  the  cerebral  lesion. 


CANCER  OF  THE  BRAIX. 
Case  XXIX.* — Cancer  of  the  Brain,  Spinal  Cord,  Liver,  and  Bones. 

History. — George  Gall,  ret.  29,  a  stoker  on  board  a  steam  vessel,  admitted  July 
1st,  1857.  About  the  beginning  of  December  1856,  he  contracted  a  cold  with 
cough,  and  profuse  expectoration,  and  has  not  since  enjoyed  good  health.  At  the 
end  of  March  1857,  he  began  to  feel  pain  in  the  lumbar  and  sacral  regions,  extend- 
ing also  to  the  neck,  and  affecting  the  .shoulder  joints,  and  spreading  down  to  the 
joints  and  muscles  of  the  arms.  The  knee  joints  were  also  painful.  They  are  re- 
ported to  have  been  swollen,  but  only  for  a  short  time.  At  the  commencement  of 
last  April,  he  seemed  to  labour  under  confusion  of  thought,  with  .shortness  of  memory, 
and  incapability  of  carrying  on  a  train  of  ideas.  Was  admitted  to  Ward  IV.  on  the 
29th  April,  and  during  the  next  two  months  became  gradually  more  weak  and 
emaciated ;  at  length  was  unable  to  walk  or  to  rise  unassisted ;  passing  his  urine  in 
fair  quantit\-,  but  involuntarily  during  sleep. 

Symptoms  ox  Admissiox. — Has  no  headache ;  is  very  silent,  but  listens  to  ques- 
tions, and  answers  them  after  a  slight  pause  intelligently.  The  question.?,  however, 
requhe  only  monosyllabic  answers.  He  says  little,  and  his  thoughts  are  apparently 
few.  Special  senses  normal.  The  pupils  are  unusually  dilated,  but  contract  on 
stimulus  of  light ;  are  equal  and  parallel.  No  paralysis  of  the  muscles  of  the  face 
or  tongue.  Marked  tenderness  over  dorsal  and  still  more  over  lumbar  vertebrae. 
Never  had  tingling  or  numbness  of  the  extremities.  AU  attempts  to  walk  cause 
great  pain  in  the  back,  to  such  a  degree  that  he  cries  out.  Great  atrophy  of  the 
muscles;  he  moves  very  little;  lies  often  in  a  cramped  position;  cannot  rise 
up  in  bed  without  assistance.  The  tongue  is  clean;  the  appetite  is  reported 
to  be  good :  but  he  frequently  vomits,  sometimes  immediately  after  a  meal,  some- 
times an  hour  or  two  afterwards.  No  increase  in  hepatic  or  splenic  dulness ; 
abdomen  appears  natural,  except  in  being  retracted  and  emaciated;  the  bowels 
are  habitually  costive.  He  has  at  present  no  cough,  sputum,  nor  dyspnoea.  The 
respiratory  murmurs  appear  healthy;  the  cardiac  sounds  are  natural.  Pulse  82, 
small  and  weak.  The  urine  is  passed  involuntarily  during  sleep,  but  voluntarily 
during  the  day.  It  is  of  a  light  straw  colour,  sp.  gr.  1005 ;  contains  no  albumen, 
but  abundant  chlorides.  Is  ordered  nutritive  food,  ivith  laxative  pills,  and,  if  neces- 
sary, eneniaia. 

Progress  of  the  C^se  — Juhj  Qih. — Is  growing  weaker ;  pulse  96,  small  and 
wiry ;  has  a  headache,  chiefly  over  the  occipital  region.  July  9th. — The  pain  in  his 
head  continuing;  the  hair  is  shaved;  cold  clotJis  are  applied  to  the  scalp,  and  a  blister 
is  put  over  the  nape  of  the  neck.     July  lOth. — Pulse  104,  very  weak;  hot  skin;  great 

*  Reported  by  Mr.  John  R.  Murray,  Clinical  Clerk. 


CANCER  OF  THE  BRAIN.  879 

thirst;  little  appetite,  and  frequent  vomiting  usually  some  time  after  taking  food. 
Is  ordered  a  saline  mixture,  and  four  ounces  of  port  wine  daily.  July  Vlth. — On 
re-examination,  besides  the  atrophy  common  to  both  lower  extremities,  there 
appears  to  be  almost  total  want  of  sensibility  and  motion  in  the  right  leg ;  the  left 
leg  being,  for  one  so  emaciated,  quite  normal.  Pupils  continue  widely  dilated ;  there 
is  no  headache  at  present.  July  \Mh. — Is  able  to  move  the  right  leg  slightly,  and 
feels  irritants  applied  to  the  sole  of  the  foot,  but  not  to  the  limb  generally.  Again 
complains  of  pain  diffused  over  the  whole  occiput;  pulse  112,  weak.  July  I8th. — 
Complains  of  his  vision  becoming  impaired ;  can  recognise  objects,  and  name  their 
number.  Had  an  evacuation  yesterday  morning,  and  for  two  days  has  not  vomited 
so  much  as  formerly.  Has  headache,  but  it  does  not  seem  severe ;  the  application 
of  cold  has  been  continued.  July  VJIIt. — Pulse  148,  small,  weak,  and  hard.  Respi- 
ration 22  per  minute.  Ordered  two  additional  ounces  of  wine ;  continue  nutrients. 
July  21st. — Vomiting  recurred  yesterday,  after  being  nearly  ab.sent  for  a  week;  is 
observed  to  recur  when  the  bowels  have  been  much  confined,  and  to  disappear  after 
copious  evacuation.  Ordered  two  pills,  and,  if  necessary,  an  injection.  July  29th. — 
Vomited  less  after  operation  of  the  laxatives ;  is  extremely  weak,  but  little  change 
can  be  noticed  from  day  to  day.  July  30lh. — This  morning  he  was  found  more 
exhausted ;  a  cold  sweat  over  the  whole  surface ;  the  respirations  short  and  hurried ; 
the  pulse  extremely  feeble,  cardiac  impulse  at  apex  increased.  Wine  was  freely 
given,  but  lie  sank,  and  finally  expired  at  2.30  p.m. 

Sectio    Cadaveris. — Forty-eight  hours  after  death. 

Body  moderately  emaciated. 

Head. — On  removing  the  dura  matter,  the  surfaces  of  the  hemispheres  were 
unusually  smooth,  from  flattening  of  the  convolutions.  The  vascularity  of  the  mem- 
branes was  normal.  On  slicing  the  brain  it  was  seen  to  be  studded  throughout 
with  nodules  varying  in  size  from  a  hemp  seed  to  that  of  a  large  hazel  nut.  They 
were  of  a  grey,  pinkish  colour,  the  smaller  of  pulpy  consistency,  the  larger  more 
firm,  and  all  capable  of  being  easily  enucleated  from  the  surrounding  brain  sub- 
stance. None  of  them  projected  from  the  surface,  but  they  were  irregularly  distri- 
buted, some  in  the  grey,  but  most  in  the  white  matter.  Here  and  there  was  slight 
softening  round  some  of  the  masses,  but  there  was  no  extravasation  of  blood. 
In  the  right  hemisphere,  projecting  a  little  through  the  roof  of  the  ventricle,  was  a 
mass  the  size  of  an  ordinary  marble.  In  the  roof  of  the  left  ventricle  was  another 
of  similar  dimensions.  The  left  corpus  striatum  contained  two  of  these  bodies, 
one  the  size  of  a  small  cherry,  situated  anteriorly;  another  that  of  a  pea,  some- 
what more  posteriorly.  Around  these  was  no  softening.  The  optic  thalami  were 
normal.  Similar  bodies  were  scattered  through  the  cerebellum,  but  there  were 
none  in  the  pons  varolii  and  medulla  oblongata.  Each  lateral  ventricle  contained 
almost  a  drachm  and  a  half  of  clear  fiuid.  On  removing  any  of  these  bodies,  there 
could  readily  be  squeezed  from  them  a  creamy  matter,  leaving  behind  an  apparently 
membranous  substance  evidently  very  vascular. 

Spinal  Column. — The  four  upper  dorsal,  and  two  or  three  of  the  lower  dorsal, 
and  the  first  lumbar  vertebrae,  were  soft  and  spongy,  the  osseous  substance  yielding 
on  pressure  a  copious,  thick,  greyish  juice.  The  membranes  of  tlie  cord  were 
healthy.  On  bisecting  the  cord,  a  mass  the  size  of  a  pea,  exactly  similar  to  those 
observed  in  the  brain,  was  found  in  its  right  halfj  opposite  the  junction  of  the  second 
and  third  dorsal  vertebraj. 

Chest  — About  the  centre  of  the  sternum  was  a  slight  bulging,  of  reddish  colour 
and  soft  consistence,  yielding  a  dirty  yellow  coloured  cancerous  juice  on  jwessure. 
Similar  soft   enlargements   were   found  in  the  anterior  portions  of  the  third  and 


380 


DISEASES   OF   THE   NERVOUS   SYSTEil. 


fourth  left  ribs.  The  lower  lobe  of  right  lung  contained  an  infiltrated  indurated 
mass,  about  the  size  of  the  fist,  in  some  places  of  a  yellow  brown,  and  in  others  of 
a  dirty  grey  colour.  Some  bronchial  glands  cancerous.  Other  thoracic  organs 
healthy. 

Abdomen- — Liver  contained  small,  rounded,  dirty  white  masses,  principally  at 
its  circumference,  varving  in  size  from  a  small  pea  to  that  of  a  horse  bean,  and  not 
projecting  from  its  surface.  Some  of  the  gastro-colic  glands  were  enlarged  and 
cancerous.     Other  abdominal  organs  healthy. 

MrsccLAR  System,  wherever  examined,  and  especially  in  the  inferior  extre- 
mities, was  atrophied,  but  presented  its  normal  colour. 

Microscopic  Examixatiox. — The  various  encephaloid  masses  scattered  through- 


Fig.  392.  Fig.  893. 

out  the  brain,  consisted  of  a  vascular  stroma,  and  a  thick  creamy  juice.  A  drop  of 
the  latter  contained  numerous  cancer  cells  in  all  stages  of  development,  as  repre- 
sented Fig.  277,  p.  200.  The  stroma  of  the  small  masses  consisted  of  a  plexus  of 
vessels  of  various  sizes,  crossing  and  inosculating  with  one  another,  many  forming 
loops  which  were  enlarged  and  crowded  with  blood  corpuscles  as  in  Fig.  114.  In 
the  larger  masses  the  vessels  had  undergone  development  by  pushing  out  from 
their  sides  prolongations,  which,  subsequently  uniting,  formed  a  plexus  (as  seen  in 
Fig.  392.)  During  this  process,  however,  another  change  had  occurred,  viz.,  an 
investment  of  these  prolongations,  which  often  assumed  the  form  of  acini  in  a 
gland,  with  a  distinct  membrane,  in  the  interior  of  which  was  a  vascular  loop.  It 
resulted  that  whilst  some  part  of  these  masses  contained  a  vascular  plexus,  with 
numerous  cancer  cells  in  a  mesh-work,  in  others  it  exhibited  a  structure,  now  villous, 
and  now  approaching  towards  that  of  a  gland  (Figs  392,  393).  This  was  evidently 
the  '-Cancer  Stromata,"  so  well  described  by  Rokitanski,  in  some  forms  of  encepha- 


Fiff.  392.     Peculiar  vascular  stroma  with  villi  in  the  larger  cancerous  masses  of 
the  brain,  acetic  acid  being  added.     The  interstices  were  crowded  with  cancer  cells. 
Fio-  393      Gland-hke  expansions  of  stroma  in  other  portions  of  the  same  mass. 
°  80  di. 


DROPSY    OF  THE    BRAIN.  381 

loma.  The  small  cancerous  nodule  in  the  spinal  cord  presented  the  same  structure 
as  those  in  the  brain.  For  the  most  part  the  nervous  substance  surrounding  these 
masses  was  quite  healthy :  but  here  and  there,  in  their  immediate  neighbourhood, 
it  contained  a  few  granule  cells.  The  cancer  of  the  lungs  and  bones  presented  the 
usual  structure  of  encephaloma  in  those  organs. 

Commerilary. — The  occurrence  of  cancer  in  tlie  brain  is  exceedingly 
rare ;  and  the  form  of  it  above  described  was  seen  by  me  for  the  first 
time,  and  examined  with  the  greatest  care.  Its  structure  histologically 
was  vervinterestincr,  and  contrasted  in  some  remarkable  particulars  with 
another"  well-observed  case  recorded  by  Dr.  Redfern  of  Aberdeen,*  in 
which  the  stroma  consisted  wholly  of  shreds  of  cell  membranes  and 
granules.  Before  death,  there  we're  manifested  both  a  cerebral  and 
spinal  disease.  The  former  occasioned  a  peculiar  perversion  of  the 
mind,  consisting  of  a  certain  confusion  of  thought  and  incapability  of 
carrving  on  ideas,  whilst  he  answered  questions  readily  and  appeared 
perfectly  conscious.  Theoretically  this  is  readily  explained  by  the  nu- 
raerous'circumscribed  cancerous  masses  which  may  easily  be  supposed  to 
have  disturbed  that  continuity  of  transmission  along  the  tubes  so  essential 
to  vio;onr  of  mind.  The  spinal  disease  was  indicated  by  local  pain  and 
incapability  of  supporting  himself  erect,  symptoms  attributable  to  the 
osseous  disease  and  weakness.  The  paralysis  of  the  right  lower  ex- 
tremity may  be  owing  to  the  nodule  of  cancer  in  tlie  spinal  cord  opposite 
the  dorsal  vertebrse  ;  but  this  is  by  no  means  certain.  There  was  some 
diflicultv  in  determining  whether"  the  indisposition  to  walk  and  power- 
lessnesswas  owing  to  atrophy  of  the  limbs  or  to  a  true  paralysis.  I  am 
disposed  to  thinkthat  both  causes  co-operated. 


^      DROPSY  OF  THE  BRAIX. 

Case  XXX. f — Chronic  Hydrocephalus — Paracentesis  Capitis— Xo  Benefit. 

History. — Esther  Little,  at.  17  months,  was  admitted  June  27,  1857.  Her  birth 
was  natural,  and  nothing  peculiar  in  the  size  or  shape  of  her  head  was  then  observed. 
For  two  months  her  health  was  perfect ;  she  then  had  convulsions,  vomiting,  and 
strabismus :  her  appetite  diminished ;  her  abdomen  swelled,  and  there  were  frequent 
green  slimy  stools.  She  was  under  medical  treatment  for  nme  weeks,  when  she 
began  to  improve,  and  from  that  time  her  mother  has  noticed  no  deficiency  in  her 
appetite.  When  five  months  old  a  swelling  appeared  on  left  side  of  neck ;  it  was 
lanced,  and  soon  afterwards  healed.     But  about  this  time  also — twelve  months  ago 

the  size  of  the  head  attracted  the  attention  of  her  parents ;  and  fi-om  that  day,  up 

to  admission,  it  has  been  gradually  increasing.  The  child  is  thought  by  her  parents 
to  feel  no  paui  in  her  head,  but  only  inconvenience  from  its  weight.  She  has  not 
sufiered  from  dentition,  and  has  now  cut  ten  teeth.     She  has  not  yet  been  weaned. 

Symptoms  ox  Admissiox. — The  child  is  not  emaciated,  the  arms,  legs,  and  body 
beino-  well  nourished ;  it  often  smiles,  but  the  smile  is  readily  converted  into  a  queru- 
lous cry.     It  is  fretful  on  the  slightest  change  in  the  position  of  its  head,  which  is  too 

*  Monthly  Journal  of  Medical  Science.     December  1850. 
f  Reported  by  Mr.  W.  Guy,  Clinical  Clerk. 


382 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


heavy  for  it  to  support.  The  head  is  of  an  irregularly  square  shape,  the  left  side 
appearing  to  bulge  posteriorly  a  little  more  than  the  right.  The  anterior  fontauelle, 
4  inches  broad,  and  9  inches  at  its  greatest  length,  gives  a  distinct  sense  of  fluctua- 
tion, being  at  the  same  time  tense.  The  veins  are  seen  with  unusual  distinctness 
coursing  over  the  head.  There  are  laminated  scabs  of  chronic  eczema  over  the  scalp. 
The  forehead  is  projecting.     The  eyes  appear  to  protrude  against  the  inferior  eyelids, 


Fig.  394. 


Fig.  895. 


Fis.  896. 


which  cover  the  greater  part  of  their  surface.  The  upper  lids  are  retracted  slightly, 
and  leave  the  sclerotic  exposed.  The  lids  are  somewhat  red.  There  is  no  strabismus ; 
there  is  intolerance  of  strong  light.  The  features  of  the  face  are  well  proportioned, 
and  the  cheeks  bear  a  good  deal  of  colour.  The  measurements  of  the  head  were 
found  to  be  24  inches  at  the  greatest  circumference  (the  girth  on  the  left  side  being 
12|),  15  inches  across  the  head  from  ear  to  ear,  and  16  inches  from  the  frontal  sinus 
to  the  occipital  protuberance.  On  examination  the  cardiac  sounds  are  healthy,  and 
the  respiratory  murmurs  are  natural.  The  tongue  is  moist  and  clean.  The  appetite 
is  reported  good.  The  child  is  not  yet  weaned,  and  is  often  at  the  breast ;  it,  how- 
ever, also  gets  milk,  beef-tea,  and  bread.  Its  bowels  are  reported  to  be  regular. 
The  urine  is  passed  in  good  quantity,  but  none  has  been  obtained  for  examination. 
The  mother  has  five  living  healthy  children. 

Progress  of  the  Case. — The  hair  being  clipped  close,  the  tincture  of  iodine 
had  been  painted  over  the  scalp.  July  Qth. — To-day,  about  1  p.m.,  tapping  was 
performed  by  Mr.  Syme.  A  small  trochar  being  introduced  to  the  depth  of  about 
one  inch  behind  the  posterior  edge  of  the  right  os  frontis,  one  inch  to  the  right  of  the 
mesial  line,  five  ounces  of  fluid  were  withdrawn  A  compress  was  then  applied  over 
the  puncture  and  secured  by  strapping.  Slips  of  diachylon  plaster  were  also  applied 
from  side  to  side  and  obliquely,  to  eflect  gentle  compression,  and  support  was  further 
given  by  a  bandage  passed  round  and  across  the  head.  There  was  very  little  crying 
on  the  part  of  the  child.  The  fluid  was  clear  as  water;  alkaline;  sp.  gr.  1009; 
depositing  slowly,  after  being  heated  and  acidified,  a  slight  amount  of  albumen,  and 
giving  also  (under  action  of  sol.  sulph.  cupri,  aqua  potassa;  and  heat)  a  trace  of  grape 
sugar.  July  12th. — Since  the  operation  there  have  been  no  symptoms  of  nervous 
excitement  or  derangement.  On  measurement  of  head  to-day,  the  same  measures 
were  obtained  as  on  admission.     July  liih. — Yesterdaj^,  on  again  measuring  the 


Figs.  394,  395,  396.  Lateral,  vertical,  and  front  views  of  the  head  of  Esther 
Little.  In  consequence  of  the  well-nourished  face  and  limbs,  the  drawing  does  not 
convey  to  others  an  idea  of  the  comparative  size  of  the  head  so  well  as  usually  occurs 
in  these  cases. 


DROPSY  OF  THE  BRAIN.  383 

head,  the  same  resuUs  were  obtained.  To-daj-,  Mr.  Syme  again  performed  paracen- 
tesis, removiug  twelve  ounces,  the  puncture  being  made  on  tlie  left  side  at  a  point 
corresponding  to  the  previous  one  on  the  right :  the  fluid  exactlj'  resembled  that 
formerly  drawn,  but  did  not  give  the  grape-sugar  re-action.  The  head  was  gently 
compressed  while  the  fluid  was  flowing  through  the  tube,  and  until,  by  means  of 
strappmg  and  bandage,  equable  pressure  was  applied  to  the  cranium.  The  scalp  was 
collapsed  and  puckered  after  the  operation,  and  the  bony  margins  of  the  fontanelle 
had  considerably  approached  one  another.  JtUy  I6(h.—C\\M  has  been  more  fretful ; 
has  passed  less  water:  ordered  ten  drops  sp.  ether  nitrici  thrice  a  day.  July  11  th. — 
The  urine  has  increased  in  amount.  The  child  has  recovered  its  usual  health.  July 
2 Isil.— To-day,  the  seventh  since  the  operation,  the  bandages  were  removed;  the 
coronal  region  felt  full,  and  on  measurement,  the  same  numbers  were  obtained. 
J^!(Z(/ 2 4^7i —Paracentesis  was  again  performed;  twelve  ounces  were  removed,  the 
fluid  being  faintly  yellow:  1008  sp.  gr.,  and  otherwise  identical  in  character  with  the 
fluid  formerly  withdrawn  At  close  of  the  operation  rigors  occurred,  and  the  child 
looked  pallid  and  faint.  It  was  revived  by  wine  and  warmth  ;  it  partially  vomited 
the  wine ;  it  was  then  kept  at  the  breast,  and  by  the  evening  it  had  regained  its 
usual  aspect.  July  25tt.— The  urine  agaui  scanty  ;  slept  well  last  night ;  is  exceed- 
ingly fretful,  and  does  not  incline  to  the  breast.  July  2Qih.—The  fontanelle  is  again 
tense ;  urine  still  scanty ;  did  not  sleep  well  last  night.  July  27//*. — Slept  better ; 
urine  slightly  increa.sed,  but  none  can  be  obtained  for  examination.  July  2Slh. — 
Again  slept  better;  appetite  is  returning;  the  chilc^  is  very  fretful ;  but  otherwise 
has  no  unusual  symptom.  The  mother  is  anxious  to  return  home,  and  a  fourth 
paracentesis  is  not  deemed  advisable.  The  head  was  again  measured,  and  found  to 
be  of  the  very  same  size  as  on  admission.     Discharged,  July  28th,  1857. 

Chemical  Examination  hy  Mr.  Turner  of  the  fluid  removed. 

The  fluid  was  especially  examined  with  reference  to  the  question  whether  it 
possessed  the  power  of  deoxidising  the  blue  hydrated  oxide  of  copper  like  grape- 
sugar.  This  property  was  possessed  by  the  first  specimen,  the  reduction  to  the  state 
of  suboxide  taking  place  alter  boihng  for  a  few  minutes.  No  such  re-action  could, 
however,  be  obtained  from  the  second  portion,  although  the  experiment  was  tried 
several  times,  both  with  the  fluid  as  received,  and  also  with  it  after  it  had  been 
considerably  concentrated  by  evaporation.  The  third  specimen,  however,  exhibited 
the  re-action  in  a  more  decided  manner  tlian  the  first.  All  three  specimens  contained 
albumen  in  small  quantity.  Heat  and  nitric  acid  causing  it  to  fall  down  as  a  white 
flocculent  precipitate.  The  following  inorganic  constituents  were  also  found  in  the 
fluid  in  minute  quantities : — Chloride  of  sodium,  phosphoric  acid,  lime,  and  magnesia. 

Commentary. — The  history  of  this  case  indicates  that,  two  months 
after  birth,  the  child  had  probably  an  attack  of  acute  meningitis  at  the 
base,  from  which  she  recovered.  From  this  period  dates  tlie  commence- 
ment of  the  hydrocephalus,  a  circumstance  which  induced  me  to  suppose 
that  the  chronic  exudation  had  in  some  manner  compressed  the  blood- 
ves.sels,  and  caused  dropsy.  1  have  previously  pointed  out  that  such  is 
the  pathology  of  effusion  following  acute  meningitis  (p.  3'25),  and  there 
is  everv  reason  to  suppose,  that  "such  is  the  explanation  of  the  slow 
accumulation  of  fluid  in  the  present  case.  With  the  exception  of  the 
cerebral  disease,  there  was  no' other  malady.  So  far  as  I  could  discover, 
there  was  especially  no  tubercular  complication,  which  is  generally  so 
much  to  be  dreaded  in  these  cases,  and  all  the  functions  were  performed 
naturally.     On  the  other  hand,  the  mother  assured  me  that  the   head 


38-4  DISEASES   OF   THE   NERVOUS  SYSTEM. 

was  daily  enlarging,  and  it  was  clear  tliat,  under  no  circumstances,  if  left 
to  nature,  would  the  child's  existence  be  an  enviable  one.  Under  these 
circurastances  I  determined  to  try  the  effect  of  cautiously  removing  the 
fluid,  and  seeing  Avhether  the  cause  producing  the  effusion  might  not 
have  ceased  to  operate,  when  assisted  by  diminished  pressure.  The  first 
five  ounces  of  fluid  removed,  produced  no  disturbance  in  the  child  what- 
ever, and,  encouraged  by  this  circumstance,  on  the  next  occasion  twelve 
ounces  were  taken  away.  On  this  occasion  the  head  was  greatly 
diminished,  and  the  scalp  considerably  corrugated  immediately  after  the 
operation.  The  head  subsequently  was  carefully  covered  with  strips  of 
adhesive  plaster  in  the  manner  recommended  by  Mr.  Barnard,  and  the 
whole  supported  bv  bandaging.  For  a  few  days  afterwards,  the  child 
exhibited  somewhat  more  restlessness,  soon  followed  by  a  little  unusual 
stupor.  This  I  attributed  to  a  re-accumulation  of  the  fluid.  On  removing 
the  bandages  the  head  was  found  to  be  of  the  same  size  as  on  admission. 
Subsequentlv  the  scalp  became  very  tense,  and  another  twelve  ounces 
were  removed,  followed  by  bandaging.  On  this  occasion,  however,  the 
operation  was  followed  by  a  rigor,  but  the  child  speedily  recovered.  The 
mother  next  day  informed  me  that  on  this,  as  on  the  preceding  occasion, 
the  urine  was  diminished,  although  I  had  endeavoured  to  meet  the  possi- 
bility of  this  occurrence  by  the  exhibition  of  nitric  aether.  This  circum- 
stance, therefore,  convinced  me  that  no  benefit  was  to  be  anticipated  from 
continuing  the  tappings,  and  the  mother  and  child  consequently  returned 
home.  I  have  since  heard  from  Dr.  Anderson  of  Selkirk,  that,  a  few 
davs  after  returning  to  that  town,  the  child  died,  but  as  he  was  unfortu- 
nately absent  at  tlie  time,  he  did  not  see  her,  and  she  was  buried  before 
his  return.  From  an  account  fui-nished  by  the  parents  of  the  symptoms 
which  preceded  death,  it  appeal's  that  there  was  no  vomiting,  unusual 
restlessness,  strabismus,  convulsions,  paralysis,  nor  coma.  But  there  was 
great  pallor,  disinclination  to  take  food,  and  exhaustion.  Had  she 
remained  in  the  Infirmary,  these  symptoms  and  the  fatal  results  might 
have  been  delayed  by  the  judicious  administration  of  nutrients  and 
stimulants. 

The  most  satisfactory  proof  of  the  occasional  benefit  of  tapping  the 
head  in  cases  of  chronic  hydrocephalus,  is  to  be  found  in  the  paper  of 
Dr.  Conquest,*  who  at  that  time  had  operated  in  nineteen  cases,  and  in 
ten  of  these  successfully.  He  tells  us  that  "  all  the  operations  were 
performed  in  the  presence  of  many  medical  gentlemen,  and  most  of  them 
before  large  bodies  of  students  at  St.  Bartholomew's  Hospital."  One  of 
these  cases,  that  of  Catherine  Seager,  in  its  general  details  was  very  like 
the  one  now  under  observation.  Two  pints  of  fluid  were  removed  by 
the  operation,  followed  by  a  convulsion.  Yet  she  was  seen  by  Dr.  Con- 
quest, two  years  and  a  half  afterwards,  perfectly  well,  and  in  complete 
possession  of  all  her  intellectual  faculties.  With  such  facts  before  us,  it 
is  clear  that  the  operation  is  warrantable  when,  from  an  absence  of 
complication,  there  is  a  reasonable  hope  of  success,  as  existed  in  the 
present  case. 

Should  another  case  present  itself  to  me,  I  would  allow  a  longer  time 
to  elapse  between  the  tappings.     "With  this  exception,  I  do  not  know,  on 

*  Laucet,  vol.  i.  1837-S,  p.  890. 


STRUCTURAL   DISEASES   OF   THE   SPIXAL   CORD.  885 

a  retrospective  view  of  all  the  circumstances,  tliat  there  was  any  point  in 
its  treatment  that  required  modification.  It  would  be  a  matter  of  great 
practical  importance  to  determine,  whether,  as  a  rule,  evacuations  of  the 
fluid  are  as  useful  in  advancing  as  in  stationary  cases  of  chronic  hydro- 
cephalus. It  is  probable  that  the  good  eflfects  described  by  Dr.  Conquest 
were  obtained  in  the  latter  kind  of  cases. 


STRUCTURAL  DISEASES  OF  THE  SPIXAL  CORD. 

Case  XXXL* — Acute  Myelitis  in  the  Cervical  portion  of  the  Cord — General  pains ^ 
resembling  those  of  Rheumatism — Fugitive  paralysis  in  the  arms  and  legs — 
Engorgement  of  the  Lungs — Death. 

History. — Duncan  M'Lean.  set.  27,  a  labourer,  married — admitted  Xovember  1st, 
1858.  Patient  states  that  on  the  19th  October  he  was  driving  cattle,  and  got  wet 
through.  Having  been  engaged  all  that  night,  he  did  not  change  his  wet  clothes, 
but  drank  a  good  deal  of  whisky.  On  the  following  day  he  went  into  a  railway 
carriage  while  perspiring  profusely,  fell  asleep,  and  felt  cold  and  stitf  when  he  awoke. 
He  went  home,  changed  his  clothes,  and  remained  well  till  the  morning  of  tlie  26th, 
when  he  experienced  pain  in  the  calves  of  the  legs,  as  he  walked  to  his  work.  This 
became  more  severe  during  the  week,  and  extended  upwards  to  the  muscles  of  the 
thigh,  and  thence  to  the  intercostals,  and  to  the  muscles  of  the  shoulder,  arm,  and 
lower  jaw.  When  he  sat,  or  stood  at  rest,  the  pain  was  scarcely  felt,  but  it  was 
excruciating  during  motion  or  when  firm  pressure  was  made  on  the  affected  mus- 
cles. On  the  30th  October,  when  standing  in  the  street — the  evening  being  cold — 
the  pain  became  exceedinglj'  severe,  so  as  to  compel  him  to  return  home.  He  had 
at  that  time  also  a  sensation  of  stiffness  over  the  body.  He  remained  in  this  state 
till  November  1st,  when,  as  he  was  coming  down  stairs  on  his  way  to  the  Infirmary, 
his  strength  failed  him,  and  he  had  to  be  conveyed  in  a  cab. 

Symptoms  on  Admission. — Pulse  70,  of  good  strength.  Respiration  normal.  Has 
a  shght  cough.  Complains  of  pain  in  almost  all  the  muscles  of  the  body,  and  this  is 
greatly  aggravated  by  pressure,  or  movement.  Bending  the  joints  only  causes  pain 
in  the  muscles.  He  cannot  put  his  tongue  far  out  on  account  of  the  pain  on  opening 
his  jaw.  It  is  slightly  furred,  dark  in  the  centre,  and  trembles  constantly.  Com- 
plains of  great  pain  at  the  back  of  his  throat  in  the  act  of  deglutition.  Appetite 
almost  gone ;  considerable  thirst ;  bowels  costive.  Urine  strongly  acid — otherwise 
normal.  The  skin  feels  rather  warmer  than  natural,  and  he  sweats  much  at  night. 
He  was  ordered  half  drachm  doses  of  bicarbonate  of  potash  thrice  daily,  dissolved  in 
four  ounces  of  tcater. 

Progress  of  the  Case. — November  Mh. — The  pains  still  continue  as  severe  as 
ever.  Otherwise  much  in  the  same  state  as  when  lie  entered  the  house.  ]J .  Spt. 
^th.  Xitrici  3  ij ;  Aq.  Acet.  Amnion.  3  ij ;  Aquce  ad  5  iv,  ft.  mist.  A  table-spuo^ifnl 
to  be  taken  every  four  hours.  Nov.  Gih — He  speaks  thick,  as  if  his  tongue  were  para- 
lysed. Has  scarcely  slept  since  he  came  into  the  hospital.  Unable  to  move  his 
hands  or  feet.  He  cannot  shut  his  eyes  fully,  the  left  beiug  uncovered  when  he  tries 
to  do  so,  to  the  extent  of  one-eighth  of  an  inch,  and  the  eyes  are  suflused  and  lachry- 
mating.  He  has  great  thirst,  and  chewing  and  swallowing  are  performed  with  diffi- 
culty.    Has  had  retention  of  urine  for  two  days,  and  required  the  use  of  a  catheter. 

*  Reported  by  Mr.  T.  S.  Clouston,  Clinical  Clerk. 
25 


386  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Retention  has  now  ceased.  He  passed  his  stools  in  bed  to-day  when  in  a  dozing 
state.  Kov ember  1th. — Countenance  anxious  and  depressed;  eyes  suifused;  pulse 
120.  Cannot  move  right  arm  or  either  leg.  He  has  the  sensation  of  pricking  with 
pins  and  needles  in  the  feet,  but  no  pain  at  any  part  of  the  spine,  except  at  the  back 
of  the  neck.  Great  pain  in  the  temporal  region.  Ordered  to  be  cupped  to  the  extent 
of  Jive  ounces  over  the  back  of  the  neck,  the  glasses  to  be  applied  along  the  middle  line. 
5.  Tinct.  Uyoscyam.  m.  x.  Aquce  5jA  ^Mttstus,  hora  soinni  sumendv^.  Kov.  8th. 
— Passed  a  restless  night.  Three  glasses  were  applied,  but  only  half  an  ounce  of 
blood  extracted.  He  is  not  in  the  least  relieved.  Complains  to-day  of  a  constric 
tion  round  his  chest,  a  little  below  the  level  of  the  nipples.  Eyes  no  longer  sufiused, 
and  he  can  move  his  right  arm  readily,  but  not  his  legs.  Tongue  coated  with  a 
dirty  fur,  pulse  1 10.  Sweats  a  great  deal,  and  the  perspiration  has  a  peculiar  mousy 
odour.  Bowels  freely  moved  b}'  castor  oil.  Ordered  again  to  he  cupped  over  nape  of 
neck  to  five  ounces.  Kov.  9th. — The  amount  of  blood  ordered  was  drawn  by  cupping 
without  producing  any  relief.  Complains  of  great  pains  in  his  hands  and  feet,  which 
has  kept  him  awake  during  the  night.  The  right  arm  is  again  paralysed,  and  he 
cannot  lift  it  from  his  chest.  The  left  arm  is  now  in  the  same  condition.  IJ.  Fulv. 
Ipecac.  Comp.  gr.  x.  To  be  taken  at  bed-time,  and  that  failing  to  induce  sleep,  to  have 
25  miniins  of  Sol.  Mur.  Morph.  Kov.  lOth. — No  change.  He  slept  for  two  hours 
after  getting  the  morphia.  5  •  ^P-  -^Ih.  Kitrici  3  ij ;  Potass.  Carh.  3  ij ;  Tinct. 
Gent.  Co  5  vi ;  Infus  Gent.  Co.  §  v  ;  ft.  Mist.  Two  table-spoonfuls  to  be  taken  thrice 
daily.  Kov.  llth. — Feels  the  sense  of  constriction  as  if  tied  with  a  cord  round  the 
chest.  He  has  a  cough,  but  cannot  expectorate  easily  on  account  of  the  constric- 
tion. Kov.  12lh. — Cannot  cough  up  the  rather  viscid  expectoration,  which  produces 
a  gurgling  in  his  throat.  There  is  some  harshness  of  inspiration.  He  can  move  his 
arms  better  than  yesterday,  and  the  left  more  than  the  right.  The  sensibility  of  the 
soles  of  his  feet  is  much  diminished,  but  is  more  acute  in  the  right  than  the  left. 
Skin  is  hot ;  per.spu-ation  copious.  Urine  is  alkaline  to-day,  and  throws  down  a 
copious  deposit  of  phosphates.  Ordered  three  ounces  of  wine  daily,  and  3  ss  of  Sol. 
Mur.  Morph.  at  night.  Kov.  13th. — Slept  very  little  on  account  of  the  pain  in  his 
legs,  toes,  and  heels.  Pulse  130,  rather  weak.  Feeling  of  constriction  not  quite  so 
troublesome  to-day  as  yesterday.  Appetite  quite  gone.  Hot  fomentations  to  he 
applied  to  the  feet  and  loiver  pari  of  the  leg,  which,  failing  to  give  relief,  they  are  to  be 
painted  over  with  the  tinct.  of  aconite.  Kov.  lith. — He  became  much  worse  last 
night,  and  to-day  his  face  is  pale  and  expressive  of  great  suffering ;  eyes  sunk,  and 
he  can  scarcely  speak.  Respiration  very  quick  and  difficult,  and  he  is  constantly 
pointmg  to  his  breast  as  the  seat  of  pain.  Loud  mucous  rattle  in  the  throat ;  marked 
dulness  all  over  right  side  anteriorly ;  feeble  respiration  and  mucous  rattle  all  over 
this  side.  Harsh  respiration  and  very  coarse  mucous  rattle  all  over  left  side.  He 
expectorates  pure  pus.  He  can  move  his  arms  more  freely  than  yesterday,  and 
now  also  his  legs,  to  a  limited  extent.  A  table-spoonfid  of  ivine  every  two  hours. 
Vespere. — Skin  covered  with  an  exceedingly  profuse  perspiration ;  respiration  still 
more  difficult  than  during  the  day;  pulse  quick  and  feeble;  almost  imperceptible. 
Abdomen  verj'  much  distended  with  gas.  impeding  still  more  the  laboured  respira- 
tion. Ordered  a  fcetid  enema.  Kov.  Ibih. — Has  rallied  considerably  to-day.  Respi- 
ration much  easier;  abdomen  less  distended;  pulse  12G,  and  much  stronger:  expec- 
toration purulent  and  copious.  His  power  of  moving  the  legs  is  greater  than 
yesterday,  but  still  very  limited.  Cracked-pot  sound,  and  great  increase  of  vocal  reso- 
nance over  the  whole  chest  anteriorly.  On  account  of  the  pain  the  attempt  gave 
him,  and  his  weakness,  his  lungs  could  not  be  examined  posteriorly.  Urine  has 
ao-ain  an  acid  reaction ;  chlorides  much  diminished.  Kov.  I6th. — Yesterday  evening 
he  vomited  about  three  ounces  of  a  thin  yeUowLsh  green  fluid.    Sense  of  constriction 


STRL'CTURAL   DISEASES   OF   THE   SPIXAL   CORD.  387 

of  chest  still  remains,  and  the  same  mucous  niles,  etc.,  as  formerlj-  mentioned.  Pulse 
120,  irregular.  Complains  of  a  burning  in  his  throat;  tongue  covered  with  a  dirty- 
greyish  fur,  and  livid  at  the  tip ;  feels  slight  nausea ;  can  take  no  solid  food,  but 
only  wine  and  beef-tea.  Sleep  is  very  much  disturbed  by  pain  and  a  sensation  of 
pricking  in  his  heels  and  ankle-joints,  and  this  is  but  little  reheved  by  the  warm 
opiate  fomentations  applied  over  those  parts.  Xov.  11  th. — Pain  in  his  heels  not 
relieved  by  aconite  or  warm  fomentations  with  opium.  It  distresses  him  exceed- 
ino-ly.  Nov.  18th. — Voluntary  motion  of  his  arms  is  now  almost  as  perfect  as  in  a 
healthy  individual,  but  is  hmited  in  the  legs.  Pulse  130,  small;  sputum  very 
copious  and  purulent.  Xov.  19th. — He  has  a  depressed  and  paUid  look,  and  is  very 
restless.  Lips  and  tongue  hvid ;  pulse  126,  weaker  than  yesterday.  Mucous  rattles 
heard  all  over  the  chest  anteriorly ;  respiration  heaving  and  quick ;  expectoration 
diminished.     Died  at  half-past  3  p.si. 

Secfio  Cadaveris, — Forty-seven  hours  after  death. 

Head. — Membranes  of  brain  rather  drier  than  usual,  but  nothing  abnormal  could 
be  detected  in  the  brain  or  its  nerves. 

Spixal  Cord. — Membranes  healthy,  but  on  slitting  up  the  cord,  its  substance  was 
found  to  be  slightly  softened  in  a  space  about  an  inch  in  length,  at  the  level  of  the 
third  and  fourth  dorsal  vertebns.  The  diseased  portion  of  the  cord  presented  its 
healthy  appearance  to  the  naked  eye,  but  the  softenmg,  though  apparent  to  the 
touch,  was  rendered  evident  by  the  flocculent  surface  produced  on  subjectuig  the  sec- 
tion to  a  slender  stream  of  water. 

Thorax — The  right  lung  was  found  to  be  strongly  adherent  to  the  thoracic  wall, 
and  there  were  many  puckerings  at  its  apex.  The  anterior  edges  of  both  lungs  were 
emphysematous,  and  on  section,  were  found  to  be  of  a  prune  juice  colour,  congested 
and  dense  in  patches,  the  parts  between  being  stQl  crepitant.  This  condition  was 
most~marked  at  the  base  of  both  lungs,  especially  that  of  the  right.  The  bronchi 
contained  a  large  quantity  of  pus,  the  mucous  membrane  being  congested,  and  of  a 
mahogany  colour.  On  squeezing  a  portion  of  the  lung-substance,  bloody  and  puru- 
lent matter  was  pressed  out.     All  the  other  organs  were  healthy. 

Microscopic  ExAJiiyATiox. — The  softened  portion  of  the  cord  contained  some 
granular  exudation  with  a  few  granule  cells.  Several  demonstrations  were  made 
from  other  parts  of  the  cord,  but  nothing  abnormal  was  found  in  them. 

Commentary. — Cases  of  acute  ravelitis  are  rare,  and  are  almost  uni- 
formly fatal.  In  the  present  instance  the  symptoms  commenced  with 
the  usual  sio-ns  of  fever  and  of  general  mnscular  rheumatism,  followed 
by  retention  of  urine  and  difficulty  of  deglutition.  The  insomnolence 
and  hao'o-ard  expression  of  countenance  led  us  to  fear  that  the  brain 
might  be  implicated  ;  but  the  total  absence  of  mental  confusion,  the 
local  pain,  and  the  appearance  of  paralysis  in  the  arms,  at  once  indicated 
the  cervical  portion  of  the  cord  as  the  seat  of  the  disease.  The  fugitive 
character  of  the  paralysis  was  remarkable,  at  first  appearing  in  the  right 
arm  and  leg;  on  the  following  day  disappearing  in  the  arms,  then  once 
more  returning,  and  again,  towards  the  close  of  the  case,  altogether  dis- 
appearing froiu  the  liiiibs.  This  must  have  been  dependent  on  the  con- 
gestion, which  was  more  intense  at  one  time  than  another,  and  which 
preceded  the  exudation.  The  sense  of  constriction  round  the  chest  was 
harassinfj,  and  latterlv  the  lungs  became  engorged,  one  of  the  most  com- 
mon complications  preceding  death  in  cases  of  myelitis  at  the  upper  part 


888  DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  the  cord.  The  treatment  was  on  his  admission  directed  to  combat 
the  supposed  rheumatism,  at  first  with  alkaline  salts,  and  secondly  with 
Dover's  powders.  As  soon  as  the  spinal  character  of  the  disease  was 
manifested,  ano<lynes  were  freely  given,  with  cupping  over  the  seat  of 
pain  in  the  neck,"  as  a  palliative.  But  it  is  to  be  observed  that  none  of 
these  remedies,  whether  internal  or  external,  gave  him  the  slightest  relief. 
The  disease  took  its  relentless  course,  and  life  was  only  prolonged  by 
assiduous  efi"orts  to  support  the  system  by  nutrients  and  by  wine. 


Case  XXXII.* — Slight  Paraplegia — Recovery. 

History. — William  Macpherson,  set.  33,  a  blacksmith,  a  very  muscular  and 
apparently  strong  man— admitted  June  1,  1853.  For  two  months  past  he  has  suf- 
fered from  pain  between  the  shoulders,  in  the  legs,  and  oyer  the  body  generally,  and 
during  the  last  three  weeks  he  has  been  very  weak,  frequently  feeling  as  if  the  arms 
and  legs  were  benumbed.  He  has  been  an  intemperate  man,  but  never  had  delirium 
tremens,  paralysis,  or  other  disease  of  the  nervous  system. 

Symptoms  ox  Acinssiox. — There  is  no  tenderness  on  percussion  along  the  spinal 
column,  and  he  only  complains  of  pain  between  the  scapulae,  shootmg  into  both 
shoulders,  increased  by  coughing  and  by  motion.  He  says  that  both  arms  are  very 
weak  and  benumbed,  and  that  they  often  tingle,  especially  when  he  coughs.  The 
arms  are  muscular,  but  the  grasp  he  takes  of  an  object  is  feeble,  while  the  sensibility 
of  the  skin  is  decidedly  diminished.  Both  arms  are  similarly  affected.  The  legs 
also  are  very  weak,  more  especially  the  left  one,  which  "  shakes  "  when  he  walks, 
especially  if  going  down  a  hiU.  During  progression  the  gait  is  unsteady,  the  left  leg 
being  jerked  outwards  in  a  semi-circle.  He  cannot  turn  round  rapidly,  and  has  slight 
difficulty  in  standing  wnth  the  eyes  shut.  The  sensibility  of  the  skin  over  the 
inferior  extremities,  as  well  as  over  the  abdomen  and  thorax,  is  diminished  to  the 
same  degree  as  in  his  arms.  Occasionally  there  are  involuntary  startings  of  the  legs 
and  ai-ms,  especially  at  night,  which  sometimes  prevent  his  sleeping.  In  all  other 
respects  the  functions  are  normal  Appetite  excellent.  Xo  constipation.  5  01. 
Olivar.  §  ss ;  01.  Crotonis  3  ij.  M.  ft.  linimeniuni  et  inter  scapulas  applicetur.  5 
Hydrarg.  Proto-iod.  gr.  vj ;  Ext.  Eyoscyam. ;  Ext.  Aloes,  aa3j,  M.  et  fiant  pil.  xij. 
Sumat  unam  ter  in  die. 

Progress  of  the  Case. — June  6ih. — Thinks  himself  somewhat  better.  Complains 
that  his  diet  is  insufficient.  To  have  lib.  of  beef  tea  in  addition  to  ordinary  diet. 
From  this  time  he  gradually  recovered,  and  was  dismissed  on  the  17tli,  stiU  a  little 
weak,  with  the  perfect  use  of  aU  his  hmbs,  and  the  sensibihty  normal 


Case  XXXIII. f — Paraplegia — Padicd  Recovery. 

History. — Benjamin  Robertson,  set.  42,  a  tailor — admitted  July  11, 1853.  States 
that  he  enjoyed  excellent  health,  untU  between  three  and  four  months  ago,  when  he 
began  to  experience  a  constant  feeling  of  coldness  in  both  feet,  accompanied  with  a 
certain  amount  of  numbness.  The  diminution  of  sensibihty  gradually  extended  up 
both  limbs,  and  in  the  course  of  six  weeks  they  were  wholly  affected.  Together 
■with  the  numbness,  the  power  of  walking  became  impaired.  This  he  attributes 
partly  to  want  of  muscular  strength,  and  partly  to  the  feelmg  of  insecurity  caused  by 

*  Reported  by  Mr.  Wm.  il.  Calder,  Clinical  Clerk, 
f  Reported  by  Mr.  Alexander  Struthers,  Clmical  Clerk. 


STRUCTURAL   DISEASES   OF   THE   SPINAL   CORD.  889 

the  loss  of  sensibility.  After  the  lower  limbs  had  become  involved,  the  fingers  of 
both  hands  became  similarly  affected.  Occasionally  he  has  felt  as  if  a  belt  were 
firmly  bound  round  the  loins  and  lower  part  of  the  chest.  He  has  never  had  pain 
in  the  back,  or  tenderness  on  percussion  along  the  spine.  For  the  last  ten  years  his 
habits  have  been  temperate,  but  previously  he  was  much  addicted  to  intoxication 
and  venereal  excesses.  The  treatment  hitherto  has  consisted  of  counter  irritation 
over  the  back,  and  internally  iodide  of  potassium. 

Symptoms  on  Admission. — Has  no  pain  anywhere,  but  sensibility  is  diminished 
in  both  lower  extremities,  and  more  esirecially  in  the  feet.  His  power  of  movement 
in  the  ankle  joints  and  toes  is  unimpaired,  but  he  has  less  command  over  the  knee 
and  hip  joints.  He  is  unable  to  draw  up  the  limbs  in  bed  beyond  a  certain  point, 
but  the  left  leg  seems  to  be  a  little  stronger  than  the  other.  He  has  no  involuntary 
startings  of  the  limbs,  but  he  has  observed  that  they  move  about  irregularly  when 
friction  is  applied  to  them.  He  has  great  difficulty  in  walking,  feeling  as  if  his  knee 
joints  would  bend  under  him,  and  before  advancing  he  requires  to  steady  himself  on 
one  foot  for  a  little.  On  shutting  his  eyes,  he  falls  forward  immediately.  The 
fingers  are  constantly  benumbed,  but  he  can  move  them  perfectly.  Arms  unaffected. 
With  the  exception  of  defoecation,  all  the  functions  are  normal ;  but  on  feehng  an 
incHnation  to  evacuate  the  bowels,  he  is  obliged  to  comply  instantly,  or  the  foeces 
would  pass  involuntarily.  ^  Stnjchniai  gr.  j. ;  Ext.  Gent.  3  ss.  Micce  Panis  q.  s. 
ft.  massa  in  pil.  xij  divideada.     Sumat  unam  ttr  indies. 

Progress  of  the  Case. — The  pills  in  the  course  of  eight  days  produced  invo- 
luntary startings  of  the  inferior  extremities,'  but  the  symptoms  otherwise  remained 
the  same.  5  01.  Olivar. ;  01.  Crotonis.  aa  ?  ss.  To  he  rubbed  over  the  lower  half  of 
the  spine,  morning  and  night.  July  2Sih. — His  general  health  remains  good,  and  he 
thinks  there  is  some  amendment,  although  none  is  very  perceptible.  From  this  time, 
repose,  good  diet,  and  occasional  counter-irritation,  constituted  the  only  treatment, 
uuder  which  he  gradually  improved,  so  that  November  \st.  wlien  he  was  dismissed, 
he  was  able  to  walk  considerable  distances  with  the  aid  of  sticks,  and  a  little  even 
without  them,  although  unsteadilv. 


Case  XXXIV. * — Paraplegia — Incurable. 

History. — Maximilian  Saulsen,  set.  35,  perfumer,  a  native  of  Warsaw — admitted 
January  9,  1851.  States  that  two  and  a  half  years  ago  he  first  felt  a  prickling  fol- 
lowed by  numbness  in  the  toes  of  his  right  foot,  which  gradually  extended,  being 
accompanied  by  diminution  of  voluntary  power  over  the  parts.  His  left  leg  then 
became  similarly  affected.  His  general  health  was  good.  In  1849  he  went  to  Ger- 
many, where  he  made  use  of  the  baths  of  Wiesbaden.  Returning  to  England,  he 
applied  to  one  of  the  London  dispensaries,  and  here  he  was  cupped  and  galvanised 
without  benefit.  During  last  summer  he  went  again  to  Oermany.  He  says  he 
could  not  walk  on  board  at  this  time ;  but  when  he  left  for  England  in  October  last, 
he  was  obliged  to  be  lifted  on  board,  his  legs  being  useless,  while  his  arms  were 
unaffected.  During  the  passage  back  from  Hamburg,  two  months  ago,  his  left  liand 
felt  benumbed,  and  he  could  with  difficulty  use  the  fingers,  except  the  little  finger, 
which  he  says  was  unaffected.  The  right  hand  remained  natural,  with  the  exception 
of  the  little  finger,  which  felt  numb.  Since  then,  the  numbness  in  the  feet  and 
inability  to  move  have  increased  very  mucli. 

Symptoms  ox  Admission. — On  admission,  his  general  appearance  is  healthy.  He 
is  unable  to  walk  to  any  distance  without  the  assistance  of  a  stick.     He  is  unable  to 

*  Reported  by  Mr.  Sanderson,  Clinical  Clerk. 


890  DISEASES   OF   THE   NERVOUS   SYSTEM, 

direct  the  motions  of  his  right  leg  without  watcliing  it.  When  he  stands  without 
support,  great  unsteadiness  is  observed;  and  when  directed  to  close  his  eyes,  he 
loses  all  control  over  his  movements,  and  would  fall  to  the  ground  if  not  prevented' 
He  is  unable  to  use  the  fingers  of  the  left  hand  with  any  precision.  Sensibility  of 
the  skin  unimpaired.  No  headache ;  no  tinnitus  aurium ;  a  little  dizziness  occasion- 
ally. Urine  passed  without  difficult}' ;  sometimes  involuntarily  during  the  night — 
1023  sp.  gr.  Complains  of  difficulty  of  defoecation.  He  was  ordered  to  be  cupped 
and  blistered.  These  remedies,  in  conjunction  with  repose  in  the  Infirmary,  produced 
considerable  amendment,  and  he  was  enabled  to  take  long  walks  with  the  aid  of  a 
stick.  On  Friday  the  10th  he  passed  a  large  lumbricus;  and  40  grains  of  Pul v.  Bad. 
Filicis  Maris  were  ordered  to  be  taken  night  and  morning.  No  more  worms,  how- 
ever, were  evacuated.  On  February  23d,  he  was  ordered  one-twelfth  of  a  grain  of 
strychnine  twice  a  day,  which  dose  was  increased  to  one-sixth  on  the  28th.  On  the 
1st  and  2d  of  March  he  was  awakened  several  times  during  the  night  by  startings  of 
the  limbs ;  and  he  stated  that  their  general  strength  was  diminished.  He  evidentlj- 
staggered  more  in  walking.  Galvanic  currents  were  then  ordered  to  be  passed  from 
the  spine  down  both  limbs,  under  which  treatment  he  continued  until  the  31st  of 
March,  when  being  in  no  way  better,  ho  was  discharged  as  incurable. 


Case  XXXV.* — Paraplegia — Chronic  Myelitis. 

History. — James  Roy,  a?t.  34,  a  tailor — admitted  September  20,  1847.  States 
that  about  three  months  ago,  he  first  observed  slight  unsteadiness  in  his  gait,  with  a 
feeling  of  coldness  in  his  lower  limbs,  which  gradually  increased.  About  a  month 
afterwards,  he  became  unusually  constipated,  with  a  want  of  power  of  expelling  the 
foeces  and  urine.  On  the  loth  feeling  unwell,  tliough  he  had  worked  all  day,  he 
retired  to  rest  earlier  than  usual,  but  feeling  uncomfortable,  he  got  up  and  found  he 
had  little  power  in  his  legs.  About  12  o'clock  that  night  they  became  completely 
insensible.  Next  morning  he  had  lost  the  functions  of  defoecation  and  micturition. 
A  medical  man  bled  him  largely,  removed  the  urine  by  catheter,  and  administered 
purgatives,  wliich  opened  the  bowels.  He  has  remained  in  the  same  situation  since, 
alwaj^s  feeling  great  faintness  on  a-ssuming  the  erect  posture. 

Symptoms  on  Admission. — All  the  parts  below  a  line  drawn  round  the  body  on 
a  level  with  the  nipples,  appear  to  be  perfectly  paralysed,  deprived  of  all  motility 
and  sensibility.  The  inferior  extremities  present  no  rigidity  whatever.  Only  the 
upper  half  of  the  chest  moves  during  respiration ;  the  lower  half  and  the  abdomen 
being  fixed.  There  is  retention  of  urine,  which  requires  to  be  drawn  off  by  cathe- 
ter ;  and  his  bowels,  whicli  are  very  costive,  are  opened  involuntarily  in  bed.  Has 
a  feeling  of  constriction  round  the  chest,  and  still  feels  faint  on  being  placed  in  the 
erect  position.  Temperature  of  the  body  everywhere  natural.  Pul.se,  90,  of  good 
strength.     Other  functions  normal. 

Progress  of  the  Case. — The  symptoms  underwent  no  change,  but  he  gradually 
became  weaker.  The  treatment  consisted  at  first  of  cupping  over  the  vertebra;, 
and  purgatives,  and  subsequently  of  the  iodide  of  potassium,  internally,  and  wine. 
October  I2th. — Diarrhoea  came  on  yesterday,  and  he  died  this  morning. 

Sectio   Cadavcris. — Twenty-Jive  hours  after  death. 

Spinal  Cord. — Permission  could  only  be  obtained  for  the  examination  of  this 
organ,  which  was  exposed  from  the  first  cervical  vertebra  downwards.     The  mem- 

*  Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


STRUCTUKAL   DISEASES   OF   THE   SPIXAL   CORD.  391 

branes  were  healthy.  Scarcely  any  arachnoid  fluid.  About  seven  inches  of  the 
cord  in  length,  corresponding  to  the  second  and  third  dorsal  vertebras,  felt  unusually 
soft.  Externally  the  softening  was  of  a  dirty  gray  color,  and  pultaceous  in  con- 
sistence, but  the  centre  was  quite  diffluent,  and  of  a  yellow  colour,  resembling  pus. 
Above  and  below  the  circumscribed  morbid  portion  the  cord  was  healthy.  No  dis- 
ease of  vertebras. 

Microscopic  Examination. — The  external  gray  softening  consisted  of  frag- 
ments of  the  nerve  tubes,  and  globules,  with  double  lines  of  various  sizes  and  forms, 
mingled  with  numerous  granule  cells  and  granules.  The  central  softening  consisted 
almost  wholly  of  numerous  granule  cells  and  fatty  molecules,  fragments  of  tubes 
being  comparatively  small  in  quantity. 

Commentary. — The  four  preceding  cases  present  the  same  disease 
in  different  stages,  that  disease  being  chronic  myelitis,  by  far  the  most 
common  lesion  of  the  cord  met  with.  Cases  XXXII.  and  XXXIII.  show 
the  occasional  good  effects  which  result  from  rest,  counter-irritation,  and 
supporting  the  nutrition  in  incipient  cases.  Bleeding  and  antiphlogis- 
tics  I  have  never  seen  beneficial,  but  frequently  injurious;  and  in  Case 
XXXV.  depletion  evidently  added  to  the  prosti'ation  of  the  patient. 
In  the  more  chronic  or  intense  cases,  nothing  but  palliatives  are  of  any 
service.  I  have  tried  galvanism  and  stiTchnine,  but  have  never  found 
them  of  any  avail  where  the  cord  was  undoubtedly  diseased.  Indeed, 
under  such  circumstances,  it  has  frequently  appeared  to  me  that  strych- 
nine i-enders  the  weakness  of  the  patient  greater,  as  in  Case  XXXIV. 
In  the  last  stages  of  the  disease,  if  chronic,  and  especially  if  sloughs 
have  formed  on  the  back,  our  whole  efforts  should  be  directed  to  luirse 
and  sustain  the  patient's  strength,  and  alleviate  the  symptoms  which 
arise  from  the  paralysed  condition  of  important  organs.  Hence  rest, 
nourishino-  diet,  and  tonics,  are  the  best  reniedies,  while  the  hydrostatic 
bed  and  every  other  contrivance  should  be  put  in  practice  to  remove 
pressure  from  the  depending  parts  of  the  body.  Mild  aperients  should 
be  employed  from  time  to  time  to  overcome  the  intestinal  torpor,  while 
bv  the  catheter  the  urinary  bladder  should  be  evacuated,  so  as  to  dimi- 
nish the  tendency  to  saline  precipitation  in  that  viscus,  and  its  subse- 
quent disorganization. 

I  have  given  phosphorus  in  seven  cases  of  paraplegia  from  chronic 
myelitis,  all  resembling  more  or  less  Case  XXXIV.,  in  the  form  of  phos- 
phuretted  oil  (4  gr.  of  phosphorus  dissolved  in  rj  of  olive  oil),  in  none 
of  these  cases  have  I  been  able  to  satisfy  myself  that  any  improvement 
was  occasioned.  I  commenced  with  three  drops  a  day,  which  were 
afterwards  cautiously  increased  to  ten,  and  in  one  case  to  fifteen  drops. 
But  these  large  doses  soon  induced  violent  nausea  and  vomiting,  and 
after  a  short  suspension  of  the  remedy,  I  have  continued  it  for  several 
Aveeks  in  doses  of  three  drops.  In  the  case  which  took  fifteen  drops 
thrice  daily  for  two  days,  the  phosphorus  was  excreted  by  the  lungs,  as 
the  breath  smelt  strongly  of  the  drug,  but  was  not  phosphorescent  at 
nio-ht — a  phenomenon  which  has  been  seen  by  some  physicians  who 
have  employed  it.  In  another  case,  that  took  ten  drops  thrice  one  day, 
a  large  amount  of  phosphate  was  passed  in  the  urine,  presenting,  under 
the  microscope,  beautiful  feathery  crystals,  which  disappeared  on  discon- 
tinuiuo-  the  drug.     From  the  trial  I  made  of  phosphorus,  it  seemed  to 


392  DISEASES   OF  THE   NEEVOUS  SYSTEM. 

me  of  little  benefit,  and  that  the  dose  of  phosphuretted  oil  should  never 
exceed  five  drops.  Even  this  amount  cannot  be  administered  for  any 
leno-th  of  time  without  deranginor  the  stomach. 

The  cord  undergoes  the  same  structural  changes  as  the  brain,  and 
after  death,  in  cases  of  true  myelitis,  exudative  softening  may  readily  be 
demonstrated  by  the  microscope.  (Sec  Fig.  106.)  Softening  from 
imbibition  of  serum,  however,  is  rare,  whilst  that  from  mechanical 
crushing  Avith  instruments  after  death  is  exceedingly  common,  and 
should  always  be  carefully  investigated  by  the  pathologist.  Spinal 
meningitis  and  hemorrhage  are  rare  diseases — the  former  generally 
resulting  from  an  extension  downwards  of  cerebral  meningitis.  I  have 
only  seen  one  case  of  spinal  hemorrhage,  and  that  occurred  in  the  sur- 
gical ward  of  Mr.  Miller.  It  occurred  in  a  woman,  who,  when  tipsy, 
was  kicked  by  her  husband  in  the  neck,  with  the  immediate  result  of 
paralysis  of  all  four  extremities,  and  of  the  trunk.  She  died  in  four 
days,  and,  opening  the  body,  I  found  a  clot  of  blood  the  size  of  a  pea  in 
the  centre  of  the  cord  immediately  below  the  medulla  oblongata,  oppo- 
site the  second  vertebra.  The  external  portion  of  the  cord,  and  the  ver- 
tebral bones,  were  unaftected.  On  microscopic  examination,  the  clot 
was  composed  of  recently  extravasated  blood  corpuscles,  surrounded  by 
mechanical  softenino-.* 


Case  XXXVI. f — Paraplegia — Tubercular  Caries  of   Dorsal    Vertebra — Myelitis — 
Puirrwnary  Tubercle. 

History. — William  "Walker,  set.  42,  mason — admitted  Oct.  17,  1850.  States 
that  for  upwards  of  twelve  years  he  has  suffered  from  occasional  cough,  usually 
dry,  accompanied  in  lower  and  middle  part  of  chest  with  pain,  extending  back  to 
the  dorsal  vertebrae.  The  pain  and  cough  have,  within  the  last  three  months, 
become  more  constant,  and  are  accompanied  by  nightly  persiDirations.  About 
fourteen  days  before  admission,  he  felt  a  prickling  and  coldness  in  the  feet,  and  an 
unsteadiness  in  walking,  especially  with  the  left  foot.  Two  days  before  admission, 
after  a  long  walk,  these  symptoms  were  augmented.  Since  then  they  have 
gradually  increased,  so  that  now  he  has  no  power  over  his  legs  beyond  bending  the 
knee  very  slightly.     Sensibility  of  the  integuments  not  impaired. 

STiiPTOits  ON  Admissiox. — On  admission,  looks  emaciated,  and  anxious.  Com- 
plains of  no  headache,  or  pain  in  spine,  save  between  the  shoulders.  He  cannot 
stand  without  support  and  when  he  tries  to  walk  he  staggers,  and  would  fall  if  not 
supported.  He  can  move  his  legs  in  bed  with  tolerable  fi-eedom ;  they  often  feel 
cold.  Superior  extremities  unaftected.  There  is  occasional  cough,  with  scanty 
expectoration.  On  percussion  no  dulness  is  perceptible,  on  either  side,  anteriorly. 
On  auscultation,  the  respiratory  murmurs  are  harsher  and  louder  than  natural  at 
apes  of  both  lungs.  The  urine  not  albuminous,  but  loaded  with  lithates,  and 
sometimes  voided  with  difficulty.     Other  ftinctions  healthy. 

Progress  of  the  C.a.se. — The  paralysis  in  this  man  gradually  increased.  He 
could  not  stand,  although,  when  in  bed,  he  could  shghtly  bend  the  knees  and  toes. 
Latterly  a  swelling  termed  over  the  lower  dorsal  and  upper  lumbar  vertebrae,  five 

*  An  interesting  case  of  true  spinal  hemorrhage,  with  an  account  of  all  the  known 
cases,  is  given  by  Dr.  Peddie.  Montlily  Journal  of  Med.  Science,  May  1847,  p.  819. 
f  Reported  by  Mr.  Sanderson,  Clinical  Clerk. 


STRUCTUEAL  DISEASES   OF  THE   SPINAL   CORD,  393 

inches  long  and  three  broad.  The  urine  became  loaded  with  phosphates,  and,  with 
the  foeces,  was  passed  involuntarily.  His  general  health  also  greatly  diminished, 
painful  twitchings  occurred  in  the  paralysed  limbs,  emaciation  became  extreme, 
the  cough  violent,  the  expectoration  copious.  Several  sloughs  formed  over  the  left 
and  right  hips,  notwithstanding  he  lay  on  a  water  bed,  and  every  care  was  taken  to 
prevent  them.  During  the  last  week  in  February,  and  two  first  weeks  in  March, 
an  abscess  formed  above  tiie  right  clavicle,  which  opened  spontaneousl}'  on  the 
15th  of  the  last-mentioned  month,  and  discharged  about  8  oz.  of  matter.  As  the 
respiratory  murmur  was  still  heard  at  the  apex  of  right  lung,  it  was  concluded 
that  the  abscess  originated  in  the  vertebral  column.  A  considerable  quantity  of 
pus  was  subsequently  discharged  daily,  being  forced  out  at  each  inspiration. 
March  2-i:th. — He  was  greatly  exhausted,  pulse  weak  and  irregular;  low  muttering 
delirium  at  night,  with  scarcely  strength  to  expectorate.  Died  the  same  evening. 
The  treatment  consisted  at  first  of  a  few  leeches  occasionally  applied  to  the  back, 
of  purgatives,  and  latterly  of  remedies  applicable  to  spinal  symptoms,  which  pro- 
duced merel}'  temporary  relief 

Sectio    Cadavet'is. — March  26. — Forty-two  hours  after  death. 

The  body  was  pale  and  greatly  emaciated. 

Over  the  left  hip  was  a  sloughing  sore,  measuring  seven  inches  in  its  longest 
diameter  from  above  downwards,  and  six  inches  across.  The  surface  irregular,  in 
some  places  an  inch  below  the  level  of  the  skin,  and  the  whole  covered  with  a  dirty 
greenish  ichorous  matter.  Over  the  right  hip  was  a  smaller  slough,  of  roundish 
form,  about  two  inches  in  diameter.  Over  the  vertebral  column,  between,  and 
somewhat  above  these  sloughs,  there  was  a  circumscribed  swelling,  of  an  oval  form, 
five  inches  long  and  three  inches  broad.  It  was  firm  and  dense  to  the  feel,  and  on 
section  was  found  to  consist  of  thickening  of  the  dermis  to  the  extent  of  three 
quarters  of  an  inch,  combined  with  oedematous  infiltration  of  the  cellular  tissue. 
Opposite  to  the  seventh  cervical  and  first  and  second  dorsal  vertebra?,  there  was  a 
slight  angular  curvature  of  the  spinal  column,  iu  the  centre  of  which  space  externally 
the  skin  presented  a  small  purplish  discoloration.  A  fistulous  opening,  the  size  of 
a  fourpenn}'  piece,  existed  about  two  inches  above  the  centre  of  the  right  clavicle. 
On  tracing  the  opening  inwards,  it  led  into  a  cavity  which  passed  behind  the  sub- 
clavian vein,  and  from  thence  backwards  to  the  tubercle  of  the  first  rib,  which  could 
be  felt  carious  and  rough,  and  from  thence  to  the  first  four  dorsal  vertebrre,  the 
bodies  of  which  bones  were  carious  throughout.  The  periosteum  had  separated 
from  the  diseased  bones,  and  formed  a  jDOUch  anteriorly,  filled  with  pus,  which  com- 
municated with  the  external  sinus.  On  examining  the  diseased  bones,  their  can- 
cellated structure  was  more  or  less  infiltrated  with  pus,  combined  with  soft  tubercular 
exudation.  The  posterior  lamina  of  the  first  dorsal  vertebrae  especiall}'  were,  from 
the  latter  cause,  of  cheesj'  consistence. 

Spixal  Cord. — The  membranes  were  healthy.  Externally  the  spinal  cord 
presented  no  appearance  of  disease.  On  making  a  longitudinal  section,  however, 
it  was  found  to  be  distmctly  softened  internally  an  inch  of  its  length,  opposite  the 
first  dorsal  vertebrae.  The  softened  white  structure  encroached  more  on  the 
anterior  white  matter  of  the  cord  than  posteriorlj",  and  it  was  of  a  light  fawn 
colour. 

Thorax. — The  pleurse  were  united  by  firm  adhesions  at  the  apices  of  both  lungs, 
and  also  over  the  middle  on  the  left  side.  At  the  apex  of  the  right  lung,  the  pleurse 
were  also  thickened  in  several  places,  presenting  a  white  appearance,  and  the  tissue 
of  the  lung  opposite  was  much  puckered.  On  section,  these  puckerings  were  found 
to  correspond  to  calcareous  concretions,  of  various  sizes,  around  which  numerous 


894  DISEASES   OF   THE   NERVOUS   SYSTEM. 

hard  miliary  tubercles,  of  a  slate  colour,  were  grouped.  Throughout  this  lung  were 
numerous  similar  tubercles,  mingled  with  black  pigment  deposits  and  calcareous 
masses,  varying  in  size  from  a  millet  seed  to  that  of  a  small  pea, — most  abundant, 
however,  at  the  apex  Similar  tubercles  existed  in  the  upper  lobe  of  left  lung; 
but  they  were  not  so  numerous.  The  bronchial  mucous  membrane  was  much 
congested ;  and  the  larger  bronchi  contained  copious  muco-purulent  fluid.  The 
bronchial  glands  were  of  black  colour,  and  here  and  there  loaded  with  calcareous 
matter. 

Abdominal  organs  healthy. 

Microscopic  Exajiination. — The  softened  portion  of  the  spinal  cord  consisted 
of  numerous  molecules  and  granules,  with  the  debris  of  the  varicose  nerve-tubes  of 
the  cord,  forming  globules  of  various  sizes  and  shapes,  of  the  white  substance 
of  Schwann.  Large  numbers  of  compound  granule  cells  and  masses  were  asso- 
ciated with  the  disintegrated  structures. 

Commevtary. — The  preceding  case  is  dependent  on  a  different 
pathological  cause,  and  presents  consequently  mai'ked.  variations  in  the 
symptoms  from  the  former  instances  of  paraplegia.  In  it,  pressure  was 
gradually  made  on  the  spinal  cord  from  without,  in  consequence  of 
scrofulous  caries.  The  anterior  columns  of  the  cord,  under  such  cir- 
cumstances, are  those  whicli  are  most  injured,  and  loss  of  motion  is  the 
leading  symptom.  In  Cases  XXXII.  to  XXXV.,  the  first  symptoms 
were  numbness  or  pricking  of  the  toes,  followed  by  perversion  or  irregu- 
larity, rather  than  loss  of  motion,  and  not  attended  with  spasms.  This 
condition  is  indicative  of  chronic  inliammation  of  the  cord  or  myelitis. 
Professor  Romberg  has  pointed  out  a  symptom  in  such  persons,  which 
he  considers  diagnostic  of  softening  of  the  gray  inatter  in  the  centre  of 
the  cord,  as  distinguished  from  lesion  of  the  white  matter.  This  con- 
sists in  ascertaining  that  a  man  cannot  stand  steadily  with  his  eyes 
shut.  This  symptom  was  well  marked  in  Cases  XXXIII.  and  XXXIV., 
and  slightly  in  Case  XXXIL,  while  everything  indicated  that  it  was 
not  so  much  the  conducting,  as  the  tonic  power,  which  was  wanting. 
These  considerations  induced  me  to  try  the  effects  of  strychnine,  which, 
however,  was  of  no  benefit  in  Case  XXXIIL,  and  in  Case  XXXIV.  in- 
creased the  irregular  movements  wheii  walking,  and  caused  loss  rather 
than  increase  of  power.  The  galvanic  currents,  which  were  subse- 
quently tried,  also  failed  in  producing  any  amendment.  In  Case 
XXXVI.  the  caries  of  the  spinal  column,  but  more  especially  the  dis- 
charge from  the  fistulous  opening,  produced  the  fiital  termination.  The 
tubercles  in  the  lung  were  all  in  a  chronic  condition,  and  although  they, 
combined  with  the  bronchitis,  account  for  the  cough  and  physical  signs, 
they  also  served  during  life  as  indications  of  the  kind  of  caries  present 
in  the  vertebral  column.  The  deformity  in  the  dorsal  region  was  only 
observable  a  few  days  before  death,  and  became  more  marked  after- 
wards. The  swelling  in  the  lumbar  region  was  a  singular  proof  of  the 
effects  occasionally  produced  by  deep-seated  sloughs  and  cicatrices,  in 
causing  local  hypertrophy  and  oedema. 

Scrofulous  or  tubercular  caries  of  the  bones  is  a  common  cause  of  para- 
plegia, and  considerable  difference  of  opinion  exists  as  to  its  mode  of  treat- 
ment. It  has  been  maintained,  for  instance,  that  caries  of  a  spongy  bone 
never  heals,  and  that  wdiere  it  can  be  reached,  the  only  remedy  is  excision. 


STRUCTURAL  DISEASES   OF   THE   SPIXAL   COED.  395 

But  it  has  frequently  happened  tliat  change  of  air  and  an  improved 
diet  have  led  to  the  most  happy  results,  and  that  the  caries  has  healed 
spontaneously.  Every  practitioner  of  experience  must  have  met  Avith 
cases  where  caries  and  distortion  of  the  vertebra?  have  terminated  in 
anchylosis,  and  the  patient  regained  his  health.  Many  dwaifs  are  living- 
examples  of  the  occui'rence  when  young  of  scrofulous  caries  in  the 
vertebral  bones,  which  had  disappeared,  leavino;  them,  although  deformed, 
quite  well.  The  theory,  therefore,  to  which  I  have  alluded  is  incorrect ; 
and  although  indirectly  it  has  led  to  many  improvements  in  surgery,  by 
caasing  excision  of  bones  and  joints,  instead  of  amputation  of  limbs,  or 
allowing  the  patient  to  sink  from  exhaustion,  there  can  be  no  doubt  that, 
notwithstanding,  many  cases  recover  under  a  proper  constitutional  treat- 
ment. Thus  I  have  seen^  some  remarkable  instances  of  caries  and 
distortion  of  the  vertebrae,  which  have  produced  perfect  paralysis, 
and  reduced  the  patient  to  a  great  state  of  weakness.  Under  such 
circumstances,  instead  of  confining  the  patient  to  bed,  under  the  idea 
that  the  weight  of  the  body  would  increase  the  curvature,  I  have 
recommended  moderate  exercise,  given  cod-liver  oil  and  nutrients,  and 
the  patient  has  ultimately  recovered.  During  a  visit  I  paid  to  Germany 
in  1846,  I  saw  in  the  wards  of  Professor  Heusinger  of  Marburg  three 
such  cases  at  once.  They  had  all  had  paraplegia.  The  one  most 
recently  treated  still  had  paralysis,  the  other  two,  who  had  been  under 
treatment  some  months,  had  recovered,  so  that  they  could  walk  without 
difficulty,  and  were  nearly  well.  I  saw  shortly  alter,  two  similar  cases 
in  the  wards  of  Professor  Jacks  of  Prague.  Ilence  I  am  satisfied  that 
our  treatment  in  all  such  cases  should  be  from  the  first  nutritive  and 
su])porting,  avoiding  depletion  and  lowoing  remedies,  and  insisting  on 
exercise  as  far  as  possible  by  walking  or  in  a  carriage.  In  this  way  not 
only  may  a  cure  be  eff"ectefl,  but  in  advanced  cases  hcaltli  maybe  sus- 
tained and  life  prolonged,  while  the  tendency  to  the  production  of  those 
sloughs  on  the  back,  which  so  commonly  hasten  the  fatal  result,  is  best 
prevented. 


Case  XXXVII.* — Paraplegia — Cancer  of  Vtrttbral  Bones — Softening  of  the  Cord 
from  Pressure — Cancer  of  Lung,  Liver,  and  Lumbar  Glands — Ulceration  of 
Urinary  Bladder, 

History.— Agnes  M'Guire,  tet.  60 — admitted  January  12th,  184:9.  "\Mth  the 
exception  of  two  attacks  of  fever,  bad  always  enjoyed  good  health  untQ  three  months 
ago,  when  she  was  seized  during  the  night  with  nausea,  vomiting,  and  purging. 
These  symptoms  continued  more  or  less  until  a  fortnight  since,  when  slie  first  became 
aware  of  a  feeling  of  coldness  in  the  lower  extremities,  especially  in  the  feet  and 
toes.  Six  days  ago,  on  waking  in  the  morning,  she  found  that  she  had  completely 
lost  all  power  over  the  lower  extremities,  and  had  a  feeling  of  great  weight  in  the 
haunches  and  lumbar  region. 

Syjiptoms  on  Admission. — There  is  great  emaciation.  The  countenance  is  expres- 
sive of  pain  and  anxiety.  Face  and  lips  pale  and  sallow.  Skin  cold  and  harsh. 
There  is  a  black  slough  about  three  inches  in  diameter  over  the  sacrum.  She  com- 
plains of  pain  m  the  breast,  chest,  and  back,  and  there  is  tenderness  over  the  abdo- 

*  Reported  by  Mr.   J.  X.  Fanning,  Clinical  Clerk. 


396  DISEASES   OF  THE   XERVOUS  SYSTEM. 

men  and  sides,  with  tympanitic  distension.  There  is  total  loss  of  motor  power,  and 
of  sensibility  from  tlie  haunches  downwards ;  but  on  pricking  the  soles  of  the  feet, 
slight  spasmodic  muscular  movements  occur.  All  attempts  to  move  the  body,  even 
by  others,  cause  great  pain,  especially  in  the  lumbar  regions.  Xo  cough  nor  expec- 
toration. Percussion  and  auscultation  over  the  anterior  surface  of  the  chest  eheit 
nothing  abnormal ;  the  posterior  surface  cannot  be  examined  in  consequence  of  tlie 
difficulty  of  moving  lier.  Heart  healthy  ;  tongue  furred;  appetite  irregular;  consi- 
derable thirst  and  occasional  nausea.  Has  passed  urine  and  fceces  involuntarily  since 
admission,  but  says  she  is  generally  costive.  Urine  abundant,  and  when  removed  by 
catheter,  is  of  a  brick  colour,  with  a  dark  sediment,  composed  of  amorphous  urates, 
triple  phosphates,  epithelial  cells,  and  blood  corpuscles.  It  is  readily  decomposed, 
and  has  an  ammoniacal  odour. 

Progress  of  the  Case. — This  woman  gradually  became  more  and  more 
exhausted.  The  slough  on  the  back  became  enlarged,  the  tympanitic  condition  of 
the  abdomen,  with  pain  there  and  in  the  back,  underwent  occasional  remissions,  but 
on  the  whole  never  left  her.  The  urine  could  never  be  passed  voluntarily,  and 
gradually  became  more  loaded  with  phosphates,  blood,  and  epithelial  cells,  and 
emitted  an  intolerably  foetid  odour.  Tlie  bowels  lor  some  time  were  constipated,  but 
diarriioea  ensued  shortly  before  death,  which  took  place  February  5tli.  The  treat- 
ment consisted  at  tirst  of  the  occasional  application  of  leeches  to  the  painful  portion 
of  the  vertebral  column,  but  they  never  caused  even  the  slightest  relief  The  con- 
stipation was  overcome  by  laxatives,  and  the  urine  frequently  drawn  off  by  catheter. 
The  slough  was  constantly  dressed  with  turpentine,  and  balsamic  ointments  and 
poultices,  and  pressure  removed  from  it  as  much  as  possible.  Warm  bottles  were 
frequently  applied  to  tiie  feet  and  lower  extremities,  but  they  could  never  overcome 
the  feeling  of  cold  which  prevailed.  Internally,  nutrients  with  wine,  and  latterly 
brandy,  were  given. 

Sectio  Cadaveris. — Twenty-five  hours  after  death. 

Head. — Erain  and  membranes  healthy. 

Spixal  Coli-jix. — The  bodies  of  the  eighth  and  ninth  dorsal  vertebras  were 
mucli  tliickened,  presenting  an  abrupt  swelling,  and  on  section  were  soft  from 
infiltration  of  encephaloma.  The  left  psoas  muscle  was  adherent  to  the  bodies  of 
the  diseased  vertebra?,  and  formed  witli  these  a  pultaceous  disorganized  mass,  con- 
sisting of  fatty  softened  muscle,  and  broken-down  cancerous  bone.  Tlie  body  of 
the  third  lumbar  vertebra  was  also  infiltrated  with  encephaloma. 

Spixal  Cord. — The  diseased  dorsal  vertebral  bones  had  encroached  consider- 
ably on  the  spinal  canal,  and  formed  somewhat  of  an  acute  angle  compressing  the 
cord,  which,  for  the  space  of  one  inch  opposite  them,  was  reduced  throughout  to  a 
pultaceous  consistence.  The  softening  was  white,  and  the  membranes  surrounding 
it  were  healthy. 

Chest. — In  the  left  auricle  of  the  heart  was  a  hemispherical,  flattened,  earthy 
concretion,  the  size  of  an  almond,  embedded  in  the  muscular  wall.  Heart  otherwise 
healthy.  Lungs  anteriorly  emphysematous.  The  left  lung  adherent  at  the  apex 
posteriorly,  on  separating  which,  half  of  the  upper  lobe  posteriorly  was  seen  to  be 
infiltrated  with  encephalomatous  exudation  of  a  dirty  white,  and  in  some  places  a 
light  pink  colour.  Throughout  other  portions  of  both  lungs,  nodules  of  similar 
encephaloma  were  disseminated,  varying  in  size  fi-om  a  pea  to  that  of  a  walnut,  and 
separated  by  perfectly  healthy  lung  tissue.  Bronchial  glands  of  a  blackish  colour, 
from  deposition  of  pigment,  but  not  cancerous. 

Abdomex. — The  liver,  kidneys,  and  lumbar  glands  were  studded  with  masses 
of  soft  cancer,  varying  in  size  in  the  first  named  organ  from  a  hazel  nut  to  that  of  a 


STRUCTUEAL   DISEASES   OF   THE   SPIXAL   COED.  397 

pigeon's  egg.  The  urinaiy  bladder  was  much  contracted  and  corrugated.  The 
inner  surface  was  rough,  in  consequence  of  red  bloody  projections  from  it,  varying 
in  size  from  a  millet  seed  to  that  of  a  pea.  In  other  places  there  were  injected 
rugje.  with  cracks  and  ulcerations  in  the  depressions,  and  considerable  depositions 
of  phosphatic  salts.  The  spleen  and  other  organs  healthy.  Considerable  tlatus  in 
the  large  intestines. 

Microscopic  Ex.i^nxATiON. — The  softened  spinal  cord  consisted  of  the  nerve 
tubes  broken  up  into  minute  fragments  of  various  shapes,  round,  oval,  tlask-sliaped, 
etc,  with  double  outlines,  mingled  with  a  multitude  of  fatty  molecules  and  granules. 
A  few  granule  cells  were  also  visible.  The  cancerous  masses  in  the  lung  presented 
broken-up  cancer  cells,  intermixed  with  nimierous  granule  cells  and  granular  mat- 
ter, as  in  the  Cancer  reiicidare  of  MuUcr.  In  the  liver,  more  characteristic  cell 
structures  were  found ;  still,  however,  here  and  there  mixed  with  retrograde  can- 
cerous masses  of  a  yellowish  colour.  In  the  bones  the  cancer-cells  were  large, 
many  of  them  containing  two  or  three  nuclei  undergoing  development. 

Commentary. — In  this  case,  encephaloma  of  various  internal  organs 
caine  on  slowly,  without  causing  any  distinctive  symptoms,  until  the 
enlargement  of  the  eighth  and  ninth  dorsal  vertebrae  from  cancerous 
infiltration,  by  pressing  on  the  spinal  cord,  occasioned  incipient  symp- 
toms of  paraplegia.  The  two  softened  vertebral  bones,  however,  sunk 
suddenly  inwards,  compressed  the  cord,  and  occasioned  in  the  night 
complete  paralysis,  followed  some  time  afterwards  by  ulceration  of  the 
bladder  and  sloughs  on  the  sacrum,  which  caused  her  death.  On  dis- 
section, the  bodies  of  the  two  vertebrje  were  seen  to  form  an  ano;le, 
compressing  the  cord,  which  was  afterwards  reduced  to  a  pulpy  con- 
sistence, and  entirely  disorganized. 

The  importance  of  rightly  understanding  the  pathology  of  struc- 
tural disease  of  the  spinal  cord  will  be  appreciated  on  retiectino;  that 
it  generally  induces  incurable  paralysis.  Its  extent  will  be  greater 
or  less,  according  as  the  lesion  involves  the  origin  of  a  greater  or 
smaller  number  of  nerves,  or  what  amounts  to  the  same  thing,  cuts  off 
their  intercourse  with  the  bi'ain.  The  recent  views  of  the  structure  of 
the  cord  (pp.  109,  110)  further  point  out  to  us,  that  disorganization 
of  the  grey  matter  not  only  diminishes  the  evolution  of  nervous  force, 
but  acts  directly  on  the  fibres  which  transmit  it  to  the  brain.  There 
is  every  reason  to  believe  that  these  fibres  not  onlv  decussate  in  the 
medulla  oblongata,  but  do  so  all  the  way  down  the  cord.  So  small, 
however,  is  this  latter  organ,  that  diseases  of  its  texture  usually  aftect 
both  halves,  and  occasion  eftects  on  both  sides  of  the  bodv,  whereas  it 
has  long  been  a  matter  of  observation,  that  a  lesion  on  one  side  of  the 
brain  causes  paralysis  only  on  the  opposite  side  of  the  body.  Hence,  in 
cases  of  hemiplegia,  the  disease  in  the  vast  majority  of  cases  is  refer- 
able to  the  opposite  hemisphere  of  the  brain,  more  especially  to  the 
cranial  portion  of  the  spinal  cord  above  the  decussation  in  the  medulla 
oblongata ;  whereas  paraplegia  is  as  frequently  found  to  depend  on 
disease  of  the  vertebral  portion  of  the  cord  below  that  decussation. 

A  very  few  cases  have  been  recorded,  however,  in  which  hemi- 
plegia has  occurred  on  the  same  side  as  a  lesion  found  in  the  brain 
after  death,  and  which  has  been  supposed  to  occasion  it.       Mr.  Hilton, 


398  DISEASES   OF  THE   NERVOUS  SYSTEM. 

indeed,  in  a  paper  read  before  tlie  Royal  Society  in  1837-38,  described 
a  disposition  of  fibres  whicli  he  thouglit  capable  of  explaining  such 
exceptional  cases.  These,  however,  are  so  rare,  that  it  can  scarcely 
be  supposed  to  arise  from  a  permanent  anatomical  arrangement,  and  it 
is  far  more  probable  that  even  in  them  there  is,  in  fact,  no  exception 
to  the  general  law.  Thus,  numerous  instances  have  occuried  of 
abscesses  softening  and  other  morbid  changes  having  been  found  after 
death,  but  in  which  there  was  no  paralysis  during  life ;  and  a  still 
greater  number  are  on  record,  in  which  there  was  well-marked  para- 
lysis during  life,  but  no  appreciable  change  in  the  structures  after 
death.  It  is  by  no  means  improbable,  therefore,  as  paralysis  may  be 
induced  without  leaving  any  traces,  that  in  these  few  cases  it  was 
caused  by  unknown  changes  in  the  opposite  hemisphere  of  the  brain  ; 
and,  as  is  sometimes  the  case,  that  the  lesion  found  in  the  hemisi)here 
of  the  paralysed  side  had  produced  no  efiect.  Such,  we  think,  is  the 
most  probable  explanation  of  these  exceptional  cases. 

In  the  vertebral  portion  of  the  cord,  although  the  general  rale  is, 
'  that  all  those  parts  are  paralysed,  furnished  by  nerves  coming  off  below 
the  seat  of  disorganization,  exceptional  cases  also  have  been  recorded. 
In  these  it  has  been  said  that  individuals  have  retained  the  power  not 
only  of  moving  the  lower  limbs,  but  of  walking,  notwithstanding  that 
the  spinal  cord  has  been  disorganized  throughout  its  entire  thickness. 
Every  one  accustomed  to  pathological  examinations  must  receive  with 
distrust  accounts  of  such  observations,  knowing  how  soon  this  portion 
of  the  nervous  system  may,  in  certain  cases,  become  softened  after  death, 
as  well  as  the  injuries  it  is  likely  to  receive  in  opening  the  vertebral 
canal.  Several  years  ago,  I  took  the  trouble  to  analyse  the  more  remark- 
able of  these  cases,  and  satisfied  myself  that  there  was  no  absolute  proof 
that  in  any  of  them  the  cord  was  wholly  destroyed  during  life. 

Thus,  in  the  celebrated  case  of  Desault  {Joiirn.  de  Chir.  de  Desault, 
tom.  iv.  p.  437),  the  appearance  of  the  parts  is  uot  described  :  it  is 
merely  stated,  "the  spinal  marrow  was  totally  divided  ;"  and  the  move- 
ments which  took  place  are  thus  narrated  : — "He  was  in  a  continual  agi- 
tation, and  moved  the  pelvis  and  inferior  extremities  even  to  the  last." 
In  all  tliis  there  is  nothing  decided.  May  not  the  movements  have  been 
excito-motory  ?  Was  the  altered  structure  well  observed  ?  Tlie  case  of 
M.  Kullier  {Journ.  de  Physiol.,  1823)  has  been  also  frequently  alluded 
to  in  connection  with  this  question.  It  was  that  of  a  gentleman  who 
hatl  complete  and  perfect  paralysis  of  the  arms,  without  loss  of  sensibi- 
lity and  motion  in  the  inferior  extremities ;  he  remained  in  this  state  six 
years,  and  died  of  pectoral  complaints.  Dr.  Abercrombie,  alluding  to  the 
case,  states  that  a  portion  of  the  cord,  six  inches  in  length,  occupying 
two-thirds  of  the  cervical  portion  and  part  of  the  dorsal,  was  entirely 
diffluent;  so  that,  before  the  membranes  were  opened,  it  moved  upwards 
and  downwards  like  a  fluid.  The  posterior  roots  of  the  nerves  of  this 
portion  preserved  their  nervous  matter  to  their  junction  to  the  mem- 
branes of  the  cord ;  but  in  the  anterior  roots  it  was  destroyed,  and  they 
were  reduced  to  an  empty  neurilemma.  [Abercrombie,  p.  350,  3d  edit.) 
This  writer  mentions  that  the  anterior  columns  were  completely  destroy- 
ed, and  others  in  alluding  to  the  case  have  thought  a  portion  of  the  cord 
was    entirely  disorganized.     The  case   itself  is  headed,    Disapjyearance 


FUXCTIOXAL   DISORDERS   OF   THE   NERVOUS   SYSTEM.       399 
(Disparition)  of  the  jVervoiis   Substance  of  the    Spinal  Marrow  in  the 


partie  antenenre  de  cette  por 
en  rapport  avec  les  racines  correspondantes  des  nerfs  spinaux;"  and 
ag;ain,  "  Cette  alteration  etait  beaucoup  raoins  sensible  lorsqu'on  regar- 
dait  la  moelle  par  sa  face  anterieure,"  etc.  From  this  it  would  appear 
that  certain  continuous  fibres  still  existed  in  the  anterior  columns,  al- 
thouo-h  they  were  seen  with  difficulty,  but  that  there  could  be  no  doubt 
many  existed  in  the  posterior.  The  persistence  of  voluntary  motion  and 
sensibility  in  the  inferior  extremities  under  such  circumstances,  when  the 
disease  too  was  chronic,  is  in  no  way  surprising. 

Instances  have  also  been  recorded,  in  which  balls  have  traversed  the 
vertebral  column  ;  or  swords  have  been  thrust  into  the  neck,  which  are 
said  to  have  entirely  cut  across  the  spinal  cord,  without  being  followed  by 
paralysis.  We  cannot  here  enter  into  the  analysis  of  these  cases,  but  those 
who  "choose  to  do  so  will  readily  come  to  the  conclusion,  that  no  positive 
proof  exists  that  the  cord  was  wholly  destroyed  during  life.  On  the 
other  hand,  without  throwing  any  doubts  on  the  accuracy  of  the  ob- 
servations which  have  been  made,  may  we  not  consider  that  the  com- 
plete destruction  which  has  been  described,  is  in  some  degree  a  post- 
mortem appearance  caused  by  partial  softening  of  the  cord,  mixing  after 
death,  perhaps,  with  the  serous  fluid  always  present  ?  Is  it  not  probable 
that  the  necessary  violence  in  opening  the  vertebral  canal  may  have 
broken  across  the  fibres,  which  during  life  were  entire  ?  Again,  may 
not  tiie  movements  described  in  many  cases  have  been  excito-motory  ? 
At  all  events  we  consider  that,  in  the  present  state  of  science,  such  views 
are  much  more  rational  than  to  suppose  that  the  influence  of  volition 
can  leap  over  four  or  five  inches  of  disorganized  spinal  cord  in  order  to 
reach  the  inferior  extremities,  or  that  impressions  made  on  the  latter  can 
be  communicated  to  the  brain  by  other  channels  than  the  nervous  sys- 
tem.* 


FUNXTIOXAL  DISORDERS   OF  THE  XERVOTJS  SYSTEM. 

Case  XXXYIILf — Partial  Amaurosis — Spectral  IlUsions—Ptrversioiis  of  Btaring, 
SmeU,  and  Touch — Sinnal  Irritation. 

History. — Mrs.  M'Kenzie,  ret.  35 — admitted  December  30,  1850.  Has  been 
travelling  companion  to  a  lady,  and  always  been  a  delicate  and  highly  nervous  per- 
son. Nine  years  ago  she  had  rheumatic  fever,  and  twelve  months  afterwards  her 
sight  became  unpaired,  owing,  she  supposes,  to  too  much  reading  at  night  with  gas 
light.  For  this  she  was  freely  bled  and  blistered,  and  was  subjected  to  a  long  anti- 
phlogistic treatment  by  an  oculist,  %vilhout  benefit.  About  the  same  period  the 
menses  became  irregular,  leucorrhoea  was  established,  and  there  was  great  spinal 
irritation.     For  these  latter  complaints  I  prescribed  for  her  several  times,  and  getting 

*  See  the  Author's  Article  on  Paralysis,  Library  of  Medicine.     Tol.  ii. 
f  Eeported  by  Mr.  Henry  Thorn,  Clinical  Clerk. 


400  DISEASES   OF   THE   NERVOUS   SFSTEM, 

better,  she  went  to  Canada.  From  thence  she  returned  four  months  ago,  and  feehng 
weak,  the  menstrual  discharge  also  having  been  excessive  daring  the  last  four 
months,  she  entered  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  she  complains  of  headache,  and  i^ain  in 
the  epigastrium,  darting  round  the  left  side,  and  extending  to  the  back.  Pressure 
over  the  fourth  and  tifth  dorsal  vertebrse,  corresponding  to  the  painful  part,  causes 
acute  pain.  There  is  also  slight  tenderness  over  the  lower  lumbar  vertebrae.  The 
let\  pupil  is  slightly  dilated,  and  vision  is  much  impaired.  She  does  not  look  straight 
forward  at  any  object  placed  before  her :  both  eyes  being  turned  to  the  left  of  it,  al- 
most at  right  angles.  She  is  much  troubled  with  ocular  spectra.  She  thinks  she 
sees  wild  animals,  flower  gardens,  oil  paintings,  and  children  dancing  before  her, 
dressed  in  clothes  of  various  colours.  She  frequently  experiences  noises  in  the  ears, 
and  especially  one  like  the  ringing  of  a  small  hand-beU.  The  sense  of  smell  is  also 
perverted ;  a  box  of  strong  snuff"  for  instance,  when  placed  below  her  nose,  having 
apparently  the  odour  of  tea.  The  sense  of  taste  is  not  altered.  The  sense  of  touch 
is  capable  of  being  perverted  by  suggestive  ideas.  On  placing  a  cold  piece  of  metal 
in  her  hand,  and  telling  her  it  was  warm,  she  declared  that  it  was  so.  Voluntary 
motion  is  also  impaired.  On  being  addressed  suddenly  she  starts ;  and  on  endea- 
vouring to  grasp  an  object,  makes  several  ineffectual  efforts  to  do  so.  At  the  same 
time,  there  is  considerable  tremor  and  twitchings  of  the  muscles  of  both  arms. 
There  is  also  great  difficulty  in  walking,  from  a  sense  of  being  pressed  down  by  a 
heavy  weight  placed  on  her  shoulders.  The  tongue  is  pale,  furred,  and  cracked ; 
there  is  an  acid  taste  in  the  mouth,  frequent  slight  difficulty  of  deglutition,  and  occa- 
sional vomiting  about  half  an  hour  after  taking  solid,  but  not  liquid,  food.  The 
bowels  are  opened  verj-  irregularh^,  and  there  is  general  constipation.  The  urine 
has  a  specific  gravity  of  1005 — not  coagulable.  The  menstruation  is  hregular,  and 
has  been  latterly  profuse.  During  the  last  six  months  it  has  appeared  five  times. 
In  the  intervals,  there  is  abundant  leucorrhcea.  On  examination  with  the  speculum, 
the  OS  and  cervix  uteri  were  found  tumefied.  There  was  no  ulceration,  but  copious 
discharo-e  of  purulent  matter  from  the  os  uteri.  The  sounds  of  the  heart  are  natural. 
Pulse  60,  soft.  Other  organs  healthy.  A  tejnd  bath  was  ordered  every  morning. 
To  use  also  a  vaginal  injection  of  one  drachm  of  alum  to  eight  ounces  of  ivater ;  and 
to  have  the  following  mixture :  5  Fe^-ri  Citratis,  3  ss ;  TV.  Card.  Comp.  §  j ;  Tr.  Au- 
rantii  3  ss ;  Infm.  Columb.   §  iv  5. :  M. ;  3  ss  to  6e  taken  three  times  a  day. 

Progress  of  the  Case. — Under  this  treatment,  and  with  an  occasional  laxative, 
her  general  health  greatly  improved.  The  menorrhagia  ceased.  The  headache 
diminished;  the  appetite  improved.  The  spectral  and  aural  illusions  ceased  to 
appear,  and  on  the  19th  of  February  she  insisted  on  going  out. 

Commentary. — In  this  case,  conjoined  with  spinal  irritation,  there  was 
imperfect  amaurosis,  one  point  of  each  retina  only  retaining  its  sensibility 
to  lio-ht,  which  point  she  brought  into  the  axis  of  vision,  by  directing 
botli  eyes  to  the  left  of,  and  at  right  angles  with,  the  object  examined. 
"With  the  exception  of  taste  also,  all  the  other  senses  were  more  or  less 
perverted.  At  the  same  time,  the  digestive  and  nterine  functions  were 
much  disordered  ;  and  it  was  observed  in  this,  as  it  has  been  in  numerous 
similar  cases,  that,  as  her  general  strength  improved  and  the  dyspnoea 
and  menorrhagia  diminished,  so  did  the  spectral  and  aural  illusions  and 
other  perversions  of  the  nervous  system  disappear.  This  fact  points  out 
how  cautiously  the  treatment  of  these  cases  should  be  conducted  in  the 
first  instance,  and  how  dangerous  the  bleedings,  cuppings,  purgings,  mer- 
curials, etc.  etc.,  must  be  in  certain  cases  of  incipient  amaurosis,  when 


FUXCTIOXAL   DISORDEES   OF   THE   NERVOUS   SYSTEM.      401 

tliese  are  practised  (as  tliey  too  often  are)  without  discrimination  or 
reference  to  the  constitutional  powers  of  the  patient. 

Another  curious  phenomenon  was  observed  in  this  case — namely,  that 
her  sensations  were  capable  of  being  governed  to  a  certain  extent  by 
sugorestive  ideas.  That  is  to  say,  on  calling  attention  to  a  particular 
object  placed  in  her  hand,  and  asserting  that  it  was  hot  or  cold  (although 
in  realitv  it  was  neither),  corresponding  sensations  were  produced  in  her 
mind.  This  peculiar  condition  of  the  nervous  system  is  one  which,  it 
appears  to  me,  is  more  deserving  the  attention  of  medical  men  than  they 
have  hitherto  paid  to  it.  It  is  well  known  to  numerous  charlatans,  who 
have  ascribed  the  phenomena  so  produced  to  an  external  power  or  force, 
which  thev  could  wield  at  pleasure.  Such  ideas  have  done  much  to 
shock  the  minds  of  physiologists  and  medical  men,  and  prevent  the 
proper  appreciation  of  many  important  facts.  Believing,  however,  that 
these  facts  are  capable  of  "being  explained  on  physiological  principles, 
and  are  capable  of  being  rendered  serviceable  in  practical  medicine,  I 
would  direct  your  attention  to  them  in  a  special  manner.  (See  p.  292, 
et  seq.)  In  no  case  I  ever  saw  was  the  inutility  of  antiphlogistics,  mer- 
cnrv,  and  other  modes  of  active  treatment  better  demonsti'ated,  even  to 
relieve  the  amaurosis,  for  which  they  were  used.  In  fact,  not  only  the 
disorder  of  the  retina  increased,  but  so  much  was  the  weakness  aug- 
mented, as  apparently  to  induce  almost  every  other  form  of  nervous  dis- 
order. On  admission  to  the  house  her  condition  was  pitiable,  and  from 
this  she  was  restored  by  rest,  good  diet,  chalybeates,  cheerful  conversa- 
tion, and  confident  predictions  of  her  recovery,  which  e\-idently  had  a 
powerful  influence  in  calming  her  mind,  and  diminishing  the  nervous 
symptoms. 

The  functional  derangements  of  the  nervous  system  are  capable  of 
assuming  at  various  times  every  conceivable  disorder  of  intelligence,  sen- 
sation, and  motion,  so  that  not  only  may  all  kinds  of  diseases  which 
have  received  names  be  simulated,  but  the  symptoms  may  be  so  cui'i- 
ously  combined  as  to  set  all  arbitrary  nosological  classification  at  defiance. 
If  it  be  farther  remembered  that  through  the  brain,  spinal  cord,  and 
nerves,  the  functions  of  every  organ  in  the  body  may  be  more  or  less 
influenced,  the  endless  variety  of  local  as  well  as  of  general  derange- 
ments will  readily  be  imagined.  To  illustrate  each  of  these  numerous 
forms  of  disease  by  cases  is,  in  a  clinical  course,  impossible ;  although 
the  wards  always  present  a  variety  of  examples  of  perverted  nervous 
function.  I  shall  content  myself,  therefore,  with  giving  a  classified  enu- 
meration of  these  disorders,  and  then  dwelling  more  especially  on  their 
pathology  and  treatment. 

The  functional  disorders  of  the  nervous  system  may  be  classified  into 
— 1st,  Cerebral ;  2d,  Spinal;  3d,  Cerebro-spinal ;  4th,  Neural;  and  5th, 
Neuro-spinal ;  according  as  the  brain,  spinal  cord,  or  nerves  are  aff"ected 
alone,  or  in  combination.  Aberrations  of  intellect  always  depend  on 
cerebral  disturbance ;  while  perversions  of  motion  and  sensibility,  if 
extensive,  indicate  spinal ;  and  if  local,  neural  disorder.  Thus  insanity 
and  apoplexy  are  cerebral ;  tetanus  and  chorea,  spinal ;  epilepsy  and 
catalepsv  are  cerebro-spinal ;  neuralgia  and  local  paralysis  are  neural ; 
and  all  combined  spasms,  dependent  on  diastaltic  or  reflex  actions,  are 

26 


402  DISEASES   OF   THE   NERVOUS   SYSTEM. 

neuro-spinal.  The  following  enumeration  of  nervous  disorders,  with  the 
meanings  that  ought  to  be  attached  to  them,  will  at  the  same  time  serve 
the  purposes  of  definition  and  of  nosological  distinctions. 


Classification  of  Functional  Nervous  Disorders. 

I. — Cerebral  Disorders,  in  luhich  the  cerebral  lobes  (or  brain  proper) 
are  affected. 

1.  Insanif)/,  or  mental  aberration  in  its  various  foims,  not  organic, 

including  delirium. 

2.  Headache    and    other    uneasy    sensations   within  the  cranium, 

such  as  lightness,  heaviness,  veitigo,  (tc,  ttc. 
.3.  Apoplexy.  Sudden  loss  of  consciousness  and  of  voluntary  motion 
commencing  in  the  brain.  The  absence  of  consciousness 
necessarily  involves  that  of  sensation.  The  same  condition 
as  regards  nervous  phenomena  exists  in  syncope  and  asphyxia, 
but  the  first  of  these  commences  in  the  heart,  and  the 
second  in  the  lungs.  Allied  to  apoplexy  is  coma  or  stupor, 
arising  ft-om  various  causes  atiecting  the  brain,  such  as  pres- 
sure, or  poisonous  agents  like  alcohol,  chloroform,  opium, 
etc.,  etc. 

4.  Trance,  or  prolonged  somnolence,  either  with  or  without  per- 

version of  sensation  or  motion.  To  this  state  is  allied 
ecstasy,  or  unconsciousness  with  mental  excitement. 

5.  Irregular  motions,  spasms,  etc.,  originating  in  excited   or  dimi- 

nished voluntary  power,  as  in  certain  cases  bf  dominant 
ideas,  somnambulism,  saltatory  movements,  tremors,  etc.,  or 
on  the  other  hand  incajyability  of  movement  from  languor, 
surprise,  mental  agitation,  etc.,  etc. 


II. — Spinal  Disorders,//*  lohich  the  cranial  and  vertebral  pjortions 
of  the  spnnal  cord  are  affected. 

1.  Spinal  irritation.   Pain  in  the  spinal  column,  induced  or  increased 

by  pressure  or  percussion,  often  associated  with  a  variety  of 
neuralgic,  convulsive,  spasmodic,  or  paralytic  disorders, 
aflfecting  in  different  cases  all  the  organs  and  viscera  of  the 
body,  and  so  giving  rise  to  an  endless  number  of  morbid  states. 

2.  Tetanus.     Tonic  contraction  of  the  voluntary  muscles.      Tris- 

mus, if  confined  to  the  muscles  of  the  jaws.  Ojnsthotonos, 
if  afi'ecting  the  muscles  of  the  back,  so  as  to  draw  the  body 
backwards.  Emp>rosthotonos,  if  affecting  the  mnscles  of 
the  neck  and  abdomen,  so  as  to  draw^  the  body  forwards  ; 
and  Fleurosthotonos,  if  affecting  the  muscles  of  the  body 
laterally,  so  as. to  draw  the  body  sideways. 

3.  Chorea.     Irregular  action  of  the  voluntary  muscles,  when  stimu- 

lated bv  the  will. 


FUNCTIONAL   DISOEDERS   OF   THE   NERVOUS   SYSTEM.      403 

4.  Hysteria.     Any  kind  of  perverted  nervous  function,  connected 

with  uterine  derangement.  Nothing  can  be  more  vague 
than  this  term. 

5.  Hifclrophobia.    Spasms  of  tlie  muscles  of  tlie  pharynx  and  chest, 

with  difficulty  in  drinking  and  dread  of  fluids. 

6.  Spasms  and  convulsions.     Tonic  and  clonic  contractions  of  the 

muscles  of  every  kind  and  degree,  not  included  in  the 
above,  orioinating  in  the  cord  (centric  spinal  diseases  of 
Marshall  Hall). 

7.  Hemiplegia.     Paralysis  of  a  lateral  half  of  the  body,  generally 

dependent  on  disorders  of  the  cranial  portion  of  the  spinal 
cord  above  the  decussation  in  the  medulla  oblongata. 

8.  Paraplegia.     Paralysis    on  both   sides   of  the  body,  generallv 

the  lower  haltj  in  consequence  of  disorder  of  the  vertebral 
portion  of  the  spinal  cord,  below  the  decussation  in  the 
naeduUa  oblono-ata. 


III. — Cerebro-Spinal  Disorders,  in  zvhich  the  cerebral  lobes  and  sjii- 
nal  cord  are  both  affected. 

1.  Epihpsi/.     Loss  of  consciousness   with  spasms  or  convulsions 

occurring  in  paroxysms.     Apoplexy  with  convulsion  or  para- 
lysis is  also  cerebro-spinal,  though  generally  organic. 

2.  Catalepsy.      Loss    of    consciousness,  with    peculiar    rigidity  of 

muscles,  so  that  w'hen  the  body  or  a  limb  is  placed  in  any 
position  it  becomes  fixed. 

3.  Hclampsia.     Tonic  spasms,  with  loss  of  consciousness  in  infants. 

The  acute  ejiilepsy  of  some  Avriters. 


IV. — Neural  Disorders,    in  which  the  nerves   are  affected   during 
their  course  or  at  their  extremities. 

1.  Neuralgia.     Pain  in  the  course  of  a  nerve,  although  in  fact  all 

kind  of  pain  whatever  is  owing  to  irritation  of  the  nerves. 
Thus  the  sympathetic  system  of  nerves  and  its  ganglia, 
though  ordinarily  giving  rise  to  no  sensation,  may  occasion- 
ally do  so,  as  in  angina  pectoris,  colic,  irritable  testicle,  and 
uterus,  and  other  agonizing  sensations,  referred  to  various 
organs. 

2.  Irritation  of  the  nerves  of  special  sense.     Of  the  optic,  causing 

fashes  of  light,  ocular  spectra,  muscce  volitantes,  colour 
blindness,  etc. ;  of  the  auditory,  causing  tinnitus  aurimn  ; 
of  the  olfactory,  causing  unusual  sensitiveness  to  odours ; 
and  of  the  gustatory,  causing  perverted  tastes  in  the  mouth. 
Itching,  formication,  and  other  sensations  referable  to  the 
peripheral  nerves,  also  belong  to  this  class. 

3.  Irritation  of  special  nerves  of  motion,  as  in  local  spasms  of  one 

or  more  muscles,  or  of  the  hollow  viscera. 


404  DISEASES  OF  THE  KEEVOUS  STSTEil. 

4.  Local  Paralysis.  Loss  of  motion  or  sensibility  in  a  limited  part 
of  the  bodv,  or  confined  to  a  special  sense,  as  in  lead  palsy, 
or  in  amaurosis,  cojjhosis,  anosinia,  ageustia,  ancesthesia. 


V. — Necro-Spixal  Disorders,  in  tvhich  both  the  nerves  and  s^nnal 
cord  are  affected. 

1.  Diastaltic  or  reflex  actions.  To  this  class  belong  all  diseases 
depending  on  irritation  of  the  extremity  of  a  sensitive  nerve, 
acting  through  the  cord  and  motor  nerves  on  the  muscular 
system,  and  producing  a  variety  of  spasmodic  disorders, 
local  or  general,  far  too  numerous  to  mention, — -nhich  can 
only  be  understood  by  a  thorough  knowledge  of  the  physio- 
logy of  the  diastaltic  or  excito-motory  system  of  nerves. 


Pathology  of  Functional  Nervous  Disorders. 

Bv  the  term  functional  disorder  of  the  nervous  system,  I  understand 
one  which  may  produce  the  greatest  pain,  spasm,  paralysis,  and  even 
death,  and  yet,  on  the  most  careful  examination  afterwards,  assisted  by 
the  most  minute  researches  with  the  aid  of  the  microscope,  not  the 
slightest  change  from  the  normal  structure  of  the  nervous  tissue  can  be 
observed.  Such  is  what  occurs  in  all  the  disorders  we  have  named,  some 
of  them,  moreover,  almost  always  fatal,  such  as  tetanus  and  hydrophobia. 
At  the  same  time  it  must  not  be  forgotten,  that  similar  phenomena  may 
be  the  result  of  structural  disease  of  the  nervous  system.  Thus  tetanic 
rigidity  may  depend  on  a  spinal  arachnitis,  as  well  as  on  the  irritation 
from  a  wound,  or  poisoning  by  strychnine,  and  delirium  and  coma  may 
be  caused  by  cerebral  meningitis,  as  well  as  by  moral  insanity,  starva- 
tion, or  poisoning  by  chloroform  or  opium.  ^Yhetber  in  these  cases 
there  be  in  fact  only  one  cause  common  to  the  whole,  it  is  difficult  to 
say,  certainly  it  cannot  be  demonstrated.  It  might  be  contended  that 
in  every  instance  there  is  a  certain  amount  of  congestion  producing 
unaccustomed  pressure,  or  that  a  peculiar  state  of  nutrition  of  the  part 
is  momentarily  produced  here  or  there  in  the  nervous  mass.  But  as 
neither  theory  appears  to  us  applicable  to  all  cases,  we  shall  consider 
the  pathological  causes  of  functional  nervous  disorders  as  of  three  kinds 
— 1st,  Congestive;  2d,  Diastaltic;    3d,  Toxic. 

Congestive  Disorders  of  the  Nervous  System. — I  have  previously  pointed 
out  the  peculiar  nature  of  the  circulation  within  the  cranium  and  verte- 
bral canal,  and  shown  that,  although  well  defended  under  ordinary  cir- 
cumstances against  any  mischievous  change,  still  when  such  change 
does  occur  it  operates  in  a  peculiar  manner.  (See  p.  115,  e<  se^r.)  In 
other  words,  so  long  as  the  bones  are  capable  of  resisting  atmospheric 
pressure,  although  the  amount  of  fluid  within  these  cavities  cannot 
change  as  a  whole,  yet  the  distribution  of  that  amount  may  vary  infi- 
nitely. Thus,  by  its  being  accumulated  sometimes  in  the  arteries,  at 
other  times  in  the  veins,  or  now  in  one  place  and  then  in  another,  unac- 
customed pressure  may  be  exercised   on  ditferent  parts  of  the  nervous 


FUNCTIONAL   DISORDERS   OF   THE   NERVOUS   SYSTEM.      405 

centres.  This,  according  to  its  amount,  may  either  irritate  or  suspend 
the  functions  of  the  parts,  a  fact  proved  by  direct  experiment,  as  well 
as  by  innumerable  instances,  where  depression  of  bone  has  caused  ner- 
vous phenomena,  which  have  disappeared  on  removal  of  the  exciting 
cause.  That  congestion  does  frequently  occur  in  the  brain  and  spinal 
cord  there  can  be  no  doubt,  although  it  cannot  always  be  demonstrated 
after  death.  The  tonic  contraction  of  the  arteries  is  alone  sufficient  to 
empty  them  of  their  contents,  and  turgidity  of  the  veins  may  or  may 
not  remain  according  to  the  symptoms  immediately  preceding  death,  and 
the  position  in  which  the  body  is  placed.  But  it  is  observable  that  all 
causes  which  excite  or  diminish  the  action  of  the  heart  and  general 
powers  of  the  body,  induce  at  the  same  time  nervous  disturbance,  by 
occasioning  a  change  of  circulation  in  the  cerebrospinal  centres — such 
as  the  emotions  and  passions,  plethora  and  anemia,  uterine  derangement, 
etc.,  etc. 

It  is  only  by  this  theory  that  we  can  understand  how  such  various 
results  occasionally  occur  from  apparently  the  same  cause,  and  again 
how  what  appear  to  be  different  causes  produce  similar  effects.  Thus 
violent  anger,  or  an  unaccustomed  stimulus  may,  in  a  healthy  person, 
induce  a  flushed  countenance,  increased  action  of  the  heart,  a  bound- 
ino-  pulse,  and  sudden  loss  of  consciousness.  Again,  fear  or  exhaustion 
may  occasion  a  pallid  face,  depressed  or  scarcely  perceptible  heart's 
action,  feeble  pulse,  and  also  loss  of  consciousness.  In  the  first  case,  or 
coma,  there  is  an  accumulation  of  blood  in  the  arteries  and  arterial  capil- 
laries, and  a  corresponding  compression  of  the  veins;  in  the  second 
case,  or  syncope,  there  is  distension  of  the  veins  and  venous  capillaries, 
with  proportionate  diminution  of  the  calibre  of  the  arteries.  In  either 
case,  owinof  to  the  peculiarity  of  the  circulation  within  the  cranium, 
pressure  is  exerted  on  the  brain.  Hence  syncope  diti'ers  from  coma 
only  in  the  extreme  feebleness  of  the  heart's  action,  the  cause,  produc- 
ino-  loss  of  consciousness,  sensation,  and  voluntary  motion,  being  the 
same  in  both.  Indeed,  it  is  sometimes  difficult  to  distinguish  these 
states  from  each  other,  and  that  they  have  frequently  been  confounded 
does  not  admit  of  doubt. 

In  the  same  manner,  partial  congestions  from  either  cause  may  occur 
in  one  hemisphere,  or  part  of  a  hemisphere,  in  the  brain,  or  in  any  par- 
ticular portion  or  segment  of  the  spinal  cord.  The  pressure  so  occa- 
sioned may  irritate  and  excite  function,  or  may  paralyse  or  suspend  it; 
nay,  it  may  so  operate  as  to  suspend  the  function  of  one  part  of  the  ner- 
vous system,  while  it  exalts  that  of  another.  Thus  all  the  phenomena 
of  epilepsy  are  eminently  congestive,  the  individual  frequently  enjoying 
the  most  perfect  health  in  the  intervals  of  the  attack,  although  the 
effects  are  for  the  time  terrible,  causing  such  pressure  that,  while  the 
cerebral  functions  are  for  the  time  annihilated,  the  spinal  ones  are  vio- 
lently excited.  In  the  same  manner  are  explained  all  the  varied  phe- 
nomena of  hvsteria  and  spinal  irritation,  for  inasmuch  as  the  spinal  cord 
furnishes,  directly  or  indirectly,  nerves  to  every  organ  of  the  body,  so 
congestion  of  this  or  that  portion  of  it  may  increase,  pervert,  or  dimi- 
nish the  functions  of  the  nerves  it  gives  off,  and  the  organs  which  they 
supply.  Congestion,  therefore,  we  conceive  to  be  the  chief  cause  of 
functional  nervous  disorders  originating  in  the  great  cerebro-spinal  centre. 


406  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Diastultic  or  Rejlcx  Disorders  of  the  Nervous  System. — We  have 
previously  seen  that  recent  researches  render  it  probable  that  the  actions 
hitherto  denominated  retiex  are  in  fact  direct  (p.  Ill),  only  that 
the  impression  wliich  is  conveyed  commences  in  the  circumference  of 
the  body,  instead  of  in  the  nervous  centres.  There  is  ever}'  reason  to 
believe  that  such  impressions  pass  through  the  cord  by  means  of  con- 
ducting nerve  fibres,  which  cross  from  one  side  of  that  organ  to  the 
other,  and  that  histology  will  yet  demonstrate  that  all  these  apparently 
confused  actions  are  dependent  on  the  existence  of  certain  uniform 
conducting  media.  Indeed,  already  we  can  judge  with  tolerable 
exactitude,  from  the  effects,  what  are  the  particular  nerves  and  segments 
of  the  cord  which  are  influenced  dui'ing  a  variety  of  actions ;  and  not- 
withstanding the  immense  difficulties  of  the  inquiry,  we  have  every 
hope  that  the  period  is  not  distant  when  the  diagnosis  of  many  more 
reflex  acts  will  also  be  rendered  certain.  The  principle  involved  in 
all  these  acts  is,  that  the  irritation  which  produces  them  is  to  be  sought 
for  in  the  nervous  extremities  rather  than  in  lesions  of  the  centres ; 
and  the  great  importance  of  this  principle  in  pathology  and  in  prac- 
tice cannot  be  too  highh'  estimated,  although  for  the  numerous  details 
which  illustrate  it,  I  must  refer  to  physiological  works,  and  especially 
to  those  of  Dr.  Marshall  Hall.  I  would  point  to  traumatic  tetanus 
and  to  the  convulsions  resulting  from  teething  and  gastric  derangements 
in  children,  as  good  examples  of  diastaltic  functional  disorders. 

In  addition  to  important  diseases  of  this  kind,  numerous  symptoms 
which  accompany  organic  changes  belong  to  the  same  category.  In 
other  words,  the  structural  lesion  constitutes  the  irritant,  or  cause, 
Avhile  the  effect  is  functional.  Thus  I  have  seen  epileptic  opisthotonos, 
after  resisting  for  yeal's  every  kind  of  remedy,  at  once  removed  on 
extracting  a  decayed  tooth.  In  the  case  of  Joanna  M'Gregor,  admitted 
Dec.  4th,  1856,  there  was  hystei'ical  epilepsv,  which  resisted  all  treat- 
ment, and  among  the  rest,  a  long-continued  use  of  the  bromide  of 
potassium,  recently  recommended  by  Sir  Charles  Locock  in  such  cases. 
The  attacks  of  universal  rigidity,  with  tremor  and  complete  uncon- 
sciousness, usually  lasted  from  three  to  four  hours.  It  was  observed, 
however,  that  immediately  before  coming  out  of  the  attack  she  was 
seized  with  suffocative  cough,  accompanied  by  great  turgidity  and 
redness  of  the  face.  It  was  thought  that  by  exciting  such  cough 
artificially,  the  attacks  might  be  shortened.  Galvanism  was  in  con- 
sequence applied  to  the  larynx  the  moment  she  was  seized,  with  the 
effect  of  at  once  exciting  cough,  flushing  of  the  face,  and  immediate 
recovery.  In  this  case,  the  spasm  of  the  larynx,  which  was  an  excito- 
motory  act,  by  pi'oducing  a  change  in  the  circulation  within  the  cranium, 
dispelled  the  congestion  causing  the  epileptic  paroxysm. 

Again,  those  compound  effects  Avhich  require  the  conjunction  of 
volition  with  diastaltic  acts  ai"e  most  interesting  to  the  scientific  prac- 
titioner, such  for  instance  as  coughing,  yawning,  laughing,  hiccough,  and 
sneezing.  Cough  more  especially  is  a  frequent  and  most  distressing 
symptom,  and,  as  we  shall  subsequently  see,  requires  for  its  successful 
treatment  a  thorough  knowledge  of  the  causes  producing  it.  If,  for 
instance,  it  originates  in  irritating  disease  of  the  larynx,  what  permanent 
benefit  can  be  produced  by  giving  opiates  which  act  upon  the  brain  ? 


FUNCTIONAL   DISORDERS   OF   THE   NERVOUS   SYSTEM.      407 

Toxic  Disorders  of  the  Nervous  System. — The  influence  exercised 
by  certain  drugs  is  of  a  kind  which  causes  a  close  resemblance  to 
various  diseases  of  the  nervous  system.  These  influences,  if  carried  to 
excess,  are  toxic,  and  dangerous  to  life ;  if  employed  moderately  and 
with  caution,  they  constitute  tlie  basis  of  our  therapeutic  knowledge  in 
a  vast  variety  of  diseases.  AVhy  one  drug  should  possess  one  power, 
and  another  a  diff'erent  one,  or  why  some  should  influence  the  brain, 
and  others  the  spinal  cord  or  nerves,  "we  are  ignorant.  Such  facts 
are  as  much  ultimate  facts  in  therapeutics  as  are  the  separate  endow- 
ments of  contractility  and  sensibility  in  physiology.  As  pathological 
causes  of  functional  disorders  of  the  nervous  system,  their  power  is 
undoubted.  By  their  means  the  five  classes  of  nervous  disorders  may 
be  occasioned  in  different  ways,  producing  altogether  distinct  and 
peculiar  eff"ects.     Thus — 

Cerebral  Toxic  Disorders  are  occasioned  by  opium  and  most  of 
the  pure  narcotics,  which  first  excite  and  then  depress  or  destroy 
the  mental  faculties.  According  to  Flourens,  opium  acts  on  the 
cerebral  lobes,  while  belladonna  operates  on  the  corpora  quadrigemina. 
The  first  causes  contraction,  and  the  last  dilatation  of  the  pupils.  Tea 
and  coffee  are  pure  excitors  of  the  cerebral  functions,  and  cause  sleep- 
lessness. Alcoholic  drinks,  cether,  chloroform,  and  similar  stimulants, 
first  excite  and  then  suspend  the  mental  faculties,  like  opium.  The 
modern  practice  of  depriving  persons  of  consciousness,  in  order,  for 
a  time,  to  destroy  sensation,  has  been  very  much  misunderstood, 
in  consequence  of  such  remedies  having  been  erroneously  and  un- 
scientifically denominated  anaesthetics.  The  fact  is,  they  in  no  way 
influence  local  sensibility,  or  the  sense  of  touch.  Their  action  is  alto- 
gether cerebral,  and  hence  the  danger  which  occasionally  attends  their 
use. 

Spinal  Toxic  Disorders. — Strychnine  acts  especially  as  an  excitor 
of  the  motor  filaments  of  the  spinal  cord,  causing  tonic  muscular 
contractions,  as  in  tetanus  from  spinal  arachnitis,  or  from  the  diastaltic 
action  of  a  wound.  Woorari  produces  exactly  an  opposite  eft'ect, 
causing  paralysis  and  resolution  of  the  same  parts.  Conium  paralyses 
the  motor  and  sensitive  spinal  nerves,  producing  paraplegia,  commencing 
at  the  feet  and  creeping  upwards.  (See  case  of  Gow,  p.  413.)  Picro- 
toxine,  according  to  Dr.  Mortimer  Glover,  causes  the  animal  to  stag- 
ger backwards,  as  in  the  experiments  of  Magendie  on  the  Crura 
Cerebelli. 

Cerehro-Sinnal  Toxic  Disorders. — Of  these  the  poisonous  eff'ects  of 
hydrocyanic  acid  off'er  a  good  example.  All  the  animals  I  have  seen 
killed  by  this  agent  utter  a  scream,  lose  their  consciousness,  and  are  con- 
vulsed. These  are  the  symptoms  of  epilepsy.  Cold  is  at  first  an  excitor 
of  the  spinal  functions,  and  is  a  strong  stimulant  to  diastaltic  activity, 
but,  if  long  continued,  produces  di'owsiness  and  stupor. 

Neural  and  Neuro-Sjjinal  Toxic  Disorders  are  especially  occasioned 
by  the  action  of  certain  metallic  poisons,  such  as  mercury,  which  occa- 
sions irregular  muscular  action  w^ith  weakness,  and  lead,  which  causes 
numbness  and  palsv,  most  common  in  the  hands.  On  the  other  hand, 
cantharides  stimulates  the  contractions  of  the  neck  of  the  urinaiy  blad- 
der, and  secale  cornutum  those  of  the  pregnant  uterus.     Stramonium 


408  DISEASES   OF   THE   NERVOUS   SYSTEil. 

acts  as  a  sedative  to  the  nerves  of  the  bronchi,  ^vhile  aconite  operates 
powerfully  in  paralysing  the  action  of  the  heart. 


Treatment  of  Functional  JVervous  Disorders. 

The  great  principle  in  the  treatment  of  congestive  disorders  of  the 
nervous  system  appears  to  be,  the  necessity  of  increasing  the  strength 
and  nutrition  of  the  body  by  all  practicable  means.  Such,  indeed,  lias 
been  the  general  practice,  the  mineral  tonics,  and  more  especially  chaly- 
beate?, being  the  chief  remedies  administered  in  such  cases,  conjoined 
with  the  various  preparations  of  quinine,  bark,  and  the  vegetable  bitters. 
Stimulants  of  all  kinds,  and  especially  the  anti-spasmodics,  have  also 
been  liberally  administered.  It  must  be  confessed,  however,  that  not 
unfrequently  antiphlogistics,  with  general  and  local  bleeding,  especially 
the  latter,  have  occasionally  been  employed.  Formerly  it  was  supposed, 
and  I  shared  in  the  opinion,  that  functional  nervous  disorders  might 
depend  upon  both  an  increased  and  a  diminished  vital  power  of  the  eco- 
nomy, and  that  for  the  former,  a  lowering,  and  for  the  latter  a  support- 
ing plan  of  treatment  would  be  necessary.  Experience,  however,  has 
satisfied  me,  that  if  the  former  cause  ever  operates  at  all,  it  is  extremely 
seldom,  and  that  nervous  disorder  is  almost  always  a  svmptom  of 
exhaustion. 

The  relief  of  pain,  more  especially  in  cephalalgia  and  spinal  irritation, 
appears  to  follow  laws  which  have  by  no  means  been  determined.  Thus 
two  or  three  leeches  applied  over  the  part  often  effect  this  object,  under 
circumstances  where  it  is  impossible  to  imagine  that  thev  can  have  dimi- 
nished the  congestion.  How,  for  instance,  in  cases  of  headache,  if  it  be 
dependent  upon  congestion  of  the  brain,  can  an  ounce  of  blood,  drawn 
by  leeches  from  the  vessels  of  the  scalp,  act  in  this  wav  ?  It  has  often 
appeared  to  me,  that  the  warm  fomentations,  usually  applied  to  the 
leech  bites  afterwards,  are  more  effectual  than  the  loss  of  blood,  and  that 
the  therapeutic  action  is  really  reflex  in  its  character.  For  the  same 
reason,  dry  is  often  as  eftectual  as  wet  cupping;. 

The  influence  of  cold  and  heat  is  equally  difficult  to  explain,  and  espe- 
cially how  in  some  cases  a  diminished,  and  in  others  an  elevated  tempe- 
rature causes  so  much  relief.  Thus  some  kinds  of  cephalalgia  and  nervous 
pain  are  at  once  alleviated  by  cold.  I  know  of  nothing  that  produces 
such  immediate  ease  and  comfort,  in  cases  of  typhus  fever,  with  head- 
ache, as  gently  pouring  cold  water  over  the  shaven  scalp.  In  other  cases 
apparently  similar,  it  is  warmth  which  operates.  I  was  summoned  to  a 
married  lady  who,  during  the  day,  had  experienced  several  rigors,  and 
found  her  in  the  evening  with  a  burning  skin,  rapid  pulse,  furred  tongue, 
intense  headache,  in  short,  all  the  symptoms  of  fever.  To  alleviate'the 
intolerable  headache,  I  poured  cold  water  over  the  head,  which  to  my 
surprise  caused  no  relief  whatever.  I  then  immediately  changed  the 
cold  for  hot  water,  and  as  if  by  magic  the  pain  at  once  disappeared. 
This  led  me  to  suppose  that,  after  all,  the  case  might  not  be  one  of  fever, 
although  at  the  time  I  could  obtain  no  information  from  the  patient  to 
satisfy  my  doubts.  But  in  a  week  she  aborted,  having  been  unconscious 
that  she  was  pregnant.     The  only  practical  rule  I  know  upon  this  mat- 


FUNCTIONAL  DISOEDERS   OF  THE  NERVOUS  SYSTEM.      409 

ter  is,  if  cold  foils,  to  try  warmth.  Most  assuredly  as  alleviators  of  local 
pain  they  are  among  the  most  powerful  means  possessed  by  the  phy- 
sician. 

As  a  true  anaesthetic,  or  destroyer  of  local  sensibility,  congelation  has 
been  shown  by  Dr.  James  Arnott  to  be  a  most  successful  and  manage- 
able remedy.  I  have  used  it  in  the  way  he  has  recommended  with 
excellent  effect  in  a  variety  of  local  painful  affections,  and  join  him  in 
condemning  the  use  of  chloroform  in  cases  where  this  safer  proceeding 
can  be  employed.  Why  remove  the  consciousness  of  an  individual  bv 
deep  intoxication,  with  all  its  attendant  risks,  when  the  same  effect  can 
be  produced  by  immersing  the  parts  in  a  mixture  of  powdered  ice  and 
salt,  without  any  risk  at  all  ? 

Counter-irritation  is  also  most  useful  in  the  relief  of  chronic  congestive 
nervous  disorders,  and  not  unfrcquently  produces  a  cure.  This  is  well 
observed  in  certain  cases  of  spinal  irritation,  in  w^hich  the  local  pain  is 
often  made  to  shift  its  position,  and  if  followed  by  other  blisters,  is  at 
length  got  rid  of.  I  once  ordered  a  blister  to  be  applied  over  some 
painful  dorsal  vertebrjB,  in  a  young  lady,  who  had  long  suffered  from  dys- 
pnoea, cough,  and  supposed  phthisis.  Xcxt  day  I  found  her  breathing 
easily,  with  no  pain  in  the  back,  which,  however,  had  shifted  to  the 
occiput,  and  occasioned  trismus.  Another  blister  applied  to  her  neck 
perfected  the  cure.  On  other  occasions,  the  disappearance  of  pain  in 
one  part  of  the  back  will  bring  on  sudden  aphonia,  palpitation,  colic,  or 
other  symptoms,  which  in  their  turn  yield  to  further  counter-irritation. 

The  great  principle  in  the  treatment  of  diastaltic  disorders  of  the 
nervous  system  is  to  remove  the  peripheral  source  of  irritation  from 
which  they  arise.  Thus  cutting  the  gums,  diminishing  acidity  in  the 
stomach,  or  removing  undue  accumulations  in  the  intestines,  are  the 
appropriate  means  for  combating  the  convulsive  disorders  of  infancy 
and  childhood.  Attacks  of  hydrophobia,  epilepsy,  and  tetanus,  may 
frequently  be  prevented  by  attention  to  the  local  causes  which  induce 
these  disorders.  Hysteria  is  always  associated  with  uterine  derangement, 
to  which  the  practitioner's  attention  should  chiefly  be  directed,  whilst 
innumerable  spasms  and  convulsions  may  be  traced  to  carious  teeth, 
disease  of  the  larynx  or  pharynx,  indigestible  food,  worms,  peculiar 
habits  and  occupations,  etc.  etc.,  on  the  removal  of  which  the  cure 
depends. 

The  ready  method  of  applying  numerous  remedies  for  the  cure  of 
morbid  states  or  particular  symptoms  is  dictated  by  our  knowledge  of 
excito-motory  actions,  and  owes  all  its  importance  to  the  labours  of  Dr. 
Marshall  Hall.  Thus  dashing  cold  water  on  the  face  and  general  surface 
in  syncope,  or  in  the  suspended  animation  of  the  new-born ;  the  irrita- 
tion of  the  fauces  to  excite  vomiting;  the  avoidance  of  this  irritation,  by 
pushing  the  bolus  rapidly  into  the  pharynx  when  our  object  is  to  excite 
deglutition ;  and  the  series  of  operations  lately  proposed  to  recover 
asphyxiated  persons,  are  all  of  this  character. 

The  great  principle  in  the  treatment  of  toxic  disorders  of  the  nervous 
system  is  to  support  and  stimulate  the  strength  of  the  patient,  until  the 
action  of  the  poison  is  exhausted.  This  subject  will  be  best  illustrated 
by  examples  ; — 


410  DISEASES   OF   THE   XERVOUS   SYSTEM, 


Case  XSXIX.* — Delirium  Tremens — Recovery. 

History. — Peter  Fraser,  aetat.  56,  an  engraver — admitted  September  22,  1851. 
He  has  generally  enjoyed  good  health.  For  some  time  his  habits  have  been  very 
intemperate,  and  he  has  had  much  domestic  annoyance.  A  year  ago  lie  had  an 
attack  of  delirium  tremens.  During  the  last  few  weeks  he  has  been  drinking  con- 
siderably, although  he  says  not  to  excess.  Fourteen  days  ago  he  began  to  feel  very 
restless  and  uneasy  while  at  work,  and  his  sleep  during  the  night  became  disturbed, 
but  he  has  had  no  tremors  or  spectral  illusions  of  any  kind. 

Symptoms  os  Admission. — He  now  complains  of  severe  pain  in  the  head,  referred 
principally  to  the  frontal  region.  Xo  pains  in  any  other  part  of  the  bodj''.  His 
hands  when  put  out  have  a  trembling  fidgetty  motion,  but  when  kept  by  his  side 
are  steady.  Tongue  is  moderately  dry,  and  covered  with  a  whitish  fur.  Bowels 
are  generally  costive,  but  were  open  yesterday.  Action  of  the  heart  hurried,  and  occa- 
sionally irregular;  impulse  strong.  Pulse  96,  full  and  strong.  Other  functions 
normal.  ^.  Sol.  Mar.  Morph.  3  ij ;  Vin.  Antimon.  3  j ;  Tiru:t.  Aurantii  3  j ;  Aqua  §  j. 
Ft.  haustu-s  hora  somni  sumendus 

Progress  of  the  Case. — September  23. — Xotwithstauding  the  draught,  pa.ssed 
a  restless  night.  Bowels  not  open  since  admission.  Pulse  90,  of  moderate 
strength.  IJ  Fulv.  Fhwi  Co.  3 j ;  Aq.  Menthce  Fip.  3  j ;  Ft.  haicstu-s  statim 
sumendm.  September  24. — Passed  a  more  quiet  night.  Bowels  open.  From  this 
time  all  tremor  in  the  hands  and  cephalalgia  left  him.  He  was  dismissed  quite  well 
September  27. 

Case  XL.f — Delirium  T)-emens  with  Ocular  Spectra — Recovery. 

History. — Elizabeth  Banks,  ajt.  34,  married — admitted  April  7,  18-51.  She 
states  that  a  fortnight  ago  she  was  suddenly  seized  with  pain  in  the  head,  trembling 
and  dizziness,  so  that  she  was  obliged  to  be  supported.  She  ascribes  the  attack  to 
the  receipt  of  unpleasant  intelligence.  There  have  been  several  of  these  attacks 
since,  during  some  of  which,  her  husband  says,  she  has  been  very  violent  in  her 
attempts  to  escape  from  imaginary  enemies.  She  confesses  to  have  been  for  some 
time  addicted  to  spirit  drinking,  and  states  that  up  to  the  time  of  this  iUness  she 
has  enjoyed  good  health. 

Symptoms  ox  Admission. — She  has  a  healthy  but  somewhat  restless  appearance. 
She  answers  questions  rationally  and  is  quite  calm,  remembering  everything  that 
has  occurred,  except  during  the  sudden  attacks  of  trembling,  etc.  She  has  pain 
over  the  whole  head  ;  there  is,  however,  no  heat  of  scalp  or  suffusion  of  the  eyes. 
The  pupil  is  natural,  and  the  iris  contracts  readily.  She  sees  various  things  before 
her,  especially  different  kinds  of  animals  running  about,  which  are  most  numerous 
and  vivid  at  night.  She  feels  also  at  times  as  if  persons  were  making  attempts 
upon  her  life.  For  the  last  three  nights  she  has  had  no  sleep,  in  consequence  of  these 
ocular  appearances.  Her  hands  are  very  unsteady,  and  the  fingers  are  constantly 
playing  with  the  bed  clothes.  Pulse  90,  of  good  strength.  Tongue  furred,  and 
rather  dry.  Bowels  habitually  constipated  and  unrelieved  for  three  days.  Other 
functions  normal.  5  Elaterii  gr.  .s.s.  ;  Fulv.  Gamb.  gr.  ij ;  Fotass.  Bitart.  gr.  x. ; 
Ft.  pulvis  statim  sumendus.  5  Sol.  3fur.  Morphice  3  j ;  Aquce  3  vij ;  Ft.  hausttus 
hora  somni  sumendus. 

*  Reported  by  ^Ir.  Scott  Sanderson,  Clinical  Clerk, 
f  Reported  by  Mr.  "W.  H,  Pearce,  Clinical  Clerk. 


FUXCTIONAL   DISORDERS   OF   THE   NERVOUS   SYSTEM.      411 

Progress  of  the  Case. — A^rril  8. — Has  slept  tolerably  during  the  night.  Is  not 
so  restless,  and  has  seen  few  ocular  spectra.  The  hands  and  her  whole  appearance 
calm.  The  purgative  powder  only  occasioned  one  stool.  From  this  time  she 
gradually  recovered,  and  was  discharged  quite  well  on  the  24th. 


Case  XLI.* — Delirium  Tremens  tviih  Convulsion  and  Coma — Recovery. 

History. — David  Seaton,  fet.  25,  a  chimney-sweep — admitted  on  the  evening  of 
September  10,  1849.  His  friends  state  that  he  has  been  greatly  addicted  to  the  use 
of  spirits,  and  that  during  the  last  three  months  he  has  had  several  apoplectic  attacks. 
He  has,  notwithstanding,  continued  to  indulge  in  drink;  was  this  morning  extremely 
violent,  and  during  the  afternoon  became  insensible. 

Symptoms  on  Admission. — On  admission  the  countenance  is  bloated  and  flushed, 
and  his  short  stout  figm-e  gives  evidence  of  great  strength.  He  is  now  comatose, 
breathes  stertorou.sly ;  pulse  60,  full  and  strong.  The  head  io  be  shaved,  12  leeches 
to  be  applied,  a  drop)  ofcroton  oil  to  be  placed  on  the  hack  of  the  tongue  with  sugar,  so  as 
io  insure  deglutition,  and  to  be  repeated  in  an  hour  if  necessary. 

Progress  of  the  Case. — September  11. — During  the  night  he  several  times 
partially  recovered  his  senses,  and  again  relapsed.  To-day  is  much  better,  and  can 
answer  questions  in  a  confused  way.  Four  drops  of  croton  oil  have  been  given,  and 
operated  once.  To  have  one  drachm  of  sol.  of  morphia  at  night.  September  12. — 
Violent  delirium  during  the  night,  with  insomnolence.  It  became  necessary  to 
employ  the  strait  waistcoat.  Pulse  quick  and  feeble.  Ice  ivater  to  be  applied  io  the 
liead.  One  drachm  of  sol.  of  morphia  to  be  repeated  at  night.  To  have  a  turpentine 
enema.  September  13  and  14. — Xo  improvement.  September  15. — Is  somewhat 
sensible;  pulse  rapid  and  feeble.  To  discontinue  the  morphia.  To  have  3J  of 
whisky  every  two  Jwurs.  September  16. — Slept  a  little  last  night.  To-day  talks 
sensibly.  Pulse  80,  stronger.  Bowels  open  by  means  of  an  injection.  From  this 
time  he  gradually  recovered,  and  was  dismissed  well  September  27. 


Case  XLII.f — Co7na  and  Death  frorn  Excessive  Drinking — Opacity  of  Arachnoid — 
Sub-arachnoid  Effusion — Fluid  Blood. 

History. — James  Dick,  wt.  48.  a  joiner — admitted  on  the  evening  of  January  31, 
1851,  in  a  moribund  condition.  He  has  been  habitually  intemperate  for  many  years. 
For  the  last  week  has  been  in  a  constant  state  of  intoxication.  This  evening' became 
suddenly  ill,  and  lost  his  consciousness.  Shortly  afterwards  he  was  conveyed  to  the 
Infirmary. 

Appearance  on  Admission. — On  admission  he  presented  all  the  appearance  of  a 
corpse.  No  breathing  was  perceptible ;  no  beating  of  the  heart  could  be  heard  with 
the  stethoscope.  The  countenance  pale ;  head  thrown  back ;  mouth  open  and 
frothy ;  eyes  turned  up,  and  pupils  dilated.  AU  efibrts  at  re-animation  were  of  no 
avail ;  he  was  dead. 

Sectio  Cadaveris. —  Thirty-eight  hours  after  death. 

Body  well  formed  and  strong,  not  emaciated.  A  little  tumidity  of  depending 
parts. 

Head. — On  removing  the  calvarium,  the  sub-arachnoid  tissue  was  seen  to  be 

*  Reported  by  Mr.  Alexander  Christison,  Clinical  Clerk. 
f  Reported  by  Mr.  Sanderson,  Clinical  Clerk. 


412  DISEASES   OF  THE  NERVOUS  SYSTEM. 

infiltrated  witli  fluid,  raising  the  araclmoid  to  tlie  level  of  the  convolutions.  The 
sinuses  were  distended  with  fluid  blood.  Tlie  cerebral  arachnoid  presented  consider- 
able opacity  all  over  the  hemisphere,  in  some  places  difl'used,  in  others  exhibiting 
minute  points  closely  aggregated  together.  The  ventricles  contained  a  small  amount 
of  fluid,  and  several  simple  cysts  in  the  choroid  plexuses.  Cerebral  arteries  and 
other  portions  of  the  brain  perfectly  healthy. 

Chest. — Both  pleurae  contained  several  ounces  of  serum,  and  were  slightly 
adherent  at  the  apices.  Both  lungs  were  health}',  with  the  exception  of  unusual 
engorgement,  posteriorly  and  inferiorly.  A  cretaceous  concretion,  the  size  of  a 
barley-corn,  in  apex  of  riglit  lung.  Bronchi  contained  a  moderate  quantity  of  frothy 
mucus,  which  was  more  abundant  in  trachea  and  larj-nx.  Pericardium  contained 
one  drachm  of  serum.  Heart  healthy.  The  blood  in  the  cavities  and  large  vessels 
remarkably  fluid. 

Abdomex. — The  liver  pale  in  colour,  and  very  soft,  weighed  3  lbs.  14  oz.  A  few 
serous  cysts  in  the  kidney.     Other  abdominal  organs  healthv. 

Microscopic  Examikatiox. — The  cells  of  the  liver  were  loaded  with  oil  granules 
of  large  size.  The  tubercles  of  the  kidney  here  and  there  also  contained  several 
fatty  granules.     Cerebral  substance  healthy. 

Commentary. — Yarions  opinions  as  to  the  nature  oF  delirinm  tremens 
have  been  held  by  medical  men,  who  have  successively  placed  it  among 
the  neuroses,  the  phlemnasise,  and  the  pyrexiae.  Until  recently,  it  was 
held  that  whilst  drinking  was  its  predisposing  cause,  the  sudden  abstrac- 
tion of  the  accustomed  stimulus  brought  on  the  attack.  This  theory  has 
been  very  successfully  combated  by  Dr.  Peddie,*  who  has  shown  that 
the  disease  is  seldom  observed  in  our  prisons,  notwithstanding  the  large 
number  of  confirmed  drunkards  admitted  there  and  immediately  placed 
upon  low  diet.  The  view  of  its  pathology  now  prevalent  is,  that  alcohol, 
a  poison  dangerous  to  life  in  large  doses,  is  also  cumulative  taken  habitu- 
ally in  small  quantities.  Like  many  others,  it  is  one  which  especially 
affects  the  nervous  system,  and  more  particularly  the  brain,  as  shown  by 
Percy,  Huss,  and  other  writers.  Hence  those  effects  denominated  intoxi- 
cation, delirium  tremens,  etc.  Formerly  the  treatment  used  to  consist 
of  supplying  the  accustomed  stimulus;  but  now,  whilst  theoretically  it  is 
clear  that  this  is  tantamount  to  adding  coals  to  fire,  it  has  been  shown 
by  experience  that  patients  more  rapidly  recover  under  the  use  of  anti- 
monials  and  nutrients.  In  the  vast  majority  of  cases  of  delirium  tremens, 
the  poison  becomes  eliminated  from  the  system  in  a  certain  time  ;  whether 
antimony,  in  half  or  quarter  grain  doses,  assists  this  process  is  not  known. 
Generally  speaking,  if  a  good  sleep  can  be  obtained,  it  is  critical,  and  the 
patient  at  once  recovers.  Opium  has  been  largely  given  to  obtain  this 
result,  but  it  is  much  to  be  doubted  whether  its  supposed  beneficial  action 
is  not  dependent  on  coincidence  with  the  muscular  fatigue  and  exhaus- 
tion which,  with  the  tendency  to  repose,  accompanies  the  elimination  of 
the  alcoholic  poison.  Practically  it  is  of  great  importance  that  the 
"windows  and  doors  of  the  room  in  which  patients  with  delirium  tremens 
are,  should  be  well  closed,  because,  although  there  is  no  violence,  a 
tendency  to  escape  from  imaginary  enemies  has  led  to  some  deplorable 
accidents.     Personal  restraint  should  be  avoided.     Nutrition  also  should 

*  Monthly  Journal  of  Med.  Science.     June,  1854. 


FUXCTIOXAL   DISORDERS   OF   THE   XERYOUS   SYSTEM,      -ilo 

be  carefnllv  maintained,  as  death,  when  it  occurs,  is  for  the  most  part  the 
result  ot"  exhaustion,  with  serous  effusion  into  the  subarachnoid  cavity. 


Case  XLIIL* — Poisoning  hy  Opium — Recovery. 

History. — Helen  M'Dermott  or  Cuthbertson,  xt.  33,  but  looking  ten  years  older, 
residing  in  the  Cowgate  as  the  wife  of  a  cooper,  was  admitted  at  3  p.m.  May  25th, 
1857.  She  has  not  iinfrequently  been  drunk,  and  had  a  quarrel  lately  with  her  hus- 
band. On  the  preceding  day  she  had  gone  out  and  purchased  two  ounces  of  lau- 
danum, namely,  one  ounce  at  two  diflerent  druggists'  shops,  and  had  swallowed  them 
(it  is  said)  half  an  hour  before  admission. 

Symptoms  on  Admission. — On  admission,  contracted  pupils,  great  drowsiness, 
relaxation  of  muscles,  and  tendency  to  cold ;  with  lividity  of  face  and  extremities. 
The  stomach-pump  was  employed  to  wash  out  the  stomach;  this  was  first  done 
with  warm  water,  and  twice  subsequently  with  mustard  and  water.  The  first 
vomited  matters  smelted  of  laudanum.  The  patient  was  stimulated  to  walk  about 
until  toward  4.30  p.m.  By  that  time  her  limbs  became  so  relaxed  that  she  sank  to 
the  ground ;  and  she  was  so  drowsy  as  to  flill  asleep  unless  pushed  or  pricked.  The 
galvanic  battery  was  then  applied  to  the  popliteal  spaces,  and  to  the  hands,  breast, 
and  neck — (Kemp's  battery  being  the  instrument  employed).  Meanwhile,  as  patient 
was  in  bed,  warmth  was  maintained  by  clothes  and  hot  bottles.  Under  stimulus  of 
the  battery,  patient  was  also  mduced  to  swallow  some  coffee.  At  6.30  p.m.  she  was 
so  easily  roused  by  galvanism — the  skin  warm,  the  pulse  (small  and  weak  before) 
becoming  more  perceptible  and  strong — that  the  stimulus  was  more  rarely  applied, 
merely  to  prevent  the  sleep  into  which  from  time  to  time  she  fell  from  becoming  pro- 
found. At  8  p.m.  a  drachm  of  brandy,  and  half  a  drachm  of  Sp.  Ammon.  Aromat. 
were  administered,  to  be  repeated  every  hour.  During  the  first  three  administrations 
of  this  stimulant  vomiting  occurred,  the  vomited  matter  consisting  of  the  coflFee  that 
had  previously  been  swallowed.  At  ten,  eleven,  and  twelve,  she  was  seen  dozing 
slightly,  but  was  easily  roused.  Xext  morning  complained  of  sickness,  and  of  not 
having  been  able  to  sleep  during  the  night ;  was  quite  conscious  and  thankful  for  her 
recovery.  Slept  during  the  day,  taking  tea  and  beef-tea.  On  the  27  th,  ha\-ing  fully 
recovered,  she  was  discharged. 

Commentari/. — The  symptoms  of  poisoning  by  opium  in  man  are 
altogether  cerebral,  the  danger  to  be  apprehended  being  a  fatal  stupor. 
To  prevent  this,  the  practice  successfully  carried  out  in  the  above  case 
is  the  one  now  generally  considered  best.  The  dose  of  the  poison  taken 
was  large,  but  fortunately  the  time  after  its  administration  was  not 
great. 

Case  XLIY.* — Poisoning  hy  Hemlock — Death. 

History  — On  Monday,  AprQ  21st,  1845,  about  seven  o'clock  in  the  evening,  a 
man,  called  Duncan  Gow,  was  brought  into  the  Infirmary  by  two  pohcemen.  It 
was  stated  that  he  had  been  found  lying  in  the  street,  apparently  in  a  state  of 
intoxication,  or  in  a  fit.  On  being  taken  into  the  waiting-room,  he  was  found  to  be 
dead. 

I  subsequently  learnt  from  his  wife  that  the  man,  forty-three  years  of  age,  a  tailor 

*  Reported  by  Dr.  John  Glen.  Resident  Physician. 

■j-  Publislied  by  me  in  the  Edin.  Med.  and  Surg.  Joum.,  Xo.  164.     1S45. 


414  DISEASES   OF  THE   NERYOUS   SYSTEM. 

by  trade,  was  in  such  reduced  circumstances  that  he  had  not  eaten  anything  on 
Monday,  until  he  took  the  substance  wliich  caused  his  death.  Two  of  his  children,  a 
boy  and  girl,  aged  respectively  ten  and  six  years  of  age,  found  what  they  took  for 
parsley  growing  on  the  bank  under  Sir  Walter  Scott's  Monument  (which  was  then 
buUdiiig),  and  knowing  tliat  their  father  was  very  fond  of  this,  as  well  as  other 
green  vegetables,  they  gathered  some  to  take  to  him.  On  visiting  the  place  with 
the  boy  four  days  afterwards,  I  found  that  the  spot  from  whence  the  plants  were 
gathered  had  been  covered  over  with  fresh  rubbish.  But  on  the  uncovered  part  of 
the  bank,  eighty  yards  westward,  the  Conium  maculatum  could  be  seen  growing  in 
considerable  quantity.  The  children  returned  home  between  three  and  four  o'clock 
P.M.  The  father,  who  had  fasted  the  whole  day,  greedily  ate  the  vegetables, 
together  with  a  piece  of  bread,  and  said  more  than  once  how  good  they  were. 
The  quantity  consumed  could  not  be  ascertained,  for  he  ate  nearly  all  that  was 
brought.  On  finishing  his  meal,  he  rose,  saying  he  would  endeavour  to  get  some 
money,  in  order  to  procure  food  for  his  children.  At  this  time  he  was  in  perfect 
health. 

From  his  own  house,  at  the  head  of  the  Canongate,  Gow  walked  about  half  a 
mile  to  the  house  of  one  Wright,  in  the  West  Port,  with  the  view  of  selling  him 
some  small  matter.  Wright,  on  his  entering  the  room,  thought  at  first  that  he  was 
intoxicated,  because  he  staggered  in  walking.  On  passing  through  the  door  also, 
which  was  narrow,  he  faltered  in  his  gait,  and  afterwards  sat  down  hastily.  He 
stayed  ten  minutes,  during  which  tune  lie  conversed  readily,  drove  a  hard  bargain, 
and  obtained  fourpence  for  what  he  sold.  He  did  not  complain  of  pain  or  un- 
easiness, was  not  excited  in  manner  or  speech,  and  his  face  was  pale  and  wan. 
On  rising  from  his  chair,  he  was  observed  by  Wright's  boy  to  fall  back  again,  as  if 
he  had  some  difficulty  in  rising.  On  making  a  second  effort  he  got  up,  and  was 
seen  by  Wright's  wife  to  stagger  out  of  the  house  and  down  the  stejas.  This  was  a 
little  after  four  o'clock. 

On  leaving  Wright's  house,  he  was  next  seen  standing  with  his  back  against 
the  corner  of  the  street,  by  Andrew  Mc'All,  a  meal-dealer  in  the  Grassmarket,  about 
200  yards  from  Wright's  house.  Mc'All  saw  him  leave  the  corner  he  was  leaning 
against,  and  stagger  to  a  lamp-post  a  few  yards  further  on.  Here  he  again  paused 
for  a  few  minutes,  and  then  again  went  forward  in  the  same  vacillating  manner, 
passed  Mc'AU's  shop,  and  sat  down  at  the  opening  of  the  common  stair  next  to 
it.  Mc' All's  words  are,  "  He  could  not  walk  rightly,  and  was  staggering  as  a  man 
in  liquor."  His  mode  of  progression  attracted  a  number  of  boys  and  girls,  who 
laughed  at  him,  believing  him  to  be  intoxicated.  He  was  heard  to  speak  to  them, 
but  what  he  said  is  not  known.  He  was  also  seen  by  two  women,  who  told  a 
policeman  to  take  him  away. 

The  policeman  (James  Mitchell,  No.  161)  told  me  that,  on  finding  Gow  sitting 
at  the  foot  of  the  common  stair,  he  thought  he  was  drunk.  He  spoke  to  him,  and 
in  reply  Gow  desired  to  be  taken  to  his  own  house,  at  the  top  of  the  Canongate. 
He  also  said  that  he  had  completely  lost  his  sight,  and  had  not  the  perfect  use  of  his 
limbs,  but  expressed  his  wiUingness  to  walk  forwards,  until  the  policeman  could 
obtain  the  assistance  of  his  comrade  in  the  Cowgate.  He  was  then  raised  up  and 
supported  by  one  arm,  but,  after  moving  with  great  difficulty  past  four  or  five 
shops,  his  legs  bent  under  him,  and  he  fell  upon  his  knees.  Mitchell  then  gave 
him  some  water  to  drink,  wliich  he  was  incapable  of  swallowing,  and  left  him  to  get 
a  barrow.  On  his  return  he  found  him  surrounded  bj'  women,  who  were  pouring 
cold  water  on  his  head,  and  sprinkling  his  forehead.  With  the  assistance  of  anotlier 
policeman  (James  Hastie,  Xo.  Ill),  he  was  then  placed  on  the  barrow.  One  of  the 
women,  Mrs.  Anderson,  on  his  being  raised,  saw  that  he  made  no  attempt  to  walk, 


FUNCTIONAL   DISORDEES   OF   THE   NERVOUS   SYSTEM.      415 

but  that,  as  he  was  i:)ulled  away  by  tlie  policemen,  his  legs  were  dragged  or  trailed 
after  him. 

The  second  policeman,  Hastie,  on  first  seeing  him,  told  Mitchell  that  it  was  not 
drink,  but  a  fit,  that  was  the  matter  with  him.  He  lifted  up  his  eyelids  and  found 
the  eyes  dull.  He  seemed  sensible,  and  endeavoured  to  say  something,  but  could 
not  articulate.  He  was  now  slowly  conveyed  to  the  main  police-office  in  the  High 
Street,  where  he  arrived  about  six  o'clock.  Mitchell  told  the  police  lieutenant  on 
duty  that,  from  the  manner  in  which  the  man  was  lying,  and  from  the  loss  of 
power  in  the  legs,  he  now  thought  he  was  not  intoxicated.  At  this  period  it  would 
seem  that,  although  the  limbs  were  completely  paralysed,  the  intelligence  was  still 
perfect,  for  he  told  the  turnkey  his  exact  address  in  the  Canongate,  in  reply  to  a 
question. 

Dr.  Tait,  surgeon  to  the  police  force,  was  now  sent  for,  and  saw  him  about  a 
quarter  past  six.  In  reply  to  a  note  which  I  addressed  to  him  on  this  subject,  he 
says : — 

"  The  first  impression  produced  on  my  mind  from  his  appearance  was,  that  he 
was  in  a  state  of  intoxication ;  he  was  then  lying  on  his  back,  with  his  head  and 
shoulders  elevated  upon  a  board  we  have  in  the  office  for  that  purpose.  He  was 
sensible  when  I  spoke  to  him,  and  tried  to  turn  his  face  towards  me,  and  slightly 
raised  his  eyelids,  but  appeared  unable  to  speak.  His  power  of  motion  appeared 
completely  prostrated,  for  when  I  lifted  his  arm,  and  laid  it  down,  it  lay  where  it 
was  put;  and  when  his  arm-pits  were  tickled,  he  seemed  to  manifest  a  little  sensi- 
bility, but  could  make  no  exertion  to  rid  himself  of  the  annoyance.  There  were 
occasional  movements  of  the  left  leg,  but  they  appeared  rather  to  be  spasmodic 
than  voluntary.  Several  efforts  were  made  to  vomit,  but  these  were  ineffectual. 
His  pulse  and  breathing  were  perfectly  natural.  He  had  spoken  to  the  turnkey  a 
few  minutes  before  I  arrived.  Heat  of  skin  natural.  I  visited  him  again,  about 
ten  minutes  before  seven  o'clock,  at  which  time  all  motion  of  the  chest  appeared  to 
have  ceased ;  the  action  of  the  heart  was  very  feeble,  and  the  countenance  had  a 
cadaveric  expression ;  pupils  fixed.     He  was  then  sent  to  the  Infirmary." 

He  was  conveyed  to  the  Infirmary  by  Hastie  and  another  policeman,  M'Pherfeon. 
After  being  put  on  the  stretcher,  Hastie  saw  him  draw  the  legs  gently  upwards,  as 
if  to  prevent  their  hanging  over  the  iron  at  its  extremity.  This  was  the  last  move- 
ment he  was  seen  to  make.  On  being  carried  into  the  waiting-room  of  the  Infirmary, 
he  was  visited  by  the  house-clerk  on  duty,  who  found  him  pulseless,  and  declared 
him,  as  previously  stated,  to  be  dead.     This  was  shortly  after  seven  o'clock  p.  m. 

Sectio  Cadaveris. — Sixty-three  hours  after  death. 

The  body  was  well-formed  and  muscular.  There  were  no  external  marks  of  vio- 
lence.    The  back  and  depending  portions  were  livid  from  sugillation. 

Head. — An  unusual  quantity  of  fluid  blood  flowed  from  the  scalp  and  longitu- 
dinal sinus  when  divided.  There  was  slight  serous  effusion  below  the  arachnoid 
membrane,  and  about  two  drachms  of  clear  serum  in  the  lateral  ventricles.  The 
substance  of  the  brain  was  soft  throughout ;  on  section  presented  numerous  bloody 
points,  but  was  otherwise  healthy.  No  fracture  could  be  discovered  in  any  part  of 
the  cranium. 

Chest. — There  were  slight  adhesions  between  the  pleuras  on  both  sides  superiorly. 
The  apices  of  both  lungs  were  strongly  puckered.  On  the  right  side  below  the 
puckering,  were  two  cretaceous  concretions,  the  size  of  peas,  surrounded  by  chronic 
pneumonia  and  pigmentary  deposit.  On  the  left  side  only  induration,  with  hard, 
black,  gritty  particles,  existed  below  the  puckering.  The  structure  of  the  lungs 
otherwise  was  healthy,  although  they  were  throughout  mtensely  engorged  with  dark- 


416  DISEASES   OF   THE   NERVOUS   SYSTEM. 

red  fluid  blood.  The  heart  was  healthy  in  structure,  but  soft  and  flabby.  The 
blood  in  the  cavities  was  mostly  fluid,  presenting  only  here  and  there  a  few  small 
grumous  clots. 

Abdomen. — The  liver  was  healthy ;  the  spleen  soft,  readQy  breaking  down  under 
the  fingers.  The  kidneys  were  of  a  brownish-red  colour  throughout,  owing  to  venous 
congestion,  but  healthy  in  structure.  The  stomach  contained  a  pultaceous  mass, 
formed  of  some-  raw  green  vegetable  resembling  parsley.  Its  contents  weighed 
eleven  ounces,  and  had  an  acid  and  slight  spirituous  odour.  The  mucious  coat  was 
much  congested,  especiallj''  at  its  cardiac  extremity.  Here  there  were  numerous 
extravasations  of  dark-red  blood,  below  the  epithelium,  over  a  space  about  the  size 
of  the  hand.  The  intestines  were  healthy,  here  and  there  presenting  patches  of 
congestion  in  the  mucous  coat.  The  bladder  was  healthy ;  its  inner  surface  much 
congested  from  venous  obstruction. 

The  Blood  throughout  the  body  was  of  a  dark  colour  and  fluid,  even  in  the  heart 
and  large  vessels. 

Commentary, — From  the  absence  of  structural  lesion,  and  the  general 
fluidity  of  the  blood,  I  was  induced  to  suspect  that  the  vegetable  matter 
found  in  the  stomach  was  of  a  poisonous  nature.  On  examining  this 
more  minutely,  it  was  seen  to  be  composed  chiefly  of  fragments  of  green 
leaves  and  leaf-stalks.  Althongh  much  was  reduced  to  a  pulp,  a  con- 
siderable quantity  of  both  had  escaped  the  action  of  the  teeth.  The 
same  afternoon,  I  carried  as  perfect  a  specimen  of  the  fragments  as  could 
be  found  to  Dr.  Christison,  who  pointed  out  that  they  could  scarcely  be 
anything  else  than  the  lacinice  of  the  Conimn  niaculatu77i,  or  common 
hemlock.  Next  day  I  bruised  some  of  the  leaves  in  a  mortar,  with  a 
solution  of  potash,  when  the  peculiar  mousy  odour  of  conia  was  evolved 
so  strongly  that  Dr.  Douglas  Maclagan  and  others,  although  previously 
unacquainted  with  its  nature,  at  once  pronounced  it  to  be  hemlock.  Dr. 
Christison  also  procured  a  recent  specimen  of  the  Conium  mar.ulatum, 
fro*m  Salisbury  Crags,  the  botanical  characters  of  which,  on  being  com- 
pared with  the  fragments  found  in  the  stomach,  were  proved  to  be  iden- 
tical. No  doubt  could  exist,  therefore,  that  the  man  died  from  having 
eaten  hemlock. 

Few  cases  of  poisoning  with  this  plant  have  hitherto  been  published, 
and  none  have  been  minutely  detailed.  The  eff'ects  imputed  to  it  in  the 
notices  given  of  prior  cases  are  very  contradictory.  In  some  it  is  said 
to  have  caused  death,  like  opium,  by  stupor  and  coma.  In  others,  con- 
vulsions of  the  frantic  kind  are  symptoms  stated  to  have  been  present. 
But  the  eff'ects  observed  by  Dr.  Christison  in  the  lower  animals,  in  his 
experiments  with  extract  of  hemlock  and  its  alkaloid  conia,  are  totally 
different,  viz.,  "  palsy,  first  of  the  voluntary  muscles,  next  of  the  chest, 
lastly  of  the  diaphragm ;  asphyxia,  in  short,  from  paralysis,  without 
insensibility,  and  with  slight  occasional  twitches  only  of  the  limbs."* 
On  this  account,  as  well  as  from  the  circumstance  that  considerable 
interest  is  connected  with  the  question,  as  to  whether  the  hemlock  of 
modern  times  be  the  Kwvaiov,  or  state  poison  of  the  Athenians,  great 
pains  were  taken  to  obtain  a  perfect  history  of  the  case.  In  preparing 
it,  I  endeavoured  to  insure  accuracy,  by  carefully  interrogating  all  who 

*  Treatise  on  Poisons,  p.  855,  1845. 


FUNCTIONAL   DISORDERS   OF   THE   NERVOUS   SYSTE:\r.      417 

saw  him  from  the  time  of  his  eating  the  hemlock  until  the  period  when 
he  was  brought  into  the  Infirmary.  Fortunately,  he  was  seen  by  many 
persons,  and  tlieir  several  accounts  are,  on  the  whole,  consistent,  and 
render  the  case  tolerably  perfect. 

The  time  of  day  mentioned  by  the  different  narrators  shows  that  the 
poison,  shortly  after  it  was  taken,  produced  want  of  power  in  the  inferior 
extremities,  without  causing  any  pain.  This  is  proved  by  what  took 
place  in  "Wright's  house.  His  gait,  which  at  that  time  was  faltering, 
afterwards  became  vacillating ;  he  staggered  as  one  drunk — at  length, 
his  limbs  refused  to  support  him,  and  he  fell.  On  being  raised,  his  legs 
dragged  after  him;  and  lastly,  when  the  arms  were  lifted,  they  fell  like 
inert  masses,  and  remained  immovable.  Perfect  paralysis  of  the  inferior 
extremities  was  ascertained  to  exist  one  hour  and  a  half  after  the  poison 
was  taken,  and  that  of  the  arms  half  an  hour  later. 

As  regards  the  existence  of  sensibility,  we  have  only  the  evidence 
afforded  by  tickling  the  arm-pits,  which,  according  to  Dr.  Tait,  seemed 
to  excite  it  a  little.  Tlae  amaurosis,  however,  is  a  proof  that  one  nerve 
of  sensibility,  at  all  events,  was  paralysed.  This  seems  to  have  happened 
when  perfect  paralysis  of  the  inferior  extremities  was  manifested. 

The  excito-motorv  functions  seemed  also  paralysed.  Tickling  the  arm- 
pits failed  in  producing  movements.  He  lost  the  power  of  deglutition. 
Dr.  Tait  says  his  efforts  to  vomit  were  ineffectual.  There  were  no  con- 
vulsions, only  slight  occasional  movements  of  the  left  leg ;  and  lastly, 
both  inferior  extremities  were  slowly  drawn  upwards,  when  placed  over 
the  iron  of  the  stretcher.  Three  hours  after  taking  the  poison,  the  re- 
spiratory movements  had  ceased  ;  the  pupils  were  fixed.  At  this  time 
the  heart's  action  was  felt  very  feeble.  These  also  ceased  about  ten 
minutes  afterwards. 

The  intelligence  remained  perfect  up  to  a  very  late  period.  When 
his  movements  were  vacillating,  he  was  seen  to  direct  his  steps  from  one 
fixed  point  to  another.  After  paralysis  of  the  inferior  extremities  was 
fully  developed  he  gave  accurate  directions  how  he  was  to  be  taken  home, 
and  described  his  principal  symptoms.  Two  hours  after  taking  the  hem- 
lock, when  brought  into  the  police-ofiice,  although  he  could  not  swallow, 
he  gave  his  address;  and  a  quarter  of  an  hour  afterwards,  when  seen  by 
Dr.  Tait,  though  he  could  not  speak,  he  appeared  sensible,  and  tried  to 
turn  his  face  towards  him. 

Death  took  place  about  three  hours  and  a  quarter  after  eating  the  poi- 
son, and  was  evidently  occasioned  by  gradual  asphyxia  fi-om  paralysis  of 
the  muscles  of  respiration.  The  appearances  observed  in  the  mucous 
membrane  of  the  stomach  were  most  probably  caused  by  the  unusual 
fluidity  of  the  blood,  and  this,  in  its  turn,  by  the  gradual  asphyxia. 

The  phenomena,  therefore,  observed  in  this  case  fully  corroborate  the 
physiological  action  of  hemlock,  as  described  by  Dr.  Christison,  from  his 
experiments  on  animals.*  It  evidently  acts  upon  the  spinal  cord,  pro- 
ducing directly  opposite  effects  to  those  occasioned  by  strychnia.  Para- 
lysis of  the  voluntary  muscles,  creeping  from  below  upwards,  is  the  cha- 
racteristic symptom,  unaccompanied  by  pains  or  derangement  of  the 
intellectual  faculties.     Some  authors  have  desciibed  delirium  and  frenzy, 

*  Transactions  of  the  Royal  Society  of  Edinburo;h,  vol.  xiiL 
27 


418  DISEASES   OF  THE   NERVOUS   SYSTEM, 

and  others  giddiness  and  convulsions,  to  have  been  occasioned.  But  such 
symptoms  were  not  observed  in  the  case  of  Go\y,  nor  in  the  experiments 
on  tlie  lower  animals  bv  Dr.  Christison.  Indeed,  the  symptoms  described 
by  Plato  in  the  case  of  Socrates,  resemble  as  nearly  as  possible  those 
which  appeared  in  Gow.  "U"e  are  told  that  Socrates  was  directed  by  the 
executioner  to  walk  about  after  swallowino;  the  poison,  until  his  limbs 
should  grow  heavy.  He  did  so,  and  then  lay  down.  On  his  feet  and 
legs  being  squeezed,  thev  were  found  insensible ;  they  were  also  pointed 
out  by  the  executioner  to  be  cold  and  stitF.  When  paralysis  had  pro- 
ceeded upwards  to  the  abdomen,  Socrates  made  a  request  to  Crito,  prov- 
ing that  his  intellect  was  then  unaffected.  In  a  short  time  aftei-,  he  be- 
came convulsed,  his  eyes  were  fixed,  and  he  died.  Whether  stiffness  was 
present  in  Gow's  case  was  not  ascertained.  The  nature  of  the  convulsions, 
whether  violent  or  otherwise,  is  not  stated  in  the  account  by  Plato,  but 
slight  spasms  were  observed  in  Gow. 

It  will  be  observed,  that  when  Socrates  felt  paralysis  coming  on  he  lay 
down.  Hence  the  staggering  and  falling  in  the  street,  observed  in  Gow, 
did  not  take  place.  The  description  of  the  effects  of  the  Kiivsiov  giveu 
by  Xicander,  however,  would  in  this  case  apply  with  great  accuracy. 
He  says  (I  quote  from  Dr.  Christison's  paper): — "This  potion  carries 
destruction  to  the  powers  of  the  mind,  bringing  shady  darkness,  and 
makes  the  eves  roll.  But  staggering  on  their  footsteps  and  tripping  on 
the  streets,  thev  creep  on  their  hands.  Mortal  stifling  seizes  the  upper 
part  of  the  neck,  and  obstructs  the  naiTow  passage  of  the  throat.  The 
extremities  grow  cold,  the  strong  vessels  in  the  limbs  contract,  he  ceases 
to  draw  in  the  thin  air,  like  one  fainting,  and  the  soul  visits  Pluto."  If 
we  abstract  the  poetical  parts  of  the  description,  and  remember  the  loss 
of  sight,  staggering  and  tripping  in  the  street,  the  difficulty  of  deglutition, 
and  place  the  loss  of  the  intellectual  faculties  last,  this  account  of  Xicander 
agrees  very  well  with  what  was  observed  in  Gow. 

A  difference  of  opinion  exists  as  to  whether  the  Conium  maculatum  of 
modern  botanists  be  the  Kuvciov  of  the  ancient  Greeks.  Into  the  botani- 
cal controversy  I  do  not  feel  myself  qualified  to  enter.  But,  if  the  symp- 
toms ascertained  to  have  existed  in  the  case  I  have  related  be  compared 
with  the  accounts  of  Plato  and  Xicander,  I  cannot  help  thinking  that  it 
will  be  found  to  favour  the  opinion  of  those  who  believe  in  their  identity. 


Case    XLT.* — Poisoning    with    Lead — Painter's   Colic — Lead    Paralysis — Partial 

Recovery. 

HiSTOKT. — Peter  Taylor,  set.  50,  a  brewer's  servant,  admitted  September  26th, 
1851.  At  his  occupation  in  the  brewery  he  frequently  uses  half  a  hundred  weight 
of  white  lead  at  a  time,  for  jointing  pipes,  and  is  in  the  habit  of  painting  with  the 
same  material.  Twelve  months  ago  had  a  severe  attack  of  Colica  Pictonum,  from 
which  he  slowly  recovered  under  medical  treatment,  and  then  resumed  hLs  work, 
being  always  subject,  however,  to  transient  twinges  of  pain  in  the  bowels,  as  well  as 
in  the  joints,  which  latter  he  attributed  to  rheumatism.  Six  weeks  ago  he  first  expe- 
rienced debility  and  want  of  power  in  both  hands,  which  has  gradually  increased 
since.     His  speech  also  has  become  slightly  affected. 

*  Pieported  by  Mr.  Scott  Sanderson,  Clinical  Clerk. 


FUNCTIONAL   DISORDEKS   OF   THE   NERVOUS   SYSTEM.      419 

Symptoms  on  Admission. — He  has  at  present  no  pain  anywhere,  and  only  com- 
plains of  want  of  power  in  both  wrist  joints.  Both  hands  drop  down  from  the  arms, 
especially  the  right,  which  forms  a  right  angle  with  the  fore-arm.  He  can  flex  them 
voluntarily  when  elevated  by  another,  but  cannot  raise  them  himself.  When  the 
metacarpal  bones  are  supported  by  the  hand  of  another,  he  can  extend  the  last 
joints  of  the  fingers.  He  has  perfect  command  of  the  shoulder  and  elbow  joints. 
His  grasp  of  an  object  is  little  impaired  ;  there  is  no  wasting  of  the  extensor  muscles 
of  the  arm,  though  they  feel  soft;  and  sensibility  in  the  paralysed  parts  is  normal. 
Bowels  still  somewhat  constipated,  but  were  opened  freely  yesterday.  Speaks  with 
unusual  slowness,  which  he  thinks  has  increased  lately.  All  the  other  functions  are 
healthy. 

Progress  of  the  Case. —  October  Isl— Since  admission  the  hoivels  have  been  kept 
open  daily  by  small  doses  of  the  sidphate  of  magnesia.  The  ar7723  have  been  put  up  in 
splints,  keeping  the  ivrist  and  hand  extended  straight  out.  Galvanism  has  been  applied 
twice  daily  for  several  minutes  in  the  course  of  the  extemors,  and  frictions  over  them  are 
occasionally  employed  in  the  interval  by  means  of  flannel  cloths.  Oct.  I5th. — He  was 
ordered  §  Potass.  Hydriod.  3  ss ;  Aquce,  Cinnam. ;  Aquoi  font,  aa  §  iij.  M.  Sumat 
§  j  ter  indies.  To-day  the  splint  was  removed  from  the  left  arm,  which  still  droops, 
but  is  more  readily  extended.  Oct.  30th. — Has  complained  of  numbness  in  the  right 
arm,  attributed  to  the  bandage.  The  splint  was,  therefore,  to-day  taken  off",  but  the 
hand  droops  as  much  as  ever,  although  he  can  move  the  metacarpal  joints  and 
fingers  a  little  better.  Nov.  IQih. — There  is  decided  improvement  in  the  power  of 
motion  in  both  wrist  joints,  especially  the  left.  ^.  Extract.  Nucis  Vomica},  gr.  vj ; 
Confect.  Rosar.  q.s.  ut  fiant  pil.  vj.  Sumat  imam  ter  indies.  Nov.  21st. — The  pills 
appear  to  cause  occasional  pain  in  the  stomach  and  bowels,  but  have  occasioned  no 
spasmodic  twitches  in  the  muscles  generally.  The  joints  have  not  improved  since 
last  report,  but  he  insisted  on  going  out.  He  was  therefore  dismissed,  with  the 
advice  to  exercise  the  wrists  in  pumping  water. 

Comm.entary. — Lead,  as  a  poison,  appears  to  act  first  on  the  peripheral 
nerves  of  the  body,  and  subsequently  on  the  nervous  centres,  its  (jhief 
manifestations  being  in  the  nerves  of  the  intestines,  causino-  colic,  and 
those  of  the  arms  producing  paralysis.  Why  this  substance  should  espe- 
cially affect  these  parts,  is  as  much  unknown  as  why  any  other  poison 
should  exert  a  special  influence  on  particular  portions  of  the  nervous 
system.  It  has  been  recently  pointed  out  that  the  metal  exists  in  the 
tissues  (in  the  form  of  carbonate),  and  sulphur  consequently  has  been 
recommended  internally  and  externally,  with  a  view  of  causing  its  more 
rapid  decomposition  and  elimination  as  a  sulphuret.  For  this  purpose 
the  sulphurous  mineral  waters  have  been  recommended.  Common  alum 
was  given  by  Gendrin,  and  an  acidulated  drink  made  with  sulphuric 
acid  by  others.  Theoretically,  this  treatment  has  its  difficulties;  for 
supposing  the  lead  to  be  converted  into  a  sulphuret,  how  is  this  in  its 
turn  to  be  removed  from  the  tissues,  any  more  than  the  carbonate,  with- 
out being  first  rendered  soluble,  and  therefore  poisonous  ?  On  the  other 
hand,  some  physicians  in  France  who  have  tried  the  chemical  treatment 
extensively,  and  among  others  Andral,  Sandras,  Piorry,  and  Grisolle, 
assert  that  it  has  no  influence  whatever,  and  that  patients  abandoned  to 
themselves  get  well  just  as  soon.  In  most  cases  the  disease  yields  to 
time  and  slow  elimination  of  the  poison  from  the  economy.  Iodide  of 
potassium  also  is  said  by  Melsens  to  have  decomposing  and  eliminating 


420  DISEASES   OF  THE  XERVOUS  SYSTEiT. 

powers.  The  latter  was  employed  in  the  above  case,  but  with  no  great 
success. 

Dr.  Christison  informs  me,  that  "  long  ago,  when  tlicre  was  a  white 
lead  manufactory  at  Portobello,  I  used  constantly  to  have  in  the  Infir- 
mary a  case  or  two  of  lead  colic  or  lead  palsy  and  neuralgia.  Every 
case  of  colic  I  saw  got  speedily  well  by  the  alternate  use  of  opium  and 
aperients,  and  every  case  of  paralvsis  by  generous  living,  stomachic 
tonics,  warm  baths,  and  especially  support  and  regulated  exercise  of  the 
arms.  One  man  I  well  remember,  who  was  three  times  under  my  care, 
in  consequence  of  his  always  returning  to  the  factory — had  colic,  palsy, 
and  also  neuralgia ;  but  he  got  well  in  no  long  time  by  attention  to  the 
above  means." 

M.  Duchenne  has  pointed  out  the  great  advantage  of  applying  gal- 
vanism not  generally  to  the  arm,  but  more  especially  to  the  muscles 
atFected,  which  in  these  cases  are  most  commonly  the  extensores  digi- 
tornm,  and  not  the  lumbricales  nor  interossei — hence  why  the  first 
phalanges  only  cannot  be  extended,  whilst  when  these  are  supported,  the 
second  and  third  phalanges  can  be  voluntarily  raised  without  difSculty.* 

*  For  a  case  of  Poisoning  by  Aconite  see  Aneurism,  case  of  Henry  Smith. 


SECTION  V. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Under  this  lioad  I  include  derangements  of  all  those  parts  which  are 
concerned  in  the  primary  digestion — that  is,  not  only  the  different  por- 
tions of  the  alimentary  canal  strictly  so  called,  but  the  liver,  pancreas, 
and  peritoneum.  The  lesions  of  the  spleen  I  shall  consider  in  the  section 
devoted  to  diseases  of  the  blood,  as  there  can  be  little  doubt  that  this, 
with  the  mesenteric  and  other  ductless  glands,  is  not  only  concerned  m 
the  formation  of  blood,  but  is  most  commonly  disordered  during  its 
unhealthy  states. 


DISEASES  OF  THE  MOUTH,  PHARYXX,  AND  (ESOPHAGUS. 

Case  XLYL^—Tomimtis. 

History.— Christina  Slater,  fet.  22,  a  well-nourished  servant  girl— admitted  May 
6th,  1857.  Three  weeks  ago,  after  exposm-e  to  cold,  during  the  family  washing,  she 
experienced  rigors,  headache,  and  thirst,  with  a  sense  of  dryness  and  swelling  in  the 
throat,  especially  on  the  right  side ;  could  with  difficulty  swallow  either  solids  or 
fluids,  the  latter  occasionally  regurgitating  through  the  nostrils.  These  symptoms 
continued  to  increase  tOl  the  night  before  admission,  when  she  felt  something  give 
way  in  her  throat.     She  spat  up  some  matter,  and  thereafter  felt  general  rehef. 

SYMPTOiis  ON  Admission. —Pulse  of  moderate  strength  and  frequency ;  no  cardiac 
hypertrophy  nor  abnormal  murmurs.  Respirations  easy  and  not  hurried.  The  voice 
is  soft  and  natural,  but  articulation  is  indistinct  and  hissing.  The  jaws  are  so  immo- 
vable as  to  be  separable  only  to  the  extent  of  a  quarter  inch ;  neither  by  the  finger, 
therefore,  nor  by  inspection,  can  the  tonsils  be  examined ;  but  there  is  tenderness  on 
pressure,  and  considerable  fulness  in  the  right  sub-parotidean  and  sub-maxillary 
regions.  The  tongue,  as  far  as  can  be  exposed,  is  covered  centrally  with  a  thick 
white  creamy  coat ;  the  edges  being  of  a  bright  red  colour.     Can  now  swallow  fluids  ; 

*  Reported  by  Mr.  "W.  Guy,  Clmical  Clerk. 


422  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

appetite  returning ;  bowels  regular.     The  urine  is  non-albuminous,  slightly  hyper- 
phosphatic,  with  a  mucous  sediment.     The  other  functions  are  normal. 

Progress  of  the  Case. — Poultices  were  applied  from  time  to  time;  on  May  lltU, 
she  was  able  to  open  her  mouth  to  the  full  extent.  Both  tonsils  were  then  seen  to 
be  enlarged,  the  one  on  the  right  side  being  the  size  of  a  walnut.  Anteriorly  it  pre- 
sented two  or  three  ulcers,  with  dense  yellow  margins,  about  the  size  of  split  peas. 
Lunar  caustic  is  to  be  applied  to  the  ulcers,  and  she  is  to  use  an  astringent  gargle. 
The  right  tonsil  still  continuing  enlarged,  was  scarified  May  2,\st,  with  marked  relief, 
and  diminished  slightly  in  size  afterwards,  under  the  action  of  tincture  of  iodine 
applied  locally.  The  diminution  being  very  slow,  and  patient  otherwise  in  good 
health,  she  was  sent,  June  Sth,  to  Mr.  Syme,  who  excised  one  half  of  the  gland. 
June  lOth. — "Was  dismissed  cured. 

Commentarij. — Hypertropliy  of  the  tonsils  is  so  common  in  young 
children  as  scarcely  to  demand  notice,  unless  suspicions  of  croup  are 
entertained,  when  they  should  invariably  be  examined.  I  have  frequently 
seen  the  fences  almost  closed  from  the  contact  of  enlarged  tonsils,  so 
as  to  cause  croup-like  breathing,  and  give  rise  to  great  alarm.  Painting 
them  with  the  tincture  of  iodine  is  the  best  remedy,  and  excision  may 
be  practised  if  much  permanent  inconvenience  be  occasioned.  In  the 
above  case,  all  the  three  lesions  which  affect  the  tonsil  were  produced, 
namely,  abscess,  ulceration,  and  enlargement.  The  former  bursts,  the 
two  latter  were  treated  successfully  by  local  applications  of  the  solid 
nitrate  of  silver,  and  subsequently  half  the  gland  was  excised. 


Case  XLVIL* — Follicular  Pharyngitis. 

History. — Peter  M'Donald,  set.  42,  a  hammerman  in  an  engine  foundry — admitted 
December  1st,  1856.  Four  months  ago,  being  previously  healthy,  he  was  attacked 
with  severe  sore  throat,  difficulty  of  deglutition,  and  subsequently  deafness  in  the  left 
ear.  He  could  not  swallow  sufficient  food,  became  weak,  and  in  a  fortnight  gave  up 
work.  He  ascribes  his  attack  to  the  sudden  changes  of  temperature  to  which  he 
was  exposed.  The  dysphagia  did  not  continue,  but  he  still  is  weak,  feels  a  dry- 
ness in  the  throat,  with  frequent  desire  to  swallow  his  saliva,  but  great  difficulty  in  so 
doing. 

Symptoms  on  Admission. — The  voice  is  hoarse.  On  examination  with  a  spatula, 
numerous  red  bodies,  of  a  somewhat  spherical  shape,  about  the  size  of  a  large  pin's 
head,  are  seen  scattered  over  the  mucous  membrane  of  palate,  fauces,  and  pharynx. 
The  mucous  membrane  of  the  fauces  and  pharynx  is  of  a  deep  red  colour ;  no  ulcers 
visible;  no  cougli ;  no  expectoration.  Digestive,  respiratory,  and  other  symptoms 
are  normal. 

Progress  op  the  Case. — Under  local  application  to  the  pharynx  with  a  sponge, 
of  the  nitrate  of  silver  solution  (  3ss  of  crystallized  nitrate  to  §  j  of  distilled  ivater)  the 
sense  of  dryness  and  the  difficulty  of  swallowing  saliva  were  reheved;  his  strength 
improved  under  good  diet,  and  he  was  dismissed  Dec.  29th. 

CommentarT/. — Pharyngitis  is  generally  indicated  by  a  high  degree  of 
redness  with  thickening  of  the  mucous  membrane  ;  and  in  certain  specific 
forms  of  it,  ulceration  is  likely  to  occur.    For  a  knowledge  of  follicular  pha- 

*  Reported  by  Mr.  Alexander  Turnbull,  Clinical  Clerk. 


DISEASES   OF   THE    MOUTH,    PHAEYXX,    AND   (ESOPHAGUS.   423 

ryngitis,  and  its  importance  in  relation  to  diseases  of  tlie  larynx,  we  are 
indebted  to  Dr.  Horace  Green  of  Xew  York.  There  can  be  no  doubt 
that  many  cases  of  chronic  cough,  generally  denominated  bronchitis, 
chronic  laryngitis,  or  clergyman's  sore  throat,  are  dependent  on  this 
lesion,  and  as  "little  that  they  are  to  be  cured  or  greatly  alleviated  by 
appropriate  applications  made  to  the  part.  For  an  account  of  these, 
however,  i  must  refer  to  what  is  said  under  the  head  of  Laryngitis. 


Case  XLYlll.*— Stricture  of  the  (Esophagus  from  EpUMionM. 

History.— William  Porter,  set  68,  a  brassfounder — admitted  May  2d,  1855. 
Two  years  ago  a  cab  ran  over  his  abdomen,  across  the  epigastric  region.  He  vo- 
mited a  considerable  quantity  of  blood  for  a  few  days  afler,  and  felt  a  pain  in  the 
back.  From  the  pain  then  felt  he  soon  recovered,  and  enjoyed  ordinary  health  till 
four  months  before  admission.  He  then  for  the  first  time  experienced  a  sense  of 
obstruction  to  the  p.agsage  of  food  at  the  lower  part  of  the  gullet.  The  dysphagia 
had  gradually  increased,  and  has  latterly  been  attended  with  paui.  He  has  had  no 
cough,  and  no  haemoptysis. 

Symptoms  ox  Admission". — Skin  dry,  patient  greatly  emaciated;  pulse,  68  per 
minute,  weak  and  irregular ;  the  tongue  is  covered  with  white  fur.  The  fauces  are 
natural ;  his  food  consists  of  bread  or  biscuit  steeped  in  tea,  milk,  or  water ;  he 
does  not  dare  to  swallow  more  sohd  food.  That  which  he  takes  (in  the  presence  of 
the  clerk)  is  returned  within  two  or  three  minutes.  The  patient  believes  that  the 
food  vomited  has  not  entered  the  stomach ;  being  asked  to  point  to  the  spot  where 
he  feels  it  stop,  he  puts  his  finger  on  the  sternum,  at  the  level  of  the  fifth  costal 
cartilage.  He  feels  pain  when  the  food  reaches  this  spot.  Three  weeks  ago,  for  a 
fortnight,  the  pain  was  felt  constantly,  even  when  no  food  was  being  taken.  The 
smaller  portion  of  food,  wliich  passes  the  obstruction  and  enters  the  stomach,  is 
retained  with  only  sliglit  uneasy  sensations.  There  is  no  tumour  to  be  detected  in 
the  epigastrium ;  the  hepatic  organ  is  normal  in  size ;  the  abdominal  walls  are 
easily  excited  to  rigidity.  The  bowels  are  costive ;  no  blood  has  ever  been  passed 
by  stool.  Nervous  and  other  systems  normal.  Nutrients  to  be  taken  in  small  quan- 
tities, in  a  liquid  form,  often  repeated. 

Progress  of  the  Case. — May  ith. — Tongue  clean ;  pulse  68,  stronger  than  on 
admission.  Vomiting  appears  to  be  longer  delayed.  3Iaij  8th. — A  probang  passed 
readily  along  the  oesophagus  to-day ;  there  is  less  uneasiness,  but  no  greater  power 
in  swallowing.  Jlay  9th. — Complains  of  extreme  weakness;  asks  for  beer,  which 
is  granted.  May  lOth. — About  2  p.m.,  while  taking  a  mouthful  of  beer,  he  sud- 
denly fell  back ;  the  mouth  open ;  the  neck  stiff ;  the  pupils  slightly  contracted ;  the 
eyes  turned  upwards ;  incoherent  muttering,  without  consciousness.  His  face  was 
pale ;  he  lay  gasping  for  breath ;  there  was  a  tracheal  rale,  and  a  fremitus  was 
felt  over  the  whole  chest.  An  inefiectual  attempt  to  vomit  was  followed  by  in- 
creased distress.  He  rapidly  sank,  and  finally  expired  at  ten  minutes  to  three 
o'clock. 

Sectio  Cadaveris. —  Twentij-two  hours  after  death. 

Chest. — Tliere  was  a  little  recent  soft  yellowish  lymph  over  the  pleura,  covering 
the  lower  part  of  the  left  lung.  The  subjacent  pulmonary  tissue  felt  firm,  was  of  a 
dark  colour,  and  presented  a  granular  section ;  it  was  also  friable,  and  portions  of 

*  Reported  by  Mr.  Q.  M.  Reid,  Clinical  Clerk. 


424  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

it  sank  iu  water.  About  two  inches  above  the  cardiac  extremity  of  the  oesophagus 
there  was  found  an  epithehal  ulcer,  nearly  encircling  the  tube.  On  slitting  it  up, 
this  ulcer  was  seen  to  be  of  a  circular  form,  an  inch  and  a  half  in  diameter.  Its 
surface  was  raised  about  one-eighth  of  an  inch  above  the  level  of  the  mucous  mem- 
brane, and  presented  the  appearance  of  a  pultaceous  mass,  of  a  dirty  white  matter, 
resembling  gruel  On  scraping  a  portion  of  it,  its  base  was  seen  to  be  composed  of 
a  whitish  curdy  matter,  easily  breaking  down  when  pressed  between  the  fingers. 
The  muscular  coat  below  was  incorporated  with  the  ulcer,  and  much  thickened,  so 
as  to  produce  a  stricture  of  the  tube,  through  which,  however,  the  forefinger  could  be 
readily  passed.  Above  the  stricture  the  oesophagus  was  dilated  into  a  pouch  the 
size  of  an  orange. 

All  the  other  organs  were  healthy. 

Microscopic  Examixatiox. — The  ulcer  presented  the  usual  structure  of  epithe- 
lioma, as  described  and  figured  pp.  177. 

Case  XLIX.* — Epithelmnatoics   Ulceration  of  the    (Esophagus,  communicating    with 
the  Lung. — Pneumonia  terminating  in  Gangrene. 

History. — John  Eraser,  set.  55,  a  flesher — admitted  September  19tli,  1855. 
States  that  for  five  or  six  years  previous  to  admission,  his  health  had  been  excellent ; 
and  that  he  took  his  food  without  any  sense  of  uneasiness,  until  three  or  four  weeks 
ago.  He  then  for  the  fii'st  time  felt  as  if  a  ball  of  wind  rose  from  his  stomach  to 
meet  the  food,  and  the  food  in  its  passage  also  gave  him  pain.  The  pain  was 
gnawing  and  paroxysmal.  During  the  last  eleven  days  he  has  brought  up  his  food 
after  abortive  attempts  to  swallow  it,  and  for  four  days  he  has  lived  on  gruel,  not 
being  able  to  swallow  any  solids. 

Symptoms  on  Admission. — Tongue  covered  with  white  fur;  fauces  natural; 
appetite  reported  to  be  good ;  thirst  not  great ;  food  consists  of  gruel  or  bread  and 
biscuit  soaked  m  fluid.  Says  that  the  food  iu  passing  down  into  his  stomach  gives 
him  great  pain  opposite  a  point  half  an  inch  above  the  lower  end  of  ensiform  carti- 
lage ;  it  is  returned  from  the  stomach  in  a  few  minutes,  again  causing  him  pain  at 
the  same  spot.  He  adheres  constantly  to  this  declaration.  Has  no  nausea ;  never 
vomited  blood  or  dark-coloured  matter.  Abdomen  is  everywhere  tympanitic.  No 
tumour  can  be  detected.  Dulness  of  the  liver  normal  The  bowels  are  very  rarely 
opened.  The  pulse  is  82,  rather  small  and  weak.  Respiratory  and  other  symptoms 
are  normal  To  have  nutritive  diet  in  a  fluid  form,  in  small  quantities  often  re- 
peated. 

Progress  of  the  Case. — From  September  22d  to  October  2d.  Has  been  taking 
thrice  daily  the  following  powders: — IJ  Bismuthi  Trisnitrat.  3  j;  Pulv.  Opii gr.  ij.  M. 
et  divide  in  pmlveres  duodecem-.  The  dysphagia  continues  unrelieved ;  the  pain  over 
ensiform  cartilage  is  felt  as  formerly ;  and  there  has  been  also  a  sharp  internal  pain 
over  the  mammaiy  regions.  October  Wth. — Describes  a  pain,  as  if  his  flesh  were 
being  torn  away,  passing  from  the  lower  dorsal  vertebrae  to  the  epigastrium.  Ex- 
perienced temporary  and  partial  relief  from  a  Mister  a2}plied  to  the  epigastrium.  Oct. 
IQth. —  Ordered  three  ounces  of  sherry  wine  daily,  and  scruple  doses  of  the  hyjMstdphite 
of  soda.  Nbv.Sth. — No  diminution  in  the  pain,  dysphagia,  or  vomiting.  Oi'dered 
one  drop  of  Fleming^s  tinctuix  of  aconite  thrice  daily.  Nov.  IZth. — Vomiting,  pain, 
and  weakness  continue.  The  aconite  is  discontinued,  and  naphtha  medicinalis  in  ten- 
drop  doses,  with  compound  tinct.  of  cardamoins,  is  substituted.  On  the  26th  Nov.  this 
mixture  was  also  slopped,  and  ice  was  ordered.     Dec.  7th. — Strong  beef-tea  injec- 

*  Reported  by  Messrs.  G.  M.  Reid  and  R.  P.  Ritchie,  CUnical  Clerks. 


.'  DISEASES   OF   THE   MOUTH,    PHARYNX,    AND   (ESOPHAGUS.   425 

tions  per  rectum  are  now  ordered  night  and  morning.  Dtc.  IGih. — To-day  vomited 
round  masses  looking  lilce  blood,  and  under  microscope,  blood  corpuscles  are  recog- 
nised ill  them.  Dec.  23d. — Blood  corpuscles  are  found  in  the  vomited  matters  to- 
day. Pulse  small,  weak,  120  per  minute.  Dec.  28th. — Has  had  a  hiccup  for  a  few 
days  past;  pulse,  100,  very  feeble,  sometimes  intermitting.  Thirst,  which  he  did 
not  feel  on  admission,  has  lately  been  urgent.  Jan.  4th. — Has  slight  pain  over  right 
hypochondrium ;  increased  on  pressure ;  fine  moist  rales  are  audible  over  base  of 
right  lung  posteriorly,  with  inspiration.  The  urine  is  not  coagulable,  but  is  defi- 
cient m  chlorides.  Jan.  5lh. — Deficiency  of  chlorides  confirmed  to-day.  Dulness, 
increased  vocal  resonance,  and  crepitation  with  inspiration,  are  detected  over  lower 
two-thirds  of  right  lung  posteriorly.  Pulse  weak,  small,  and  scarcely  perceptible. 
To  have  §  ij.  of  wine  additional.  Jan.  1th — Same  signs  as  in  last  report.  Chlorides 
are  more  abundant.  Weakness  extreme.  Jan.  8th. — Chlorides  again  decreased; 
the  pulse  is  imperceptible  ;  the  skin  cold ;  in  the  evening  vomited  three  ounces  of 
bright  red  blood.     He  died  almost  immediately  afterwards  at  9  p.m. 

Seciio  Cadaveris. — Sixty-two  hours  after  death. 

The  body  was  much  emaciated. 

Throat. — The  larynx,  pharynx,  and  cervical  portion  of  oesophagus  were  natural. 

Thorax. — The  heart  was  natural.  There  were  a  few  adhesions  in  the  left  pleura, 
but  the  lung  was  healthy.  On  the  right  side  of  the  chest  there  were  firm  adhesions 
superiorly,  and  on  the  external  lateral  aspect.  In  attempting  to  remove  tlie  lung  a 
fuugating  growth  situated  over  the  spinal  column  was  broken  into.  This  growth 
(connected  with  the  oesophagus)  was  found  to  have  involved  a  portion  of  the  tissue 
of  the  right  lung  near  its  root.  On  removal  of  the  oesophagus,  it  was  seen  that  a 
portion  of  it,  about  three  inches  in  length,  commencing  a  little  above  the  root  of  the 
lung,  and  going  down  to  about  an  inch  above  the  diaphragm,  was  converted  into  a 
fungating  substance  of  soft  cheesy  consistence.  A  part  of  anterior  wall  of  the 
oesophagus  had  been  broken  down  and  removed  in  taking  out  the  right  lung;  the 
whole  of  the  internal  aspect  of  the  affected  portion  of  the  oesophagus  presented  a 
fungating  ulcerated  surface.  The  calibre  of  the  tube  must  in  consequence  have 
been  much  diminished.  The  lower  end  of  the  oesophagus,  as  well  as  the  stomach 
and  pylorus,  were  natural.  In  the  stomach  there  were  three  ounces  of  a  brownish 
fluid  resembling  coflee  grounds. 

On  removing  and  cutting  into  the  right  lung,  a  cavity  about  the  size  of  a  walnut 
was  found  in  its  posterior  part,  a  little  above  the  root  of  the  lung.  This  cavity  was 
filled  with  a  brown  foetid  fluid,  and  the  surrounding  pulmonary  tissue  was  softened, 
hepatized,  and  broken  down.  Higher  up  were  two  smaller  cavities,  presenting 
similar  characters,  and  surrounded  by  a  layer  of  condensed  pneumonic  substance. 

The  abdominal  organs  were  natural. 

Microscopic  Examination. — The  fungating  mass  presented  all  the  usual  appear- 
ance of  epithelioma,  containing  imbedded  in  the  deeper  friable  portion  of  the 
growth,  numerous  masses  of  concentrically  arranged  cells,  such  as  are  rej^resented 
Fig.  212,  p.  177. 

Comynentary. — Epithelioma  of  the  oesophagus  was  present  in  the 
two  cases  above  recorded  in  different  degrees.  In  Case  XLVIIL,  the 
disease  was  limited  to  a  patch  about  one  and  a-half  inch  in  diameter, 
causing  at  that  point  a  stricture  of  the  tube,  and  immediately  above  it 
a  considerable  dilatation.  From  the  impossibility  of  taking  nourish- 
ment, extreme  debility  was  induced,  of  which  he  died.  In  Case 
XLIX.,    the    epithelioma    was    more    extensive,  surrounding   the    oeso- 


426  DISEASES   OF   THE   DIGESTIVE   SYSTE^I. 

phagns  internally  over  a  space  three  inches  in  depth,  causing  great 
thickening  of  the  tube  extending  through  all  the  coat,  and  even  affect- 
ing the  root  of  the  right  lung.  The  whole  of  the  involved  tissues 
were  of  the  consistence  of  soft  cheese,  and  here  and  there  pulpy  and 
even  diffluent.  It  was  evident  that  at  length  a  comniuuication  was 
formed  between  the  oesophagus  and  the  lung,  the  occurrence  of  which 
was  indicated  by  a  pneumonia,  v\ith  all  the  physical  signs  and  general 
symptoms  characteristic  of  that  lesion. 


Case  L.* — Carcinomatous  Stricture  of  (EsopJia^us — Cancer  of  the  Liver — Pidmonary 
Emphysema  and  Tubercle — Pneumonia. 

History.— John  Currie,  set.  53,  a  cooper— admitted  18th  February,  1857.  "Was 
accustomed  to  drink  hea-vily  tiU  within  the  last  half  year.  Was  weU  fed,  strong, 
and  healthy.  Has  had  rheumatic  fever  thrice,  the  last  time  being  twelve  years 
ago,  without  any  cardiac  symptoms  which  he  can  remember.  Had  inflammation 
of  the  chest  eighteen  years  ago.  Had  general  dropsy  nme  months  ago ;  entered 
the  hospital  and  was  discharged  cured  in  three  weeks.  It  is  about  six  months 
ago  since  the  patient  first  experienced  pain  in  the  epigastrium  after  taking  food, 
with  pyrosis  and  anorexia  For  three  months  he  continued  in  this  state,  losing 
flesh  and  becoming  weaker.  Three  months  ago  he  began  to  vomit  his  food,  at 
first  m  the  evening,  and  subsequently  during  and  after  all  his  meals.  He  has 
vomited  a  little  blood  on  three  or  four  occasions.  The  character  of  the  vomited 
matters  is  reported  by  him  to  have  been  as  at  present. 

STiiPTOMS  ox  ADinssiox. — The  tongue  is  clean ;  there  is  no  pain  nor  any  diffi- 
culty in  swallowing  tiU  the  food  readies  a  point  which  he  indicates  as  beneath  the 
lower  part  of  the  sternum  and  the  epigastrium  He  has  to  rest  after  each  mouthfiil 
tin  the  food  passes  this  point.  If  it  passes,  he  has  no  further  pain  ;  but  the  greater 
part  does  not  pass,  and  causes  him  great  pain  tUl  it  is  dislodged  by  vomiting.  The 
matter  vomited  consists  of  undigested  food  and  clear  mucus.  Fluids  and  sohds 
are  equally  troublesome  for  him  to  swallow.  He  has  often  hiccup  while  eating,  and 
brings  up  flatus  with  great  relief  He  feels  a  constant  '•  working"  at  his  stomach. 
There  is  a  fulness  and  resistance  on  palpation  over  epigastrium ;  but  little  tender- 
ness, and  no  tumour.  The  area  of  hepatic  dulness  vertically  below  the  nipple  mea- 
sures three  inches,  and  laterally  three  and  a-halC  Xo  splenic  enlargement  detected. 
Xo  abnormality  on  examination  of  abdomen.  Bowels  are  rather  costive.  The 
cardiac  dulness  at  the  level  of  the  nipple  is  If  inch.  The  apex  is  felt  and  distinctly 
seen  beating  in  the  sixth  intercostal  space,  and  it  is  seen  also  in  the  fifth  intercostal 
space.  These  two  pulsations  alternate,  or  are  not  exactly  synchronous.  At 
the  apex,  over  a  Umited  area  of  about  one  square  mch,  a  short,  blowing  murmur, 
not  loud,  is  heard  with  the  first  sound,  the  second  sound  being  healthy.  At  the 
base,  both  sounds  are  feeble,  but  fi-ee  from  abnormal  murmur.  The  pulse  is  76 ; 
irregular  in  rhythm.  The  respiratofy  system  is  normal,  with  the  exception  of  a 
few  snoring  rales  posteriorly.  The  urine  is  high-coloured,  sp.  gr.  1027;  not 
albuminous. 

Progress  of  the  Case. — I  took  charge  of  this  case  on  the  1st  of  May,  up  to 
which  time  his  symptoms  had  continued  the  same,  notwithstanding  careful  regula- 
tion of  his  diet  and  the  administration  of  morphia,  tr.  ferri  muriatis,  creosote,  wine, 
and  the  application  of  a  blister.  The  report  on  May  I2this: — Xo  improvement; 
pain  in  the  epigastrium  stUl  severe.      He  is  weaker,  much  emaciated,  and  destitute 

*  Reported  by  Messrs.  J.  T.  Walker  and  VT.  H.  Davies,  Clinical  Clerks. 


DISEASES   OF   THE    MOUTH,    PHARYNX,    AXD   CESOPHAGUS.   427 

of  appetite.  Jfaij  80th. — Patient's  diet  now  consists  of  arrow-root  twice  daily, 
beef-tea,  tea  and  bread,  and  §  iv  of  sherry  wine.  He  is  unable  to  take  any  other 
nourishment.  Since  admission,  has  been  rarely  out  of  bed.  June  lOth. — No 
change  in  symptoms.  Continues  same  diet.  July  1st. — For  the  past  week  the 
strength  has  gradually  increased.  He  has  been  up  out  of  bed  for  several  days,  and 
to-day  he  ventured  into  the  green  for  a  short  time.  Has  some  calf's  foot  jelly. 
July  I9th. — Has  relapsed:  he  now  feels  a  constriction  higher  up  in  the  oesophagus, 
opposite  the  lower  part  of  his  throat,  and  is  unable  to  swallow  even  the  little  he 
has  hitherto  taken.  Is  greatly  emaciated.  Weakness  extreme.  July  21  ih. — 
Complains  now  wholly  of  the  restriction  superiorly.  Beef-tea  enemata  with  port 
wine  have  been  ordered  four  times  a  day.  July  30ih. — Enemata  discontinued  from 
the  resistance  of  the  patient.  He  is  able  to  swallow  wine,  which  he  relishes. 
Aug.  2d. — Since  last  report,  in  same  state,  but  more  feeble ;  Ues  very  much  on  his 
left  side ;  groans  at  intervals,  his  voice  being  comparatively  strong ;  but  articulation 
is  very  indistinct.  Has  no  cough  nor  apparent  dyspnoea.  Not  taken  any  food  for 
four  days.     Aug.  3d. — Died  apparently  from  exhaustion  at  10.30  p.m. 

Sectio  Cadaveris. —  Thirty-nine  hours  after  death. 

Body  presented  the  last  stage  of  emaciation,  the  abdominal  wall  at  the  umbilicus 
being  so  retracted  as  to  be  in  contact  with  the  vertebral  column. 

Thorax. — The  pericardium  was  universally  adherent ;  the  adhesions  were  old 
and  firm.  The  lower  half  of  each  aortic  valve  was  thickened  and  almost  rigid;  but 
on  trial  there  is  no  incompetence.  The  heart  weighed  nine  and  a  half  ounces,  the 
left  ventricle  being  slightly  thinner  than  usual.  Both  lungs  were  emphysematous 
anteriorly ;  and  throughout  the  spongy  portion,  indurated  nodules  could  be  felt,  vary- 
ing in  size  from  a  coffee  bean  to  that  of  a  hazel  nut.  On  section,  these  presented 
aggregations  of  miUary  tubercle  of  a  yellow  colour,  for  the  most  part  of  cheesy  con- 
sistence, but  here  and  there  softened,  forming  purulent  collections  and  small  abscesses 
the  size  of  a  pea.  In  the  left  lung,  the  posterior  third  of  the  lower  lobe  presented 
all  the  characteristics  of  red,  in  one  or  two  places  passing  into  grey,  hepatization.  In 
the  right  lung,  posteriorly,  were  two  or  three  masses  of  red  hepatization  the  size  of  a 
walnut. 

Digestive  Orgaxs. — The  posterior  third  of  the  tongue  presented  a  tuberculated 
appearance ;  the  mucous  membrane  on  section  was  found  thick,  dense,  almost  carti- 
laginous, of  greyish  colour,  and  yielding  on  pressure  a  thin  greyish-white  juice.  The 
mucous  membrane  of  the  pharynx  was  natural.  In  the  oesophagus,  an  inch  and  a 
half  above  the  bifurcation  of  the  trachea,  there  existed  a  stricture  admirting  only  the 
point  of  the  little  finger.  When  opened,  the  mucous  membrane  appeared  natural, 
the  sub-areolar  tissue  somewhat  thickened.  Lower  down  the  cardiac  orifice  was 
felt  excessively  contracted,  so  that  nothing  larger  than  a  crow's  quill  could  be  passed 
through  it.  The  stricture  extended  along  nearly  two  inches  in  length,  being  strictly 
limited  to  the  oesophagus.  The  liver  and  stomach  being  removed  together,  a  large 
mass  of  greyish-white  colour  and  firm  consistence  was  found  projecting  from  the 
posterior  surface  of  the  liver,  and  firmly  adherent  to  the  cardiac  portion  of  the 
stomach  just  where  the  oesophagus  enters  it.  From  the  surface  of  the  hver  there 
projected  other  rounded  masses  of  greyish-white  colour,  with  central  depressions, 
and  so  firm  as  to  creak  under  the  knife.  On  laying  open  the  stricture,  the  mucous 
membrane  was  found  not  ulcerated;  but  in  the  sub- mucous  tissue  was  deposited 
hard,  cancerous  matter,  not  separable  by  any  margin  from  the  similar  substance 
already  described  as  projecting  from  the  liver.  The  stomach  was  contracted,  but 
otherwise  healthy. 

Abdomen. — The  kidneys  felt  indurated ;  but  when  examined,  appeared  natural. 


428  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

The  spleen  weighed  onlj'  two  ounces;  its  structure  was  natural     Other  organs 
healthy. 

Microscopic  Examination. — The  cancerous  masses  in  the  liver  and  in  the  oesopha- 
gus contained  numerous  large  cancer  cells  in  all  stages  of  development,  embedded 
in  a  fibrous  stroma.  The  tubercles  in  the  lungs  exhibited  the  usual  appearance  of 
mDiary  tubercle  in  various  stages  of  disintegration,  associated  with  pus.  The  red 
and  grey  hepatization  was  composed  of  an  exudation  in  the  air-cells  and  smaller 
bronchial  vessels,  which  presented  various  stages  of  transformation  into  pus,  being 
most  recent  in  the  former,  and  most  perfect  in  the  latter.  Many  of  the  pus  cells 
contained  fatty  granules,  and  exhibited  different  degrees  of  disintegration. 

Commentary. — This  man  literally  died  of  starvation,  from  tlie  utter 
impossibility  of  introducing  nourishment  into  tlie  system.  The  cancer- 
ous mass  originally  formed  in  the  liver,  had  surrounded  and  compressed 
the  cesophagus  and  cardiac  orifice  of  the  stomach,  so  as  to  reduce  the 
canal  to  the  size  of  a  crow's  quill,  a  stricture  that  extended  through  a 
curved  line,  nearly  two  inches  long.  A  second  stricture,  but  not  to  so 
great  an  extent,  existed  above  this  in  the  oesophagus.  It  is  not  surpris- 
ing, therefore,  that  at  last  no  kind  of  nourishment  could  pass  these  ob- 
structions, the  absence  of  contractile  power  in  the  diseased  oesopliagus 
above  being  insufficient  to  propel  even  fluids  through  the  stricture  below. 

What  appears  to  me,  however,  the  most  remarkable  feature  in  this 
case,  is  the  occurrence  in  the  same  individual  of  recent  cancer,  tubercle, 
and  pneumonia.  Whether  the  tubercle  or  the  cancer  was  first  formed, 
it  becomes  exceedingly  difticult  to  determine,  but  certainly  the  nodulated 
groups  of  miliary  tubercle  in  the  lungs  were  in  every  respect  similar  in 
general  appearance  and  structure  to  what  is  observable  in  phthisical  cases. 
It  is  true  there  was  no  especial  accumulation  of  tubercle  at  the  apex  of 
either  lung,  neither  was  there  cough,  nor  any  symptoms  of  pulmonary 
disease  shown  throughout  the  whole  course  of  his  disease.  But  as  a 
decided  form  of  exudation  its  presence  was  undoubted.  The  pneumonia 
must  have  come  on  during  the  latter  days  of  his  life,  when  he  was  in  a 
state  of  extreme  weakness.  But  it  occasioned  no  active  symptoms,  and 
though  conjoined  with  great  emphysema  anteriorly  in  both  lungs,  produced 
no  dyspnoea.  The  pathological  fact,  however,  of  the  occurrence  of  these 
three  forms  of  exudation  in  one  individual  is,  though  undoubtedly  rare, 
well  calculated  to  demo.nstrate  the  fallacy  of  all  exclusive  views  as  to 
their  production  in  individuals  of  a  peculiar  diathesis. 

Temporary  dysphagia  occasionally  occurs  in  cases  of  hysteria  or  of 
spinal  iiTitation,  but  when  permanent  it  is  always  the  result  of  organic 
disease  of  the  pharynx  or  oesophagus.  In  the  great  majority  of  cases  it  is 
owing  to  some  growth,  cancerous,  epitheliomatous,  aneurismal,  or  of  some 
other  form,  which,  by  attacking  the  parts  themselves,  induces  stricture  of 
its  walls,  or  by  compressing  them  from  without,  causes  a  mechanical  ob- 
struction to  the  tube.  In  a  few  rare  cases  it  has  depended  on  pouch-like, 
or  spindle-form  dilatations,  which,  by  becoming  impacted  with  food,  have 
caused  the  impediment.  In  all  these  cases  the  cure  will  depend  on  the 
means  at  our  disposal  of  removing  the  obstructing  cause,  such  as  exter- 
nal tumours  compressing  the  part ;  but  if  it  depend  on  disease  of  the 
harynx  or  oesophagus,  the  treatment  must  be  for  the  most  part  pallia- 


FUNCTIONAL   DISOKDERS   OF   THE   STOMACH.  429 

tive.  There  may  be  a  simple  stricture,  which  may  require  surgical  in- 
terference by  bougies  or  catheters,  but  more  generally  as  observed  by  the 
physician,  it  is  the  result  of  cancer  or  epithelioma,  as  in  the  cases  nar- 
rated. Under  such  circumstances,  the  treatment  must  be  directed  to 
support  nutrition  by  unirritatingfood,  given  in  small  quantities  and  in  a 
form  that  the  patient  can  most  easily  swallow.  Remedies  of  various 
kinds  to  alleviate  or  check  the  vomiting  may  be  tried,  but  are  seldom  of 
permanent  benefit.  Very  rarely,  an  effort  at  healing  is  set  up  by  nature, 
which  for  a  time  causes  diminution  in  the  more  distressing  symptoms,  of 
which  Case  XIII.  is  a  remarkable  example. 


FUNCTIONAL  DISORDERS  OF  THE  STOMACH. 

Case  LI.* — Dyspepsia. 

History. — James  Scott,  set.  51 — admitted  27th  September  1852.  He  states  that, 
about  two  months  previous  to  admission,  he  experienced  severe  shooting  pains  dart- 
ing from  the  left  scapula  to  the  epigastrium  and  left  hypochondriura.  For  many 
j'ears  back  he  has  been  much  addicted  to  intemperate  habits,  and  latterly  his  appe- 
tite for  food  has  been  considerabl}^  impaired. 

Syjiptoms  on  Admissiox. — On  admission,  the  tongue  is  furred,  and  cracked  in 
the  centre ;  he  has  almost  constantly  a  sour  taste  in  the  mouth,  worse  in  the  morn- 
ing after  taking  food ;  frequent  acid  eructations ;  bad  appetite,  and  considerable  thirst. 
About  a  quarter  of  an  hour  after  meals  he  experiences  a  feeling  of  heat  and  pain  in 
the  epigastrium,  with  acid  eructations  and  flatulence;  the  latter  also  troubles  him 
during  the  night,  when  the  stomach  is  empty.  These  symptoms  continue  generally 
for  about  an  hour  and  a  half,  when  they  gradually  abate,  and  soon  after  disappear 
entirely.  He  then  again  takes  food,  and  the  symptoms  return  in  about  a  quarter  of 
an  hour  afterwards,  as  already  noticed.  He  does  not  think  that  one  kind  of  food 
disagrees  with  him  more  than  another.  He  has  often  much  nausea  and  loathing  of 
food,  but  no  vomiting.  There  is  some  tenderness  on  pressure  at  a  point  about  the 
centre  of  the  epigastrium,  where  he  states  there  is  always  more  or  less  pain,  gene- 
rally of  a  dull,  heavy  character,  but  sometimes  occurring  in  sharp  twinges,  shooting 
to  the  left  scapula,  and  somewhat  increased  on  pressure.  There  is  no  unusual  hard- 
ness or  tumour  to  be  felt ;  and  there  is  no  dulness  on  percussion.  There  is  no  ten- 
derness or  enlargement  of  the  liver ;  urine  normal.  He  is  of  a  very  desponding  dis- 
position, and  does  not  sleep  well  at  night.  Other  functions  normal.  5  Poiassce 
bicarbonatis,  3ij;  Tind.  Gentian  Co.  ^i;  Infus.  Gentian  Go.  ?v.  M.  ft  mist.  Half 
a  loine- glassful  to  be  taken  thrice  a-day. 

Progress  of  the  Case. — December  31s<.  Still  complains  of  flatulence  and 
distension  of  the  abdomen ;  considerable  pain  in  the  epigastrium,  increased  on  pres- 
sure. A'pplicentur  hirudines  quatuor  epiga^tr-io  et  jyostea  foveatur.  Jan.  3d  — 
Appetite  improved ;  still  acid  eructations,  with  sour  taste  in  the  mouth ;  pain  in  the 
epigastrium  relieved  after  the  application  of  the  leeches  and  warm  fomentations. 
He  is  very  desponding  about  his  complaints,  which  he  much  exaggerates.  Jan. 
10th. — The  sour  taste  and  flatulence  diminished ;  pain  and  uneashiess  in  the  stomach 
much  relieved ;  no  tenderness  on  pressure ;  appetite  much  improved ;  no  sickness 

*  Reported  by  Mr.  James  D.  Maclareu,  Clinical  Clerk. 


430  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

or  vomiting;  bowels  regular;  stools  natural.     Dismissed  in  order  to  return  to  his 
work.     The  diet  ordered  has  been  of  a  gentle,  unstimulating,  but  nutritious  kind. 

Commentary. — In  this  case  derangement  of  digestion  depended  on 
intemperate  habits,  and  was  accompanied  by  excess  of  acidity  in  the 
stomach.  The  treatment  was  directed  to  counteract  this  condition  by 
alkahes,  vegetable  bitter,s,  and  a  regulated  diet,  which,  to  a  certain  extent, 
succeeded.  But  all  such  cases  require  exercise,  regular  habits,  and 
moral  control,  without  which  medical  treatment  is  unavailing. 


Case  LII.* — Dyspepsia —  Oxaluria. 

History. — John  Millar,  a>t.  28,  a  typefounder— admitted  December  26th,  1852. 
He  states  that  he  had  always  enjoyed  good  health,  with  the  exception  of  occasional 
palpitation  of  the  heart,  until  about  eight  months  ago.  Vertigo  came  on  suddenly 
when  he  was  at  work,  but  disappeared  in  a  few  minutes.  Smce  then,  he  has  had 
many  attacks  of  the  same  kind ;  and  of  late,  these  have  been  accompanied  with 
pain  and  palpitation  of  the  heart,  and  tinnitus  aurium.  Some  years  ago  he  was 
much  addicted  to  drink,  but  for  the  last  four  years  he  has  been  more  temperate. 

Symptoms  on  Admission.— On  admission,  the  heart  was  found  to  be  healthy, 
and  the  pulse  natural.  The  tongue  was  dry  in  the  centre,  moist  and  white  at  the 
edges,  with  numerous  transverse  fissures.  He  had  a  disagreeable  taste  in  his  mouth 
in  the  morning,  and  no  appetite  for  food ;  had  never  vomited,  nor  experienced  pain 
in  the  stomach ;  bowels  constipated.  There  was  an  anxious,  haggard  expression  of 
countenance,  and  an  evident  tendency  to  exaggerate  his  symptoms ;  he  complained 
of  vertigo,  tinnitus  aurium,  and  muscffi  volitantes.  The  urine,  after  standing  some 
time,  exhibited  a  slight  deposit,  in  which  numerous  large  crystals  of  oxalate  of  lime 
were  visible  on  microscopic  examination;  sp.  gr.  1028;  otherwise  normal.  The 
other  functions  were  normal.  5  Acid.  nii. ;  Acid  mtriat.  aa  3  iss ;  Tinct.  gent.  co. 
§  i ;  Infus.  gent.  co.   "^y.  M.     A  table-spoonful  to  be  taken  three  times  a-day. 

Progress  cf  the  Case. — January  8Wi.— Since  last  report,  tlie  oxalates  have  dis- 
appeared, the  appetite  has  improved,  the  cardiac  and  cerebral  symptoms  are  removed, 
and  he  is  to-day  dismissed  cured. 

Commentary . — Dr.  Golding  Bird  was  the  first  to  point  out  that 
oxaluria,  associated  with  dyspepsia,  was  a  very  common  disorder,  and 
that  its  treatment  by  nitro-mnriatic  acid  was  the  most  successful  one. 
The  oxalic  acid  is  probably  derived  from  urea  or  uric  acid,  and  its  pre- 
sence in  the  urine  is  often  associated  or  alternates  Avith  these  compounds. 
No  doubt  the  tonic  treatment  practised  in  the  above  case  is  the  best 
mode  of  relief,  but  here  also  a  regulated  diet,  with  exercise  and  mental 
occupation,  are  necessary  to  render  the  benefit  permanent. 


Case  LIII.| — Dyspepsia — Hypochondriasis —  Oxaluria. 

HiSTORY.—Thomas  Pollock,  set.  24,  hawker— admitted  25th  December,  1852.  He 
says  that,  three  years  and  a  half  ago,  when  stooping  down  in  a  field  during  a  dark 
night  to  evacuate  his  bowels,  he  felt  a  sharp,  hard  body,  like  the  stump  of  a  shrub, 

*  Reported  by  Mr.  James  D.  Maclaren,  Clinical  Clerk. 
■J-  Reported  by  Mr.  William  Calder,  Clinical  Clerk. 


FUNCTIONAL   DISORDERS   OF   THE   STOMACH.  431 

penetrate  his  anus,  causing  acute  pain,  which  continued  for  a  fortnight,  and  has 
occasionally  returned  ever  since.  No  blood  passed  at  the  time,  but  he  has  been 
under  the  care  of  various  medical  practitioners,  and  undergone  numerous  kinds  of 
treatment.  He  has  never  had  diarrhoea ;  but  is  addicted  to  masturbation.  He  has 
consulted  the  numerous  works  advertised  in  the  papers  on  manly  vigour,  etc.,  but 
has  derived  no  benefit  from  them. 

SyJiPTOMS  ON  Admission. — On  admission,  tongue  moist,  but  furred,  cracked,  and 
fissured  in  the  centre  ;  says  he  experiences  a  feeling  of  load  after  taking  food,  with 
occasional  nausea.  He  has  no  vomiting,  but  an  acid  and  sometimes  disagreeable 
taste  in  the  mouth  ;  frequent  flatulence  and  constipation,  for  which  he  is  in  the  habit 
of  taking  aperient  medicine.  '  On  placing  the  hand  on  the  epigastrium,  he  says  that 
there  is  soreness  beneath  the  xiphoid  cartilage,  increased  on  pressure.  Has  occa- 
sional involuntary  emissions  of  semen.  The  urine  contains  a  slight  sediment  on 
standing,  which  is  crowded  with  large  and  small  crystals  of  oxalate  of  lime  ;  sp.  gr. 
1020;  otherwise  normal.  Sleepless  at  night;  anxious  and  desponding  about  his 
complaints,  which  he  attributes  to  the  accident  formerly  mentioned,  although  it 
produced  no  local  effects  at  the  time,  nor  any  structural  change  since.  Says  that  he 
has  frequent  vertigo,  tinnitus  aurium,  muscie  volitantes,  and  cephalalgia.  The 
other  functions  are  normal.  5  Acid,  nitrici ;  Acid,  muriat.  aa  3  i ;  Tinct.  gent.  co. 
1 1 ;  Infus.  gent.  co.  §  v.  if.     A  table-spoonful  three  times  a-day. 

Progress  of  the  Case  — January  3d — He  has  continued  to  take  the  acid  mix- 
ture, bat  does  not  admit  that  he  is  in  any  way  better.  On  the  2d,  the  oxalates  dis- 
appeared from  the  urine,  and  were  replaced  by  a  copious  deposit  of  amorphous 
lithates.  Omittatur mist.  a.cid.  ^  Liquoris potassce,  Z ii ;  Tine,  cardamom,  co.  §i; 
Infus.  quassias,  §  vii.  M.  Two  table-spoonfuls  night  and  morning.  Jan.  Aih.— As 
he  still  continues  to  complain  of  pain  in  the  sacral  region,  which  he  attributes  to  the 
accident,  a  blister,  three  inches  by  four,  was  ordered  to  be  applied  there.  Jan.  lOth. — 
Since  the  apphcation  of  the  blister  the  pain  in  the  sacrum  has  disappeared.  He 
expresses  himself  as  being  much  better,  and  was  now  dismissed. 

Commentary. — In  tins  case  the  presence  of  oxalates  in  the  urine  was 
associated  with  the  same  class  of  symptoms  as  in  the  former  one,  but 
the  tendency  of  the  patient  to  exag-geratc  his  complaints  was  more 
marked.  He  had  also  a  firm  belief'  in  their  being-  caused  by  an  acci- 
dent, wliich  possibly  never  happened,  and  even  if  it  had,  conld  not  have 
occasioned  his  symptoms.  The  acid  and  tonic  mixture  removed  the 
oxalates,  bnt  lithates  took  their  place  in  tlie  urine,  which,  in  their  turn, 
were  got  rid  of  by  alkalies.  Still,  the  fixed  idea  as  to  the  cause  of  the 
disease  continued,' and  he  seemed  no  better.  A  blister  was  now  applied 
to  the  sacrum,  and  he  readily  adopted  the  idea  that  his  local  com|'laints 
disappeared  with  the  pain  of  the  blister,  and  became  cheerful  and  well. 
No  case  could  better  illustrate  the  efi'ccts  of  mental  depression  on  the 
digestive  organs  than  this.  For  a  period  of  three  years  he  had  been  the 
subject  of  delusion  and  genital  irritations,  heightened  by  the  study  of 
those  publications,  which,  to  the  disgrace  of  the  newspaper  press,  are 
daily  advertised  to  the  people  as  the  only  means  of  restoring  vigour  to 
the  constitution.  At  length,  satisfied  with  their  ineflficiency,  he  entered 
the  Infirmary ;  the  error  of  his  practices  was  kindly  pointed  out  to 
him,  nutritious  diet,  regular  habits,  and  tonic  treatment  were  obviously 
beneficial  ;  and  fortunately  his  hypochondriasis  yielded  to  the  shnple 
expedient  of  substituting 'real  for  supposed  pain,  and  leading  him  to 
imao;ine  that  the  one  had  cured  the  other. 


432  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 


General  Patholoc/y  and  Treatment  of  Dyspepsia. 

Bv  dyspepsia  (from  (Jjo'irs'rrw;  I  digest  with  difficulty)  is  generally 
understood,  all  those  functional  derangements  of  the  stomach  which  are 
primary  in  their  origin,  that  is,  not  dependent  upon,  or  symptomatic  of, 
inflammation  or  other  disease  in  the  economy.  Such  a  disordered  con- 
dition is  exceedingly  common,  and  often  constitutes  the  despair  of  the 
physician,  arising,  as  it  frequently  does,  from  causes  which  are  obscure, 
or,  if  discovered,  are  beyond  his  control.  This  will  become  apparent 
by  considering,  in  the  first  place,  those  circumstances  which  require  to 
be  imited  to  secure  a  healthy  digestion.  These  are — 1st,  A  proper 
quantity  and  quality  of  the  ingesta.  2d,  Sufficient  mastication  and 
insalivation.  3d,  Active  contractility  in  the  muscular  coat  of  the  sto- 
mach. 4th,  Proper  quantity  and  quality  of  the  gastric,  biliary,  and 
pancreatic  fluids.  5th,  A  consecutive  and  harmonious  action  of  the 
intestinal  canal.  Dyspepsia,  or  indigestion,  may  be  produced  by  any 
cause  which  occasions  derangement  of  one  or  more  of  these  conditions ; 
and  hence  it  is  why  so  many  different  circumstances  may  produce  some- 
what similar  symptoms,  and  why  so  many  different  remedies  have  been 
found  effectual  in  various  cases.  Xotwithstanding  that  you  will  fre- 
quently meet  with  instances  which  baffle  all  preconceived  rules,  there 
can  be  no  doubt  that  a  careful  attention  to  the  essential  physiological 
conditions  above  enumerated  will,  in  the  great  majority  of  cases,  conduct 
Tou  to  a  successful  rational  treatment.     Thus — 

1.  Of  all  the  causes  of  dyspepsia,  excesses  in  eating  and  drinking  are 
the  most  common.  An  over-distended  stomach,  or  too  rich  a  meal, 
not  unfrequeutly  induces  a  feeling  of  weight  or  fulness  in  the  epigas- 
trium, nausea  and  eructation  of  acid,  bilious,  or  gaseous  matters,  with 
a  loaded  tongue,  headache,  and  other  general  symptoms.  This  is  acute 
dyspepsia,  or  the  embarras  gastrique  of  the  French.  Occasionally,  there 
is  more  or  less  vomiting  of  bilious  matter,  when  the  attack  is  vulgarly 
called  a  bilious  seizure.  If  called  to  see  such  a  case,  immediately  on  its 
occurrence,  and  before  the  ingesta  have  left  the  stomach,  as  determined 
by  the  sense  of  load  at  the  epigastrium,  and  by  percussion,  an  emetic 
should  be  given  ;  and  if  vomiting  be  present,  it  should  be  assisted  by 
warm  diluents.  As  soon  as  the  stomach  is  quieted,  or,  if  you  have  been 
called  in  at  a  late  period,  when  the  ingesta  have  passed  into  the  intes- 
tines, a  purgative  should  be  administered,  consisting  of  four  grains  of 
calomel,  with  four  of  compound  extract  of  colocynth,  followed  in  a  few 
hours  by  a  draught  of  salts  and  senna.  If  necessary  also  an  enema  may 
be  given.  The  purging,  with  a  day  or  two's  confinement  to  farinaceous 
food,  will  generally  get  rid  of  such  an  attack ;  but  their  fi-equent  repeti- 
tion leads  to  the  chronic  form  of  dyspepsia,  in  which  careful  regulation 
of  the  diet,  with  exercise,  must  constitute  the  chief  treatment.  Hence 
the  advantage  of  what  is  called  "  change  of  air,"  and  much  of  the  benefit 
which  is  derived  from  watering  places.  Chronic  dyspepsia,  however, 
is  far  more  commonly  caused  by  excess  of  spirituous  and  vinous  drinks, 
than  by  eating,  and,  in  such  cases,  abandonment  of  the  evil  habit  is  a 
si7ie  qua  non  in  the  treatment.     Tea  drinkers  are  very  liable  to  the  dis- 


FUNCTIONAL   DISORDERS   OF   THE   STOMACH.  4:33 

ease,  and  its  frequency  among  female  servants  is  probably  owing  to  over 
indulgence  in  this  beverage. 

2.  It  may  frequently  be  noticed,  that  those  who  liave  acquired  the 
habit  of  eating  rapidly  are  more  or  less  dyspeptic.  I  knew  a  journey- 
man printer,  who  had  been  much  tormented  with  indigestion,  but  who 
was  cured  by  changing  his  residence.  The  reason  of  this  cure  was  for 
some  time  a  mystery  ;  on  again  changing  his  house,  the  disease  returned  ; 
still  no  apparent  cause  couhl  be  discovered.  I  ascertained,  at  length,  that 
it  depended  not  on  the  locality  per  se,  but  on  its  distance  from  the 
printing  house.  When  far  off  he  ate  his  dinner  with  his  family  rapidly, 
having  only  just  time  enough  to  walk  home  and  back  within  the  hour. 
When  he  lived  near,  the  time  otherwise  spent  in  walking  was  occupied 
in  eating,  or  in  oheerfal  converse  with  his  wife  and  family.  Since  I 
made  this  observation,  it  has  often  occurred  to  me  that  the  distance  of 
the  residences  of  artisans  from  their  place  of  employment  may  be  the 
occasional  cause  of  the  dyspeptic  symptoms  they  frequently  suffer  from. 
The  exact  object  of  the  saliva  in  the  process  of  digestion,  whether  it  be 
to  convert  the  farinaceous  compounds  of  the  food  into  glucose,  or  by  its 
viscidity  to  mix  up  air  with  the  portions  swallowed,  is  not  positively 
determined;  but  its  necessity  for  digestion  is  shown  by  what  happens  in 
cases  where  the  under  lip  has  been  lost  by  accident  or  disease,  or  where 
salivary  fistulte  have  formed ;  in  such  cases  dyspepsia  is  generally  pre- 
sent, and  in  some  the  disordered  digestion  has  been  cured  by  operations 
that,  by  restoring  the  parts  to  their  normal  condition,  prevent  the  escape 
of  saliva.  Again,  persons  habituated  to  the  dirty  habit  of  spitting,  are 
for  the  most  part  dyspeptic.  In  all  cases  where  dyspepsia  can  be  traced 
to  this  source,  the  treatment  becomes  obvious. 

3.  The  contractile  movements  of  the  stomach  which,  by  kneading  the 
ino-esta,  and  keeping  them  in  constant  motion,  secure  their  intimate 
admixture  with  the  gastric  juice,  and  the  rapid  transference  to  the  duo- 
denum of  such  portions  of  it  as  are  transformed  into  chyme,  are  evidently 
of  great  importance  to  the  proper  performance  of  digestion.  The  experi- 
ments of  physiologists  have  shown  that  digestion  goes  on  in  gastric  juice 
taken  out  of  the  stomach  much  slower  than  in  the  stomach,  and  that 
section  of  the  pneumogastric  nerves,  by  arresting  the  contractile  move- 
ments, permits  only  the  circumference  of  the  mass  in  contact  with  the 
secreting  surface  to  be  digested.  These  facts  at  once  explain  the  well- 
known  influence  of  mental  emotions  upon  the  stomach.  Contentment 
and  hope  are  as  favourable,  as  dissatisfaction  and  despondency  are  inju- 
rious, to  good  digestion.  Nothing  is  more  common  than  dyspepsia 
among  literary  men  wdio  overtask  their  mental  faculties;  among  young 
persons  of  very  excitable  minds ;  and  among  individuals  of  a  melancholy 
temperament,  hypochondriacs,  etc.  etc.  It  is  in  such  cases  that  cheerful 
society,  active  and  appropriate  occupations,  change  of  scene,  removal 
from  mercantile  or  literary  employments,  variety  in  trains  of  thought, 
and  so  on,  are  beneficial.  Hence  also  many  of  the  good  effects  of  travel, 
visits  to  watering  places,  etc.  etc. 

4.  Our  knowledge  with  regard  to  the  offices  performed  by  the  gastric, 

28 


434  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

biliarv,  and  pancreatic  juices  in  digestion  Las  of  late  years  been  much 
advanced.  Thus,  the  gastric  juice  operates  more  especially  on  the  albu- 
minous, and  the  pancreatic  juice  on  the  fatty  compounds  of  the  food. 
The  function  of  the  bile  is  more  obscure ;  it  probably  acts  as  a  means  of 
precipitating  or  separating  some  of  the  excretory  matters  from  chyme, 
and  so  facilitates  assimilation  of  the  nutritive  portions.  Digestion  may 
be  deranged  by  all  tliose  causes  which  increase  or  diminish  too  much  the 
secretion  of  these  three  fluids.  Thus  excess  of  acidity  in  the  stomach  is 
one  of  the  most  conmaon  causes  of  dyspepsia,  and  is  associated  vvith  that 
form  of  it  which  accompanies  scrofulous  and  tubercular  diseases.  It 
may  be  in  such  excess  as  to  neutralise  the  alkaline  action  of  the  pan- 
creatic juice,  and  I'ender  it  incapable  of  emulsionising  fatty  matters.  In 
such  cases  the  alkalies,  with  bitter  tonics  and  the  direct  introduction  of 
animal  oils  in  excess,  are  indicated.  On  the  other  hand,  the  gastric  juice 
mav  be  diminished  in  quantity,  as  frequently  occurs  in  persons  who  sud- 
denly overtask  the  powers  of  the  stomach  at  feasts,  or  in  old  persons 
w'ith  feeble  digestion.  The  sense  of  load  after  eating  is  generally  indi- 
cative of  slow  digestion  from  this  cause.  In  acute  cases,  a  stimulant 
rouses  the  stomach  to  increased  action,  and  hence  the  moderate  use  of 
drams  and  generous  wines  after  dinner  is  occasionally  useful.  In  old 
persons  the  sense  of  load  and  feebleness  is  best  removed  by  giving  up  tea, 
and  drinking  at  night  a  little  weak  brandy  and  water.  In  chronic  cases, 
acids  are  indicated,  especially  muriatic  acid.  The  Tr.  Ferri  co.  of  the 
pharmacopoeia  is  a  useful  preparation  in  chlorotic  females.  The  pre- 
pared gastric  juice  of  the  calf  has  been  lately  recommended  as  a  remedy 
in  these  cases ;  and  is  undoubtedly  in  some  cases  of  much  service. 

We  have  no  distinct  means,  as  far  as  I  am  aware,  of  rousing  the 
pancreas  into  action,  and  yet  many  cases  are  on  record  in  which  fatty 
matters  have  passed  undigested  through  the  alimentary  canal  in  conse- 
quence of  obstruction  to  the  pancreatic  duct.  In  such  cases,  and  in  all 
those  in  which  fatty  matters  are  difficult  to  digest,  alkalies,  especially 
the  sodce  bicarb,  with  vegetable  tonics,  are  indicated. 

When  the  bile  is  deficient,  constipation  and  dyspepsia  are  usual 
results,  and  are  to  be  relieved  by  gentle  mercuidal  purgatives,  with 
extract  of  taraxacum,  and  by  remedies,  such  as  rhubarb,  and  especially 
the  compound  rhubarb  pill,  which,  by  acting  on  the  duodenum,  also 
favour  the  flow  of  bile  into  the  upper  part  of  the  alimentary  canal.  Dr. 
Clav  of  Manchester  has  recommended  in  such  cases  the  administration 
of  ox-gall,  a  remedy  which,  althoagh  not  extensively  given,  is  evidently 
rational,  and  calculated  by  its  purgative  action  to  be  highly  serviceable. 
Excess  of  bile,  on  the  other  hand,  ought  to  be  treated  by  drastic  purga- 
tives, diuretics,  and  diaphoretics,  according  to  circumstances,  to  cause 
excess  of  excretion.  Exercise  should  also  be  insisted  on  to  call  the 
lungs  into  action,  and  thus  relieve  the  liver  in  its  ofllce  of  separating 
hydro-carbon. 

5.  A  derangement  of  the  consecutive  and  harmonious  action  of  the 
alimentary  canal  is  another  frequent  cause  of  dyspepsia,  for  it  is  as 
necessary  that  those  portions  of  the  food  which  are  not  assimilable 
should  be  removed  out  of  the  economy,  as  that  the  nutritive  materials 
should  be  absorbed.     Hence,  whatever  impedes  the  contractility  of  the 


FUNCTIONAL   DISORDERS   OF    THE   STOMACH.  435 

intestinal  canal,  whatever  alters  the  structure  of  its  nnicous  membrane,  or 
whatever  mechanically  obstructs  its  calibre,  induces  dyspeptic  symptoms. 
The  removal  of  these  various  conditions,  whether  by  stimulating  the 
nervous  centres,  by  appropriate  diet,  or  by  purgatives  and  astringents, 
need  not  be  more  particularly  dwelt  upon  here.  I  would  only  observe 
that  the  constant  use  of  laxatives,  however  they  may  temporarily  relieve, 
cannot  cure,  and  that  in  all  chronic  cases  a  proper  action  of  the  bowels 
must  be  obtained  as  much  as  possible  by  means  of  dietetic  and  hygienic 
regulations. 

In  many  cases  of  dyspepsia,  two  or  more  of  these  classes  of  causes 
may  be  combined  so  as  to  render  the  indications  for  treatment  complex 
and  apparently  contradictory.  In  other  cases,  one  or  more  causes  may 
exist,  although  from  the  indications  present  their  nature  cannot  be  deter- 
mined ;  in  such  cases,  our  treatment  must  always  be  more  or  less  vague 
and  unsatisfactory.  Lastly,  there  are  a  few  instances  where  dyspepsia 
can  only  be  explained  by  idiosijncrasy,  in  which  we  find  this  or  that 
particular  article  of  diet  to  derange  the  digestive  functions,  and  in  which 
avoidance  of  the  oftending  cause  is  the  only  plan  of  treatment  that  is 
attended  with  success. 

In  addition  to  the  different  kinds  of  dyspepsia  to  which  I  have 
directed  your  attention,  it  is  practically  important  to  keep  in  remem- 
brance the  leading  symptoms  which  may  be  present,  and  the  remedies 
by  which  they  may  be  removed.  The  symptoms  are  anorexia,  acid 
eructations,  sense  of  load  at  the  stomach,  cardialgia,  vomiting,  flatulence, 
palpitations  of  the  heart,  and  cephalalgia.  Some  persons  talk  of  a  sto- 
mach cough,  but  this  is  more  commonly  dependent  on  sources  of  irrita- 
tion in  the  oesophagus  or  pharynx,  which  have  hitherto  been  overlooked. 
I  have  already  alluded  to  the  mode  of  treating  most  of  these  symptoms. 
Palpitations  of  the  heart  often  occasion  alarm  in  young  dyspeptic  per- 
sons ;  and  in  such  cases,  besides  remedies  directed  towards  the  stomacli, 
change  of  scene,  removing  attention  from  the  affected  organ,  and  varied 
reading,  should  be  enjoined.  The  sense  of  load  in  the  stomach  is  most 
frequently  removed,  as  I  have  previously  said,  by  acids  ;  and  sour  eruc- 
tations and  cardialgia  are  best  relieved  by  alkalies  and  bitter  tonics. 
Vomiting  and  flatulence  are  often  very  troublesome  symptoms.  The 
varied  remedies  which  may  be  employed  in  a  case  of  chronic  vomiting 
may  be  gathered  from  the  following  history  : — 


Case  JAY* — Dyspepsia — Vomiting  of  fermented  matter  containing  Sarcirm. 

History. — Thomas  Spence,  set  53,  a  weaver, — admitted  September  6,  1852.  He 
states  that,  for  fourteen  or  fifteen  years  past,  he  has  been  subject  to  occasional  vomit- 
ing, which  generally  occurred  on  Sundays,  owing,  he  supposes,  to  want  of  exercise 
at  his  usual  employment.  On  these  days  he  scarcely  ever  took  his  meals  from  fear 
of  the  almost  certain  vomiting  which  would  follow.  For  two  or  three  years  past  he 
has  been  liable  to  frequent  heartburn,  waterbrash,  and  acid  eructations,  but  was  able 
to  continue  at  his  usual  employment  till  about  six  months  ago.  Since  then,  he  has 
been  gradually  losing  his  appetite,  and  his  strength  has  become  much  prostrated. 

*  Reported  by  Mr.  "William  Calder,  Clinical  Clerk. 


4:36  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

He  has  never  vomited  blood  or  any  dark-coloured  matter,  and  has  never  passed  any 
such  by  stool. 

Symptoms  on  Admission. — On  admission  tongue  clean ;  no  difficult}-  in  deglu- 
tition ;  appetite  capricious,  but  always  best  in  the  morning  and  earlj^  part  of  the  day. 
Shortly  after  taking  food,  he  begins  to  have  uneasy  sensations  in  the  epigastrium, 
sickness,  and  a  sense  of  weight  at  the  stomach.  When  these  symptoms  appear,  the 
abdomen  generally  begins  to  swell,  and  in  about  an  hour  to  an  hour  and  a  half,  the 
food  is  vomited.  The  rejected  matters  consist  generally  of  the  half-digested  food, 
■with  a  thick,  dirty,  frothy  scum  on  the  surface,  resembling  yeast.  He  has  also  fre- 
quent pyrosis,  acid  eructations,  and  flatulence,  the  latter  sometimes  so  great  as  to 
occasion  a  sensation  of  choking,  especially  after  vomiting.  These  symptoms  are 
worse  after  some  kinds  of  food  than  others :  oatmeal,  especially  in  the  form  of  por- 
ridge, produces  them  in  the  severest  form ;  broths,  vegetables,  or  any  kind  of  slops, 
disagree  with  him  ;  animal  food  suits  him  best,  but  w'hen  even  this  is  taken  for  any 
length  of  time,  the  symptoms  soon  reappear.  The  abdomen  at  present  is  much 
swollen,  very  tense,  and  tympanitic  on  percussion,  with  considerable  tenderness  over 
the  epigastrium.  The  bowels  are  generally  constipated  ;  the  stools  usuallj'  of  a  dark 
colour  and  hard  consistence.  He  has  occasionally  slight  pain  and  difficulty  in  void- 
ing his  urine,  W'hicli  is  slightly  phosphatic.     Other  functions  are  normal. 

Progress  of  the  Case. — On  taking  charge  of  this  patient  on  the  1st  of  Novem- 
ber, I  found  him  vomiting  from  time  to  time  large  quantities  of  fluid  mixed  with  undi- 
gested matters,  on  which  there  gatliered,  after  a  shoi't  time,  a  thick  brownish  scum, 
exactly  resembling  yeast.  On  examining  this  scum  with  the  microscope,  it  was  ascer- 
tained to  contain  a  large  number  of  sarcinse  ventriculi  (see  p.  83,  Fig.  61),  mingled 
with  starch  corpuscles,  more  or  less  broken  down,  and  granular  matter.  Erom  the 
ward  books,  I  learnt  that  his  treatment  had  consisted  in  the  successive  administra- 
tion of, — 1.  The  local  application  of  leeches  ,•  2.  Of  the  sulj^hite  of  soda,  in  scruple 
doses,  with  two  grains  of  aromatic  powder  three  times  a  day ;  3.  Of  half  a  grain  of 
protochloride  of  mercury  at  night ;  4.  Of  a  scruple  of  the  sulphite  of  soda  every  three 
hours,  which  was  subsequently  increased  to  half  a  drachm ;  5.  Of  creasote  mixture  ; 
6.  Of  a  naphtha  mixture ;  7.  Of  bismuth  and  aromatic  powders ;  and  8.  Of  pills  of 
calomel  and  opium.  These  different  kinds  of  treatment,  some  of  which,  especially 
that  of  the  sulphite  of  soda,  had  been  continued  for  several  weeks  without  intermis- 
sion, seemed  to  have  produced  no  good  effect.  November  llth. — During  the  last  four 
days,  he  has  vomited  every  night,  four  hours  after  dinner,  that  is,  about  six  p.m. 
The  ejected  matter  presents  the  same  yeast-like  character  formerly  described  ;  but 
the  sarcinas,  though  still  abundant,  are  not  so  numerous.  He  complains  of  a  great 
sense  of  distension,  and  a  feeling  of  "  working  "  or  "  bubbling  "  in  the  stomach  shortly 
before  vomiting.  5  -^cid.  Bydrocyan.  dil.  m.  xviij ;  Syrup.  Aurant.  §  j ;  Aquce  §  v. 
M.,  half  an  oz.  three  times  a  day.  Nov.  20ih. — The  hydrocyanic  acid  checked  the 
vomiting  till  last  night,  when  it  returned  with  more  violence  than  ever.  Nov.  24t/i. 
— Vomiting  stiU  continues  regularly  every  day.  Omittatur  Mist.  Acid.  Hydrocyan. 
'^,  Liquor.  Pota^ss.  3  ss;  Aquce  §  vss.  Two  taUe-spoonfids  to  be  taken  every  four  hours. 
Dec.  2d. — Alkaline  mixture  again  checked  the  vomiting,  which,  however,  returned 
last  night  to  a  slight  degree.  Applicet  Vesical.  4X5  Ejngastrio.  Dec.  8ih. — Vomit- 
ing has  once  more  returned  daily  smce  last  report.  ]J  Ti7ict.  Ferri  Muriat.  §  i. 
Sumat  3  ss  ter  in  die  ex  aqua.  Dec.  I6th. — The  vomiting  has  been  again  checked, 
but  once  more  returned  in  a  slight  degree  at  one  a.m.  this  morning.  The  matter 
ejected  exhibits  very  little  of  the  usual  frothy  scum,  but  consists  of  a  brown  liquid 
like  coffee,  with  a  few  slu'eds  of  undigested  food.  It  is  of  intensely  acid  re-action, 
and  contains  only  a  few  sarcinte.  The  dose  of  the  Acid  Tincture  has  been  reduced 
to  M.  XV.     The  diet  during  this  period  has  been  principally  animal,  porridge  and  vege- 


rUNCTIOXAL   DISORDEES   OF   THE   STOMACH.  437 

tables  invariably  increasing  his  complaint.     To-day  he  left  the  hospital  to  visit  his 
friends  in  the  countr\',  expressing  himself  as  greatly  relieved. 

Commentary. — Tlie  kind  of  chronic  vomiting  and  dyspepsia  here 
spoken  of  has  been  long  known  in  Scotland,  and  was  described  by  Cul- 
len  as  a  form  of  pvrosis.  It  was  supposed  to  be  associated  with  the 
habit  of  largelv  consuming  oatmeal  as  a  principal  part  of  the  diet ;  but 
its  real  pathologv  was  unknown.  In  1843  Mr.  Goodsir  discovered  in  the 
ejected  matter  from  the  stomach,  in  a  case  of  this  kind,  organized  forms, 
which,  from  their  resembling  a  wool  pack,  he  denominated  sarchue.  He 
considered  that  they  were  of  a  vegetable  nature,  and  by  multiplying 
fissiparously,  give  to  the  contents  of  the  stomach  the  appearance  of 
yeast,  which  ts  also  known  to  be  dependent  on  the  development  and 
growth  of  vegetable  structures.  The  occurrence  of  these  sarcinse  in  the 
stomach  of  course  explains  their  frequent  presence  in  the  foeces,  although 
whether  thev  are  ever  developed  in  the  intestines  is  unknown.  In  two 
cases  I  have  seen  them  in  the  urine,  when  they  were  uniformly  smaller 
in  size  than  the  sarcince  ventriculi.  They  have  also  been  discovered  by 
Virchow  in  an  abscess  of  the  lung;  and  I  have  recently  seen  them  in 
the  juice  squeezed  from  an  oedematous  lung.  The  origin  and  exact 
mode  of  development  of  these  structures  are  unknown ;  but  their  pre- 
sence is  no  doubt  the  real  cause  of  the  chronic  vomiting  and  other 
symptoms  of  the  individuals  affected  ;  and  the  cure  of  the  disease  will 
depend  on  the  use  of  such  means  as  are  capable  of  insuring  their  de- 
struction and  preventing  their  return.  It  is  obvious,  however,  that  the 
means  which  destroy  or  check  vegetable  growths  on  the  external  surface 
of  the  bodv  (see  Favus),  are  not  applicable  to  the  mucous  lining  of  the 
stomach.  "Besides,  we  do  not  know  whether  these  parasites  grow  in  an 
exudation  poured  out  on  the  mucous  membrane,  or  are  developed  onlv 
in  a  fluid.  Ao-ain,  it  it-  very  possible  that,  on  being  introduced  from 
without,  the  conditions  necessary  for  their  development  may  be  depen- 
dent on  particular  kinds  of  ingesta — a  view  which  derives  support  from 
the  facts  observed  in  the  case  before  ns,  namely,  that  the  sarcinaj  were 
alwavs  increased  by  farinaceous  kinds  of  food.  On  all  these  points, 
however,  we  are  as  yet  ignorant,  and  our  efforts  at  cure  hitherto  have 
not  so  much  been  directed  to  cutting  off  the  sources  of  growth,  as  to 
destrovins:  the  sarcinse  after  it  has  proceeded  to  a  certain  extent.  With 
this  viewit  has  been  imagined,  that  the  sulphite  of  soda  would  destroy 
them,  bv  causing,  on  its  union  with  the  gastric  juice,  the  extrication  of 
sulphurous  acid,  which  is  so  destructive  to  vegetable  life.  This  remedy 
has  consequentlv  been  given,  and,  not  unfrequently,  with  success ;  but  in 
the  present  case  it  was  of  no  benefit.  Subsequently  a  variety  of  medi- 
cines Avere  administered,  several  of  which  succeeded  in  checking  the 
vomiting  for  a  time.  Indeed,  it  was  remarked  that  the  mere  circumstance 
of  chano-ing  the  medicine  was  sufficient  to  stop  the  vomiting  for  several 
davs,  when  it  returned  and  continued  as  before.  Of  all  the  numerous 
remedies  tried,  the  Tr.  Ferri  Muriatis  seems  to  have  done  most  good. 
The  following  case  offers  a  remarkable  contrast  to  the  one  just  given, 
for,  although  of  some  standing,  it  was  rapidly  cured  by  the  sulphite  of 
soda. 


438  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


Case  LY.* — Dys2)epsia — Vomiting  of  fermented  matter  containing  SarcincB. 

History. — Christina  Torrence,  vet.  18,  servant — admitted  July  11,  1853.  For 
the  last  three  j^ears  has  been  suftering  from  more  or  less  pain  in  tlie  stomach,  loss  of 
appetite,  and  occasional  vomiting,  generally  soon  after  meals.  The  ejected  matters 
have  always  been  very  acid,  and  have  varied  in  appearance  with  that  of  the  food 
taken,  which,  for  the  most  part,  consisted  of  tea  and  porridge,  with  ver}'  little  animal 
food.  She  is  thin,  and  her  general  strength  has  been  much  reduced.  She  has  taken 
all  kinds  of  medicines,  and  has  been  treated  homoeopathically  for  some  time  without 
the  slightest  relief 

Progress  of  the  Case. — On  admission  she  was  ordered  bismuth  and  aromatic 
powders,  which  slightly  alleviated  some  of  the  sj^mptoms.  On  the  14th,  however^ 
there  was  vomiting  of  a  brown  frothy  fluid,  to  the  extent  of  §  iv,  which,  on  micro- 
scopic examination,  was  demonstrated  to  contain  numerous  sarcinaj.  A  scruple  of 
Sulphite  of  Soda  was  ordered  to  he  taken  three  times  a-da]].  On  tlie  2 2d  vomiting 
again  returned,  but  the  rejected  fluid  contained  no  sarcinaj.  From  this  time  all  pains 
ceased,  other  symptoms  disappeared,  and  she  was  dismissed  quite  well  July  28th. 


ORGANIC  DISEASES  OF  THE  STOMACH. 

Case  LYI.f — Chronic  Ulcer  of  the  Stomach — Recovery. 

History. — Janet  Grant,  sii.  30,  married — admitted  14th  November,  1852.  She 
stated  that  she  enjoyed  tolerably  good  health  till  twelve  months  ago,  when  she  had 
an  attack  of  hsematemesis,  which  returned  on  three  successive  days  early  in  the 
morning.  The  vomiting  was  preceded  by  a  sense  of  weight  and  uneasiness  in  the 
epigastrium,  nausea,  dimness  of  sight,  and  feeling  of  syncope,  which  actually  occurred 
on  one  or  two  occasions.  After  vomiting  took  place,  she  generally  suS'ered  from 
severe  griping  pains  in  the  bowels  until  they  were  opened.  The  stools  were  often 
of  a  dark  brown  colour.  The  quantity  of  matters  ejected  from  the  stomach  varied 
from  one  to  two  pints,  and  contained  coagula  of  blood.  She  has  been  twice  received 
into  the  Infirmary,  and  on  both  occasions  dismissed  much  relieved.  After  January 
1852,  she  continued  in  good  health,  and  was  able  to  follow  her  usual  occupation  till 
the  3d  of  November,  1852,  when  the  hsematemesis  returned,  having  been  preceded 
by  the  symptoms  already  enumerated.  On  this  occasion  there  was  less  blood  than 
formerly ;  but  the  vomited  matter  still  contained  numerous  bloody  coagula.  She  had 
no  recurrence  of  vomiting  for  eight  days,  but  remained  very  weak,  and  was  confined 
to  bed.  On  the  11th  November  she  passed  by  stool  some  matters  like  slimy  tar. 
Since  then  she  has  frequently  vomited,  sometimes  as  often  as  three  or  four  times 
a-day,  a  quantity  of  matter  consisting  principally  of  dark-coloured  blood.  Tlie  pain 
in  the  head,  epigastrium,  and  between  the  scapulse,  has  increased  since  that  time. 

Symptoms  on  Admission. — On  admission,  tongue  moist,  slightly  loaded ;  appetite 
bad ;  food  is  rejected  from  the  stomach  almost  immediately  after  being  taken ;  pain 
and  tenderness  in  the  epigastrium  on  pressure;  slight  tenderness  over  the  whole 
abdomen,  which  becomes  much  distended  after  taking  food.  Bowels  rather  costive ; 
no  blood  in  the  stools  at  present,  and  no  blood  corpuscles  in  the  vomited  matters 
when   examined   by   the   microscope.      Urine   normal.      Other  functions   normal. 

*  Reported  by  Mr.  Joseph  Johnston,  Clinical  Clerk. 
•)•  Reported  by  Mr.  F.  M.  Russell,  Clinical  Clerk. 


ORGANIC   DISEASES   OF   THE   STOMACH.  439 

B  Sulph.  Magnes.  ^ss;  Acid.  Sulph.dil.  I'l;  Infus.  Eosarum  §  viij.  Sumant.  §ij, 
et  repehint.  eras  jnane.  5  Acid.  GaUic.  5  i;  Fidv.  Opii  gr.  iij.  M.  et  divide  inpulv. 
xij.     Sumai  unum  tei-  in  die. 

Progress  of  the  Case. — November  \^th. — Had  some  vomiting  to-day,  but  no 
blood.  Still  considerable  pain  in  epigastrium.  Bowels  freelj'  moved  by  medicine ; 
stools  very  dark  in  colour.  Xov.  17th. —  Omitt  Acid.  Gallic.  5  Bismuthi  albi  3  ss. 
Fidv.  Opii  gr.  iss.  M.  et  div.  in  pulv.  vj.  Sumat  unum  ter  in  die.  Farinace&u-s  diet. 
Nov.  ISih. — Complains  of  burning  pain  at  lower  part  of  the  sternum;  former  pain  in 
epio'astrium  somewhat  easier;  no  vomiting  since  the  16th;  bowels  open;  stools  still 
of  a  dark  colour ;  great  thirst ;  tongue  loaded  and  coated  with  brown  fur  in  centre  : 
with  bad  taste  in  the  mouth.  Nov.  20th. — StiU  considerable  pain  and  tenderness  in 
epigastrium,  which  is  now  referred  to  one  spot  about  the  size  of  a  crown  piece ; 
bowels  confined;  pulse  75,  natural.  Applicentur  hirudines  iv  epigastric.  Kep)etat. 
mist,  cathartic,  si  opus  sit.  Nov.  23d. — Complains  still  of  pain  m  epigastrium,  which 
was  slightly  relieved  by  the  leeches;  has  had  no  return  of  vomiting;  bowels  open. 
Applicet.  Vesical  (3  x  2)  epigastric.  Nov.  2(ith.—Fa.m  in  epigastrium  considerably 
relieved  since  the  application  of  the  blister.  Still  bad  appetite  and  sour  taste  ui 
mouth.  IJ  Carb.  Potass.  3  i-  ^'v.  in  pulv.  xij ;  sumat  unum  ter  in  die.  Dec.  9th. — 
Pain  in  epigastrium  much  reUeved,  and  only  returns  at  intervals,  and  in  much  less 
degree  than  formerly.  She  now  takes  her  food  weU;  bad  taste  in  mouth  gone; 
bowels  still  costive;  pulse  80,  of  good  strength.  Dec.  Uth. — Her  former  stomach 
symptoms  have  entirely  disappeared.     Dismissed. 

Commentary. — The  vomiting  excited  on  taking  food,  tlie  lia?niatemesis, 
and  the  local  pain  increased  af  the  epigastrium  on  pressure,  indicated  the 
presence  of  an  idcer  in  the  stomach,  which,  by  opening  blood-vessels, 
had  several  times  catised  extravasations  of  blood.  Before  I  saw  her,  an 
astringent  mixture,  with  gallic  acid,  had  been  ordered  to  check  the  ten- 
dencv  to  hemorrhage.  For  this  I  substituted  quietude,  a  farinaceous 
diet,  "to  be  taken  insraall  quantities  at  a  time,  fi-equently  repeated,  and 
powdeis  of  white  bismuth  and  opium,  to  check  acidity  and  relieve  pain. 
The  pain  not  subsiding,  six  leeches  were  ordered  to  the  epigastrium,  fol- 
lowed bv  warm  fomentations,  and  subsequently  a  blister  was  applied 
there,  the  result  of  which  treatment  was  gradual  abatement,  and  at 
length  complete  disappearance  of  all  her  symptoms. 

Case  LYII.* — Chronic  Ulcer  of  the  Stomach — Cure. 

History. — Mary  Reed,  set.  38,  married — admitted  December  20th,  1852.  She 
states  that  about  four  years  ago,  having  been  exposed  to  cold  and  wet,  she  was 
seized  with  shivering,  followed  by  severe  pains  in  the  epigastrium,  with  uneasy 
sensations  in  the  lower  part  of  the  abdomen,  resembling  labour  pains ;  these  were 
accompanied  by  thirst,  loss  of  appetite,  sickness,  and  vomiting.  These  symptoms 
disappeared,  but  re-occurred  at  intervals  up  to  December,  1851,  when  she  had  a  more 
severe  attack  than  before,  and  since  then  she  has  always  been  complaining  more  or 
less  of  the  same  thing.  About  three  months  ago,  she  felt  as  if  something  gave  way 
in  the  left  hypochondrium,  and  nearly  fainted.  She  immediately  afterwards  vomited 
about  a  tea-cupful  of  blood;  this  took  place  four  or  five  times  during  the  night;  but 
the  last  time  the  ejected  matters  were  paler  and  more  watery,  having  somewhat  the 
appearance  of  finely  grated  carrots.     The  loss  of  appetite,  thirst,  pain  in  epigastrium 

*  Reported  by  Mr.  F.  S.  B.  F.  de  Chaumoat,  Clinical  Clerk. 


440  DISEASES    OF   THE   DIGESTIVE   SYSTEM. 

and  bowels,  with  frequent  severe  headache,  have  continued  up  to  the  present  time. 
She  has  had  no  return  of  the  hrematemesis,  but  generally  vomits  her  food  about  half 
an  hour  after  it  has  been  taken. 

Symptoms  on  Admission. — On  admission,  she  has  a  pale  anasmic  appearance. 
The  tongue  is  furred,  appetite  bad,  pain  in  epigastrium  and  distension,  with  a  sense 
of  load  at  the  stomach  after  meals,  which  continues  till  relief  is  aftbrded  by  vomiting, 
which  comes  on  generally  in  about  half  an  hour.  She  complains  also  of  pain  in  the 
left  hypochondrium ;  has  no  uneasy  sensations  in  the  bowels,  but  habitual  costive- 
ness,  for  which  she  has  been  in  the  habit  of  taking  laxative  medicine.  She  has  been 
much  troubled  with  laalpitation,  but  the  heart  sounds  and  impulse  are  normal ;  pulse 
96,  small,  and  rather  soft;  micturition  normal;  urine  of  a  pale  colour,  sp.  gr.  1022, 
with  slight  deposit,  showing  phosphates  under  the  microscope.  Catamenia  now 
present.  She  does  not  sleep  well,  has  slight  headache  and  occasional  vertigo,  with 
muscss  volitantes,  pain  in  lumbar  region,  but  no  tenderness  over  spine.  Other  func- 
tions normal.  To  re^nain  quiet  in  bed.  Farinaceous  diet  in  small  quantities.  To  have 
the  hoivels  gently  opened. 

Progress  op  the  Case. — December  23d — Bowels  moved  since  last  report ; 
complains  of  much  pain  in  the  epigastrium ;  has  had  no  vomiting  of  blood  since 
admission.  Applicent.  hirudines  iv  part,  dolent.  et  postea  foveatur.  Omitt.  alia. 
IJ  Lactis  Recent.  §  xii. ;  Aq.  Calais  §  vj  M.  To  be  taken  as  a  drink  when  thirsty. 
Dec.  SOth. — Continues  somewhat  easier;  complains  still  of  occasional  pain  in 
stomach ;  appetite  rather  improved  ;  less  thirst.  Bowels  very  costive.  Jan.  Uh. — 
Complains  still  of  severe  pain  in  epigastrium,  with  nausea,  but  no  vomiting. 
Tongue  rather  furred.  It  has  been  found  that  the  patient  has  been  getting  up  and 
walking  about  after  the  visit,  and  has  taken  some  beefsteak,  contrary  to  orders. 
5  Pulv.  Scammon.  et  Pulv.  Jalap,  a  a  gr.  x.  M.  Ft.  pulv.  hora  somni  sumend. 
Jan.  Gih. — Bowels  well  opened,  tongue  much  cleaner,  feels  better,  and  slept  well 
during  the  night.  To  have  rice  diet.  Has  been  complaining  again  of  pain  in 
stomach ;  tongue  furred,  but  moist ;  appetite  rather  better ;  slept  well  during  the 
night ;  bowels  open.  Jan.  9th. — Has  been  rather  sick  to-day,  and  vomited  a  little 
during  the  night  for  the  first  time  since  admission  She  still  complains  of  pain  in 
epigastrium.  AppUcet.  Vesical.  (3  x  2)  part,  dolent.  Jan.  12th. — Has  been  much 
relieved  since  the  application  of  the  blister,  and  exjjresses  herself  as  feeling  a  great 
deal  better.  Tongue  moist,  and  cleaner  than  before ;  less  thirst ;  appetite  improved ; 
bowels  still  costive.     Jan.  20th. — Dismissed  cured. 

Coynmentary. — This  case  in  all  its  essential  features  is  very  similar 
to  the  former  one,  with  the  exception  that  vomiting,  instead  of  occurring 
immediately  after  taking  food,  came  on  half  an  hour  later.  TIjc  same 
treatment  was  pursued,  but  was  not  so  carefully  followed  out,  for  it  was 
ascertained  that  she  was  continually  getting  out  of  bed,  and  committing 
indiscretions,  which  caused  returns  of  the  symptoms. 


Case  LYIII.* — Chronic  Ulceration  and  Perforation  of  the  Stomach — Peritonitis — 
Limited  Pneumonia  with  Gangrene — Abdominal  Abscess,  simulating  Pleurisy — 
Death. 

History. — Evina  Clark,  set.  29,  single,  housemaid — admitted  December  T,  1852. 
Froju  the  age  of  fifteen,  she  has  had  more  or  less  derangement  of  the  functions 
of  the  stomach,  as  exiiibited  by  frequent  vomiting  of  greenish  matters,  not  pre- 

*  Reported  by  Mr.  F.  S.  B.  F.  de  Chaumont,  Clinical  Clerk. 


ORGANIC   DISEASES   OF   THE   STOMACH.  441 

ceded  by  am^  nausea.  She  attributes  her  complaint  to  a  severe  stomach  disease 
at  the  age  of  fifteen,  which  confined  her  to  bed  for  some  months.  Two  months  ago 
the  vomitings  became  more  frequent,  and  have  continued  worse  than  usual  ever 
since.  She  has  been  in  the  habit  of  taking  very  large  quantities  of  bi-carbonate  of 
soda,  sometimes  even  as  much  as  1  oz  per  day.  On  the  day  before  admission,  she 
took  a  dose  of  castor-oil,  and  this  morning  (Dec.  7)  she  rose  at  five  o'clock  to  stool, 
then  returned  to  bed.  At  half-past  five,  she  again  rose  to  see  what  o'clock  it  was, 
and  again  returned  to  bed  and  fell  asleep  without  having  experienced  any  pain. 
About  six  o'clock  she  awoke  with  severe  pain  in  the  epigastrium,  and  a  feeling 
of  faiutness.  Her  mistress,  on  being  summoned  to  her  bedside,  administered  to 
her  half  a  glass  of  brandy  in  some  hot  water.  Immediately  after  this  was  swal- 
lowed, the  former  pain  became  excruciating;  the  abdomen  was  then  fomented 
with  hot  water,  and  medical  assistance  sent  for.  The  medical  man  ordered  warm 
bran  poultices  to  be  applied,  which  somewhat  relieved  the  symptoms ;  three  hours 
afterwards  the  pain  again  becoming  violent,  one  drachm  of  tincture  of  opimn  was 
admbiistered,  and  she  was  sent  to  the  Infirmary.  The  catamenia  have  always  been 
regular. 

Symptoms  ox  Admission'. — On  admission  she  was  in  a  state  of  extreme  depres- 
sion, the  surface  cold,  face  livid,  pulse  108,  almost  imperceptible ;  and  the  house- 
clerk  administered  a  draught  which  was  at  hand,  composed  of  S}).  Ammon.  Arornat. 
rain,  x ;  Sp.  ^ther.  Sulph.  min.  xv ;  Sol.  Mur.  Mmph.  min.  xx ;  Aqv.ce  §  ss. 
Warm  fomeaiations  to  the  epigastrium  were  also  ordered.  "When  first  seen  at  the 
hour  of  visit,  she  complained  of  intense  pain  in  the  abdomen,  especially  in  the 
epigastrium  and  left  hj-pochondrium,  which  was  increased  by  pressure.  The  tongue 
was  slightly  furred  in  the  centre,  but  moist.  She  had  great  thirst,  no  nausea  ;  bowels 
had  been  freely  opened  at  five  o'clock  that  morning.  Heart  sounds  normal ;  pulse 
136,  the  strength  having  much  improved  since  the  draught,  which  caused  no  in- 
crease of  the  pain.  Is  evidently  under  the  influence  of  opium.  All  the  other  func- 
tions are  normally  performed.  To  have  immediately  an  enema  of  beef-tea  with  an 
ounce  of  brandy.     The  warm  fomentations  to  be  continued. 

Progress  of  the  Case. — In  the  evening  the  pain  was  dimiaished  to  a  feeling 
of  soreness;  pulse  129,  small;  lividity  efface  and  depression  continued;  surface 
cold ;  no  rigors.  Has  had,  at  intervals  of  three  hours,  four  enemata  of  beef-tea,  T\-ith 
an  eg%,  two  containing  an  ounce  of  brandy,  and  two  with  one  drachm  of  laudanum. 
She  has  also  been  sucking  ice  to  relieve  her  thirst.  December  8th. — There  has  been 
profuse  sweating  during  the  night;  face  is  still  pale;  pulse  126,  weak  and  thread}-; 
acute  pain  continues  on  pressure  below  ensiform  cartilage.  The  abdomen  is  tense 
and  tympanitic,  but  the  tenderness  is  slight ;  considerable  flatulence  in  stomach ; 
febrile  symptoms  well  pronounced.  IJ  Bismuthi  albi,  gr.  xviii ;  Pulv.  Opii  gr.  iii. 
M.  fiantpiil.  vi.  One  to  be  taken  every  six  hours.  The  nutritive  and  anodyne  enemata 
to  be  continued.  Dec.  9th  — She  vomited  yesterday  afternoon,  3  p.m.,  about  a 
pint  of  green  fluid,  and  at  the  same  time  passed  a  fluid  foeculent  stool.  Slept  a 
little  during  the  night.  To-day  she  is  somewhat  refreshed,  but  the  symptoms  are 
the  same  as  yesterday.  Dec.  lOth. — Yesterday  evening,  the  epigastric  pain  having 
increased,  and  extended  into  left  hj-pochondrium,  six  leeches  were  applied,  followed 
by  warm  fomentations.  To-day  pain  and  tenderness  continue;  pulse  120,  improved 
in  strength.  Six  more  leeches  to  be  applied.  The  anodyne  and  nutritive  enemata 
to  be  continued.  To  svxk  ice  to  relieve  the  thirst.  Dec.  Wth. — Bowels  were  open 
shortly  before  the  visit ;  pulse  128,  full ;  tongue  dry;  thirst  continues ;  but  appetite 
is  returning.  Tenderness  of  epigastrium  and  abdomen  has  nearly  disappeared.  To 
have  beef-tea,  by  the  mouth,  in  table-spoonfuls  at  a  time,  and  occasionally  toastand- 
water  to  relieve  the  thii'st,      Dec.  IWi. — The  beef-tea  produced  a  disagreeable  but 


442  DISEASES   OF   THE   DIGESTIVE   STSTEil. 

not  painful  sensation  in  tiie  stomach,  but  there  has  been  no  vomiting.  Pulse  to-daj 
128,  of  good  strength ;  feels  much  easier,  and  can  turn  herself  more  freely  in  bed. 
There  have  been  two  foecal  evacuations  since  yesterday.  Dec.  \%lh  — She  has  no 
pain ;  pulse  1 28,  of  moderate  strength.  To  have  a  little  toasted  bread  soaked  in 
beef-tea.  Dec.  \4th. — The  toast  and  beef  tea  occasioned  uneasiness  and  tightness  in 
the  epigastrium  and  both  hypochondria,  foUowed  by  dyspnoea  and  general  restless- 
ness, but  no  pain.  The  bowels  were  opened  twice  during  the  afternoon  and  evening. 
To-day  there  is  tenderness  over  the  right  hypochondrium ;  febrile  symptoms  have 
again  returned;  pulse  132,  rather  feeble.  Six  leeches  to  be  applied  over  the  tender 
part.  To  have  enemata  of  brandy  and  beef-tea  every  iivo  hours.  To  suspend  the 
administration  of  food  by  the  mouth.  Dec.  loth. — At  the  evening  visit  yesterday 
the  febrile  symptoms  had  greatly  increased;  thirst  excessive;  tongue  dry  and 
cracked ;  abdominal  tenderness  much  relieved  by  the  application  of  the  leeches. 
To-day  the  febrile  symptoms  continue ;  face  is  flushed ;  and,  on  being  interro- 
gated, she  states  that  she  had  a  rigor  and  feeling  of  cold  yesterday  afternoon.  On 
percussing  the  chest  posteriorly,  there  is  dulness  over  lower  third  of  right  lung,  with 
double  friction  murmur  and  cegophonic  vocal  resonance;  on  the  left  side  also  slight 
dulness  inferior! y,  wnth  crepitation  during  inspmation ;  pulse  132,  feeble.  The 
enemata,  which  have  been  continued  at  intervals,  are  no  longer  retained.  Inter- 
Tnittantur  enemata.  To  have  a  Utile  calf  ^s-foot  jelly  by  the  mouth,  alternated  tvith  a 
table-spoonful  of  clear  broivn  soup  every  tvjo  hours.  ^  Solutionis  tartratis  anti- 
inonii,  Z  iij ;  Potassce  aceiatis,  3  ij ;  Sp.  aetheris  nitrici,  3  v ;  aquce,  3  V.  M.  Fiat 
onistura.  A  table-spoonful  every  four  hours  in  tioo  or  three  iabk-spoonfuls  of  ivaier. 
Dec.  IGth. — Yesterday  evening  there  was  great  exhaustion  and  feebleness;  the 
mixture  tvas  suspended;  and  a  table-spoonful  of  vnne  was  ordered  every  tivo  hours. 
To-day  no  tenderness  over  abdomen,  but  the  dyspnoea  and  the  physical  thoracic 
signs  continue ;  febrile  symptoms  still  strongly  marked ;  pulse  140,  soft  and  vibrat- 
ing; there  is  much  flatulence.  At  her  own  request,  she  was  aWovced  fifteen  grains 
of  the  bi-carbonaie  of  soda.  To  continue  the  jelly  and  broivn  soup,  vnth  half  an  ounce 
of  sherry  every  hour.  Dec.  11th. — Feels  better  to-daj' ;  urine  loaded  with  lithates ; 
flatulence  has  been  relieved  by  the  bi-carbonate  of  soda.  Dec.  18th. — Xo  change. 
To  have  milk  and  lime-vjater  to  drink.  Dec.  I9th. — Complains  of  increased  paiia  in 
inferior  portion  of  right  side  of  chest,  where  there  is  stQl  dulness  and  loud  friction. 
Some  dyspnoea.  Si.v  leechct  to  be  applied.  Dec.  20th. — Pain  was  relieved  by  the 
leeches,  but  the  dyspnoea  and  physical  signs  on  both  sides  of  chest  continue.  Blister, 
4  by  3,  to  be  applied  over  lower  portion  of  right  lung  poster iot'ly.  Dec.  21st — Has 
had  copious  sweating  during  the  niglit ;  otherwise  the  same.  Dec.  22d. — Much 
weaker ;  pulse  136,  small  and  weak ;  lithates  have  disappeared  from  the  urine ; 
great  dyspnoea.  5  ^P-  -^th.  Kit.  §  ss ;  Tinct.  Colchici,  3  ij ;  Aquce,  §  v ;  a  table- 
spoonful  every  four  hours.  To  have  an  enema  of  beef-tea  and  egg ;  and  rice,  with 
beef-tea,  by  the  mouth.  Dec  23d — Is  free  from  pain ;  general  symptoms  unchanged ; 
pulse  124,  weak ;  slight  subsultus  tendinum ;  appetite  capricious ;  prefers  arrow- 
root to  rice.  Dec.  2oth — Complains  now  of  diarrhoea.  Haheat  Enema,  c.  Tr.  Opii 
min.  ±1.  Dec.  26fh. — Diarrhoea  continues;  early  this  morning  took  the  following 
draught: — 5  Sol.  Mur.  Morph.m.'s.v;  Tinct.  Catechu,  3ss;  Syrup).  Limonum.,  Zj-^- 
No  change  in  the  febrile  symptoms,  dyspnoea,  or  the  pulmonarj'-  physical  signs ;  has 
no  pain;  pulse  124,  weak;  skin  clammy;  states  that  she  felt  very  cold  during  the 
night.  Dec.  27th. — Diarrhoea  continues.  To  have  an  enema  of  starch  and  opium. 
Dec.  28/7i.— Diarrhoea  has  ceased;  dyspnoea  and  febrile  symptoms  increased;  no 
pain;  face  pale  and  anxious.  Dec.  29th. — Evidently  weaker ;  breathing  laboured ; 
pulse  140,  weak  and  thready ;  countenance  of  a  yellow  waxy  tinge.  There  was 
profuse  sweating  this   morning;    other  symptoms   unchanged.      Dec.    SOth. — She 


ORGANIC   DISEASES   OF   THE   STOMACH.  443 

continued  to  sink,  and  died  tliis  morning  at  3  a.m.,  death  having  been  preceded  by 
repeated  vomiting  of  dirty  brownish-green  matter. 

Sectio  Cadaveris. —  Thlviy-thrce  hours  after  death. 

Head  not  examined. 

Thorax. — Two  drachms  of  clear  serum  in  the  pericardium ;  heart  healtliy ;  the 
right  kmg  healtliy,  but  its  lower  lobe  and  the  diaphragm  on  that  side  were  con- 
siderably pushed  upwards  by  an  abscess  containing  nearly  a  pint  of  pus,  situated 
above  the  liver  and  below  the  diaphragm :  the  left  lung  also  healthy,  with  the 
exception  of  a  gangrenous  ulcer,  the  size  of  a  shilling,  in  the  centre  of  the  lower 
lobe  inferiorly,  where  it  rested  on  the  diaphragm.  This  ulcer  presented  a  brownish, 
broken  up,  sloughing  surface,  and  was  surrounded  by  red  hepatization,  occupying 
the  pulmonary  substance  to  about  the  extent  of  a  hen's  egg. 

Abdomen.— On  reflecting  the  integuments,  a  considerable  quantity  of  pus 
escaped  from  the  abscess  above  alluded  to  on  the  right  side,  immediately  below  the 
diaphragm  and  above  the  liver.  This  abscess  contained  nearly  a  pint  of  pus,  and 
was  situated  in  a  circumscribed  pouch  formed  by  the  diaphragm  above,  the  liver 
below,  the  peritoneum  anteriorly  and  externally,  and  false  lymph  of  considerable 
tenacity  internally.  Lymph  also  glued  these  parts  and  the  small  curvature  of  the 
stomach  together.  On  reflecting  the  integuments,  the  anterior  wall  of  the  abscess 
was  removed,  and  so  the  pus  escaped.  The  stomach,  transverse  colon,  and  coils 
of  intestine  in  the  superior  third  of  the  abdomen,  were  all  glued  together  by  bands 
and  flakes  of  lymph,  which,  though  of  tolerable  tenacity,  were  gelatinous  in  con- 
sistence, and  could  readily  be  torn  through  by  the  fingers.  In  the  left  hypochondrium 
there  was  a  layer  of  this  lymph  half  an  inch  in  thickness,  softened,  purulent,  and 
gangrenous  in  the  centre,  situated  above  the  spleen,  and  communicating,  by  a 
sloughened  opening,  with  the  ulcer  and  hepatization  in  the  lung  formerly  described. 
On  cutting  open  the  stomach,  in  the  line  of  its  large  curvature,  there  flowed  out  a 
dirty,  greenish-brown,  grumous  liquid,  containing  coagulated  masses,  apparently  of 
milk,  tinged  of  a  dark-red  colour  by  port  wine.  In  the  posterior  part  of  the  stomach, 
about  its  centre,  was  observed  an  oval  ulcer,  the  size  of  a  flve-shilling  piece,  with 
smooth,  thickened  edges,  and  surrounded  by  puckered  folds  of  the  mucous  mem- 
brane, which  was  otherwise  healthy.  The  ulcer  was  adherent  to  the  pancreas 
behind,  which  constituted  its  base ;  but  the  adhesions  round  its  superior  half  were 
composed  of  the  same  gelatinous  lymph  as  has  been  previously  alluded  to.  On  dis- 
secting the  ulcer  from  its  attachments,  it  was  seen  to  have  completely  perforated  the 
coats  of  the  stomach,  although  the  opening  behind,  viewed  on  the  serous  surface, 
was  not  above  the  size  of  a  shilling.  On  removing  the  intestines  from  the  pelvis, 
flakes  of  purulent  lymph  were  observed  between  several  of  the  coils  and  on  the 
serous  membrane  of  the  pelvic  cavity.     AU  the  other  organs  healthy. 

Commentary. — All  tlie  facts  connected  with  this  case  were  obtained 
witli  great  accuracy,  and  left  us  in  little  doubt,  from  the  commencement, 
that  we  had  to  treat  a  chronic  ulcer  of  the  stomach,  which,  on  the 
morning  of  the  day  she  was  admitted,  had  perforated  the  organ,  and 
induced  the  violent  pain  she  complained  of.  The  peritonitis,  which 
may  have  been  induced  by  the  perforation  alone,  was  undoubtedly 
auo-mented  by  the  brandy  and  water  administered  to  rally  her  from 
the  state  of  collapse  into  which  she  was  thrown  by  the  immediate 
effects  of  the  accident.  On  entering  the  house  also  about  five  hours 
after  slie  became  ill,  a  stimulating  and  anodyne  draught  was   adminis- 


444  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

tered  by  tlie  clerk  to  rouse  lier  from  her  depressed  condition.  As  this 
was  followed  by  no  increase  of  local  pain,  but  bv  improvement  of  the 
vital  powers,  we  may  fairly  conclude  that  the  practice,  though  highly 
questionable,  ft'as  not  productive  of  injurv.  Nothing,  indeed,  is  more 
natural  on  the  sudden  occurrence  of  violent  pain  in  the  epigastric 
region  with  a  feeling  of  syncope,  than  to  have  recourse  to  stimulants, 
for  perforations  of  the  stomach  are  rare  occurrences,  and  it  is  not 
every  one  who  at  such  a  moment,  even  among  the  profession,  has 
sufficient  coolness  and  discrimination  to  detect  the  real  nature  of  the 
disease.  Hence,  why  so  frequently  these  perforations  are  fatal,  not 
so  much  from  their  own  natural  results  as  from  the  stimulating  reme- 
dies administei-ed,  which  pass  through  the  aperture  into  the  abdominal 
cavity.  Indeed,  had  not  brandy  and  water  been  given  in  this  instance, 
there  is  every  reason  to  suppose  that  the  perforation  might  not  have 
occasioned  much  mischief,  for  it  occurred  early  in  the  morning,  before 
breakfast,  and  long  after  her  evening  meal,  and  consequently  when 
the  organ  was  empty ;  and,  besides,  it  is  to  be  observed  that  such 
perforations  have  a  great  tendency  to  become  re-closed  by  the  rapid 
formation  of  fibrous  lymph  round  their  edges.  In  this  case,  however, 
extensive  peritonitis  was  alreadv  occasioned  when  I  first  saw  her,  and 
the  subsequent  treatment  was  directed — 1st,  To  prevent  the  intro- 
duction of  fuTther  matters  into  the  stomach ;  2d,  To  rally  her  from 
collapse  by  stimulating  and  nutritive  enemata;  and  3d,  To  conduct 
the  inflammation  to  a  favourable  termination  by  local  fomentations  and 
opiates  largely  administered  in  the  form  of  enemata,  and  subsequently 
in  pills  by  the  month.  This  treatment  was  attended  with  apparent 
success,  so  that  on  the  fifth  day  nourishment  was  cautiously  adminis- 
tered by  the  mouth,  and  also  with  tolerable  benefit.  On  the  eighth 
day,  however,  rigors  appeared,  followed  bv  fever,  which  was  atti'ibuted 
to  a  pleurisy  on  the  right  side,  where  increased  thoracic  dulness  was 
discovered  inferiorly,  with  loud  friction  and  oegophony.  Circumscribed 
pneumonia  evidently  also  existed  on  the  left  side,  as  indicated  by 
crepitation.  This  formidable  complication  was  attempted  to  be  relieved 
by  gentle  salines,  and  topical  bleeding  bv  leeches.  It  was  soon  appa- 
rent, however,  from  the  appearance  of  dyspncea  and  other  symptoms, 
that  there  was  now  little  hope  of  recoverv,  and  notwithstanding  the 
liberal  administration  of  stimulants,  the  patient  sank  on  the  twenty- 
third  day.  Dissection  exhibited  exactly  what  was  anticipated  with 
regard  to  the  stomach  and  peritoneum,  but  showed  that  the  signs  of 
the  presumed  pleurisy  were  occasioned  by  an  abscess,  which,  by  pushing 
up  the  diaphragm  and  occupying  the  lower  portion  of  the  thoracic 
space  on  the  right  side,  had  given  rise  to  all  the  physical  signs  of 
pleuritis.  On  the  left  side  there  was  limited  pneumonia,  as  was  expected, 
the  lung  communicating  by  a  gangrenous  idcer  in  the  diaphragm, 
with  the  lymph  exuded  above  and  around  the  spleen.  The  edges  of 
the  ulcer  of  the  stomach  were  firmly  united  to  the  pancreas,  so  that  the 
patient  undoubtedly  died  from  tlie  extensive  peritonitis. 


ORGANIC   DISEASES   OF   THE   STOMACH.  445 


Case  LIX.* — Clironic  Ulceration  in  the  Stomach — Perforation  occasioned  by  a  Fall{?) — 

Jiecovei'y. 

History. — Barbara  Ferguson,  servant,  aged  51 — admitted  Januar}-  6,  1853. 
States  that  she  enjoyed  excellent  health  till  about  eight  years  ago,  when  she  first 
began  to  complain  of  her  stomach — suffering  from  pain  of  a  cutting  or  grinding  cha- 
racter, always  worse  after  taking  food.  Her  appetite  has  all  along  continued  good, 
but  she  often  experienced  considerable  thirst ;  has  never  had  nausea  or  vomiting. 
She  believes  that  she  has  been  getting  worse  lately,  but  has  had  no  distinct  exacer- 
bation. On  January  the  4th  instant,  stepping  upon  a  chair,  her  foot  slipped,  and 
she  fell  with  the  stomach  across  the  back  of  it.  She  was  immediately  seized  with 
intense  pain  in  the  epigastrium,  rapidly  extending  over  the  whole  abdomen.  She 
did  not  faint,  and  was  still  able  to  speak,  but  had  to  be  carried  to  bed.  The  accident 
occurred  about  9  P.  M  ,  three  hours  after  she  had  taken  any  food,  which  had  consisted 
of  some  coffee,  with  a  few  mouthfuls  only  of  bread.  She  was  immediately  ordered 
a  one-grain  pill  of  opium,  which  was  to  be  repeated  every  four  hours.  On  the  next 
day,  as  the  acute  pain  still  continued,  four  leeches  were  applied  to  the  epigastrium, 
followed  by  warm  fomentations.  She  has  had  nothing  by  the  mouth  except  the 
opium  pills,  up  to  date  of  admission. 

Symptoms  ox  Admissiox. — On  admission  she  appears  very  weak  and  nervous, 
and  in  a  state  of  partial  collapse;  the  countenance  is  sallow;  pulse  100;  weak: 
heart  sounds  normal ;  no  headache,  but  a  feeling  of  vertigo  on  attempting  to  rise  or 
change  her  position ;  tongue  clean,  moist ;  no  nausea  or  vomiting ;  appetite  gone ; 
considerable  thirst ;  pain  in  epigastrium,  which,  with  the  whole  abdomen,  is  exces- 
sively tender  on  pressure ;  she  has  had  great  dysuria  and  pain  on  micturition  ever 
since  the  accident.  All  the  other  functions  are  normal ;  ordered  to  have  no  food  by 
the  mouth,  hut  an  enema  of  beef-tea,  with  the  yolk  of  an  egg,  immediately,  to  befolloived 
in  two  hours  by  an  opiate  enema,  with  40  minims  of  tincture  of  opium ;  to  be  kept  quiet, 
and  not  to  get  out  of  bed. 

Progress  of  the  Case. — January  1th. — TTas  almost  free  from  pain  yesterday 
evening,  and  felt  altogether  much  better,  having  slept  a  good  deal  during  the  after- 
noon. The  beef-tea  enema,  with  yolk  of  egg,  has  been  repeated  at  intervals  of  four  hours, 
and  she  had  another  opiate  at  4  a.ji.,  after  which  she  slept  well.  To-day  she  feels 
easier ;  pain,  or  rather  tenderness  in  epigastrium  somewhat  diminished ;  and  consi- 
derable pressure  may  now  be  exerted  without  causing  uneasiness.  She  has  stUl 
thirst;  tongue  dry;  very  httle  inclination  for  food ;  pulse  1 00,  soft.  Jan.  Sth. — Was 
considerably  easier  last  night,  and  expressed  a  desire  for  some  food;  the  pulse  was 
of  better  strength,  90.  To-day  is  still  improving ;  complains  of  no  pain  when  lying 
quiet,  but  still  pain  on  pressure  in  epigastrium ;  she  expresses  fear  and  pain  when 
other  parts  are  touched,  but  not  to  the  same  extent;  pulse  95,  of  moderate  strength. 
She  has  had  the  beef-tea,  etc.,  enemata  as  before,  with  an  opiate  enema  every  10  or  12 
hours — to  have  beef-tea,  and  milk  by  the  mouth,  in  table-spoonfuls  at  a  time,  repeated 
every  five  minutes  if  the  2'>atient  desires  it.  Jan.  9th. — Felt  rather  uneasy  after  taking 
the  beef-tea  and  milk,  which  occasioned  a  sense  of  '"working  "  in  the  stomach.  An 
opiate  enema  was  ordered  in  about  two  hours,  and  in  the  evening  she  expressed 
herself  as  free  from  uneasiness,  and  rather  refreshed  from  the  beef-tea.  To-day  she 
feels  not  quite  so  well,  and  her  general  appearance  is  more  depressed.  She  has  con- 
tinued the  beef-tea,  but  has  had  an  egg  and  beef-tea  enema  t^\ace  a  day  in  addition  ; 
pulse  88,  of  good  strength ;  bowels  have  not  been  open  since  admission  ;  to  have  a 
warm  icater  enema,  with  an  ounce  of  castor  oil,  followed,  if  necessai-y,  by  an  opiate  one. 

*  Reported  by  Mr.  F.  S.  B.  F.  de  Chaumout,  Clinical  Clerk. 


4-i6  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Jan.  10th. — Felt  rather  weak  and  exhausted  after  bowels  were  opened;  the  opiate 
enema  was  administered  two  hours  afterwards,  and  she  has  felt  better  since ;  had 
some  tea,  with  a  little  toast,  by  the  mouth  this  morning ;  takes  beef  tea  for  dinner, 
but  cannot  eat  rice  or  any  farinaceous  food ;  no  bad  effects  have  followed  tak- 
ing food  by  the  mouth ;  pulse  88,  of  good  strength ;  little  pain  complained  ofj  and 
she  can  now  sustain  considerable  pressure  on  epigastrium  without  suffering.  Slept 
less  last  night  than  before;  urine  clear,  sp.  gr.  1020,  contains  phosphates.  Omit  the 
enemata.  Jan.  2iih. — Since  the  last  report  she  has  been  doing  well,  and  gradually 
gaining  strength.     Dismissed. 

Commentary. — Many  cases  are  on  record  of  evident  perforations  of  the 
stomach,  which  have  been  cured  by  judicious  treatment,  and  the  one  just 
narrated  seems  to  me  to  be  an  instructive  example  of  this  favourable 
termination  of  tlie  lesion.  The  symptoms  at  the  commencement  were 
very  lilie  those  of  Case  LVIIL,  but  were  induced  by  a  blow  on  the 
epigastrium  instead  of  coming  on  after  straining  at  stool.  Violent  pain, 
tenderness  on  pressure,  and  collapse  were  the  immediate  effects.  For- 
tunately, I  saw  the  patient  immediately  after  the  accident,  and  took  care 
not  to  administer  brandy,  or  stimulating  draughts.  A  grain  of  opium  in 
the  form  of  pill  was  administered  every  four  hours,  quietude  enjoined, 
and  complete  abstinence  insisted  on.  Xext  day  the  local  pain  continued, 
and  on  the  following  morning  I  sent  her  to  the  Intirmary.  Xourisliment 
was  administered  by  enemata,  and  on  the  fourth  day  was  cautiously  given 
by  the  mouth,  and  no  untoward  symptom  ensued.  From  this  time  she 
slowly  recovered.  Of  course  we  have  no  positive  evidence  that  there  was 
a  perforation  in  this  case.  For  eight  years,  however,  she  had  been  sub- 
ject to  severe  attacks  of  pain  in  the  stomach,  increased  on  taking  food, 
but  there  had  been  no  vomiting.  It  is  possible,  that  the  blow  may  have 
been  sufficiently  strong  in  itself  to  induce  the  pain  and  subsequent 
symptoms,  although,  from  all  the  inquiries  I  could  make,  it  did  not  appear 
to  be  so.  One  of  her  fellow-servants  indeed  maintained  that  it  must 
have  been  trifling.  Wherever  anatomical  evidence  fails,  there  must  be 
more  or  less  uncertainty  hanging  over  the  history  of  those  cases  which 
recover;  but,  taking  all  the  circumstances  into  consideration,  I  cannot 
help  thinking  that  had  brandy  and  water  been  given  in  this  as  in  the 
former  instance,  there  is  every  chance  that  here  also  fatal  peritonitis 
would  have  been  occasioned. 

From  wliat  I  have  observed  of  post-mortem  examinations  in  the  Royal 
Infirmary  of  Edinburgh,  it  does  not  appear  to  me  that  chronic  ulcer  of 
the  stomach  is  a  common  disease  here.  Without  having  made  any  exact 
calculation,  nothing  positive  can  be  said,  but  I  do  not  think  that  the 
disease  exists  in  more  than  3  per  cent,  of  those  examined  ;  whereas  in 
the  Copenhagen  and  some  German  hospitals,  it  is  said  to  vary  from  6  to 
13  per  cent.*  This  frequency  of  it  has  been  thought  to  be  dependent 
on  habits  of  intemperance  and  particular  diet ;  and,  if  so,  we  might  have 
anticipated  that  the  habit  of  drinking  raw  whisky  would  have  rendered 
it  more  common  in  Scotland  than  it  appears  to  be.  Its  morbid  anatomy 
was  first  admirably  described  and  figured  by  Cruveilhier.f     The  ulcer  is 

*  See  an  able  Memoir  on  the  subject  by  Dr.  Brinton.     London,  18.57. 
\  Anat.  Pathologique.     Liv's  x.  et  xx. 


ORGANIC   DISEASES   OF   THE   STOMACH.  447 

chronic,  of  circular  or  oval  tbni),  generally  varying  in  size  from  afourpenny 
to  that  of  a  crown  piece,  having  an  abrupt,  slightly  thickened  margin  as 
if  it  had  been  punched  out,  and  an  indurated  smooth  base.  It  may  be 
shallow  or  deep,  and  frequently  perforates  all  the  coats  of  tbe  stomach, 
in  which  case  the  external  is  larger  than  the  internal  aperture.  It  has  a 
great  tendency  to  contract  adhesions  by  its  external  borders  to  neigh- 
bouring viscera,  more  especially  the  pancreas,  immediately  over  which,  in 
the  posterior  wall  of  the  stoniach,  the  ulcer  is  most  commonly  situjited. 
When  it  occurs  in  the  anterior  wall,  it  less  readily  contracts  adhesions, 
and  therefore  is  more  likely  to  induce  perforation.  The  ulcer  may  heal 
at  any  period  of  its  progress,  leaving  a  cicatrix,  which  varies  in  appearance 
according  to  the  amount  of  tissue  previously  lost.  Sometimes  there  is  a 
mere  scar,  at  others  a  stellate  puckering.  Occasionally  there  is  a  dense 
thickening,  with  rigid  folds,  causing  contractions  in  one  place,  and 
pouches  in  another, "and  this  contraction  may  even  be  circular,  causing  a 
stricture  of  the  organ.  Mmeral  deposits  are  now  and  then  found  adherent 
to  the  cicatrix. 

The  three  leading  symptoms  of  chronic  ulcer  of  the  stomach  are  pain, 
increased  on  pressure,  vomiting  after  taking  food,  and  haimatemesis.  Of 
these,  the  last  is  the  most  important  in  a  diagnostic  point  of  view,  because 
its  presence  renders  certain,  what  would  otherwise  only  be  conjectural. 
The  disease,  however,  may  exist  without  as  yet  having  so  injured  a  blood- 
vessel as  to  occasion  hemorrhage.  Hence  the  symptoms  of  chronic 
'  dyspepsia,  with  vomiting  after  food  and  fixed  pain,  if  long  continued, 
should  invariably  give  rise  to  the  suspicion  of  an  ulcer,  and  lead  to  an 
appropi'iate  treatment. 

The  remedies  I  have  found  most  efficacious,  in  simple  chronic  ulcer  of 
the  stomach,  are  quietude,  careful  regulation  of  the  diet,  bismuth  and 
opium  pills  or  powders,  and  sometimes  warmth,  at  others  cold  applied 
locally.  It  may  frequently  be  observed  that  the  mere  coming  into  a 
hospital  and  remaining  quietly  in  bed  has  a  favourable  eftect  in  modify- 
ing the  distressing  symptoms.  I  have  also  remarked  that  those  patients 
who  are  always  getting  up  and  walking  about  sutfer  much  more  than 
those  who  remain  in  bed,  especially  at  the  commencement  of  the  disease. 
Hence,  repose  in  an  easy  position  should  be  enjoined.  The  diet  should 
consist  of  farinaceous  pulpy  substances,  occasionally  mixed  with  beef-tea, 
or  milk,  given  in  small  quantities,  frequently  repeated.  If  the  stomach 
will  not  tolerate  the  food  warm,  it  should  be  given  cold.  When,  despite 
this  treatment,  vomiting  continues,  it  is  best  to  suspend  all  nourishment 
for  a  day  or  two,  and  give  nutritive  enemata.  As  the  patient  gets  better, 
the  amount  of  solid  food  should  be  very  cautiously  increased.  Thirst  is 
a  distressing  symptom  in  such  cases,  and  is  best  allayed  by  allowing  ice 
to  dissolve  in  the  mouth  slowly,  or  sipping,  at  intervals,  milk  and  lime- 
water,  mingled  in  equal  proportions.  The  pain  is  alleviated  best  by  bis- 
muth and  opium,  combined  in  the  form  of  pill  or  powder.  Sometimes 
local  warmth,  but  more  frequently  pounded  ice,  mixed  with  salt  in  a 
bladder,  applied  over  the  part,  will  give  relief.  Two  or  three  leeches,  or 
a  counter-irritant,  may  succeed  when  evei'ything  else  fails,  and  should  be 
tried.  Quietude  and^  suspending  all  ingesta  for  a  time,  I  believe  to  be 
the  best  remedies  for  hemorrhage,  and  where  exhaustion  from  want  of 
food  exists,  nutrient  enemata,  with  wine,  must  be  administered.    ^^  hen  a 


448  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

perforation  occurs,  I  have  already  pointed  out  tlie  great  importance  of 
avoiding  the  giving  of  stimuli  by  the  mouth  (Cases  LVIII.  LIX.),  and 
have  stated  the  practice  which  should  be  perseveringly  followed,  namely, 
the  administering  of  opium  in  the  form  of  pill,  quietude,  avoidance  of 
purgatives,  and  nourishing  at  first  by  enemata,  and  then  cautiously  by 
unirritating  substances,  given  in  small  quantities  by  the  mouth. 


Case  LX.* — Cancer  of  Stomach,  Pancreas,  and  Mesenteric  Glands — Cijstic  Atrophy 

of  Right  Kidney. 

History. — Thomas  Gaffney,  get.  50,  married,  a  labourer — admitted  November  24, 
1856.  Stales  that  up  to  twelve  months  ago  he  was  ia  good  health,  but  since  that 
time  he  has  been  troubled  with  pyrosis  and  occasional  vomiting,  with  diminished 
appetite.  Three  months  ago,  feeling  much  pain  in  the  epigastrium,  he  noticed  that 
he  had  a  tumour  in  that  region.  It  was  very  sore,  continued  to  increase  in  size,  and 
became  more  and  more  painful.  At  present  he  is  very  emaciated,  and  suffers 
severe  pain  in  whatever  position  he  places  himself 

Symptoms  on  Admission. — Teeth  and  gums  dry ;  tongue  dr}',  whh  a  longitudinal 
fissure  down  tlie  centre.  Thirst  only  occasionally  felt.  Has  no  appetite.  Has  no 
diflQculty  in  swallowing ;  but  complains  of  constant  pain  in  the  epigastrium.  It  is  not 
distinctly  increased  on  taking  food.  The  food  cannot  be  retained  on  bis  stomach, 
coming  up  in  mouthfuls  from  an  hour  to  an  hour  and  a  half  after  ingestion.  The 
vomited  matter  is  described  as  resembling  in  colour  coffee  grounds.  On  examining 
the  epigastrium  in  the  mesial  line,  two  inches  below  the  ensiform  cartilage,  and  three 
inches  above  the  umbilicus,  there  is  felt  a  small  tumour  about  the  size  of  a  walnut  of 
an  irregular  margin  superiorly.  The  convex  surfiice  looks  outwards  and  down- 
wards. It  may  be  moved  upwards  and  to  the  riglit,  but  not  downwards  or  to  the 
left.  In  left  half  of  epigastrium,  over  a  space  of  two  square  inches,  there  is  dulness 
on  percussion,  and  on  palpation,  a  deep-seated  strongly-resisting  tumour  is  felt, 
with  a  distinct  margin  to  the  riglit  side.  It  appears  to  pass  upwards  under  the 
superior  part  of  left  hypochondrium,  where  percussion  gives  forth  a  comparatively 
dull  resonance.  Percussion  elsewhere  over  abdomen,  tympanitic.  Over  the  hepatic 
organ  and  over  the  tumour  there  is  great  tenderness  on  percussion.  Occasionally 
the  tumour  is  felt  more  distinctly,  and  is  then  rough  and  nodulated.  The  chest  is 
barrel-shaped.  Percussion  is  unusually  resonant.  Respiration  is  feeble  anteriorly 
and  is  harsh  posteriorly,  the  expiratory  murmur  being  prolonged.  No  dyspnoea. 
Sputum  scanty.  Prsecordial  region  unusually  resonant  on  percussion.  Transverse 
dulness,  two  and  a  quarter  inches.  Cardiac  sounds  healthy,  but  feeble.  Apex  of 
heart  cannot  be  felt.  Pulse  small  and  weak,  68  per  minute.  Sleeps  but  little. 
Urine  normal.  The  diet  is  io  be  carefully  regulated ;  small  quantities  of  nutritive  food 
and  wine  to  be  taken  at  frequent  intervals.  A  mixture  of  snotv  and  salt  put  into  a  bladder 
is  to  be  applied  over  the  tumour.  To  take  two  of  the  folio-wing  pills  every  night : —  IJ  Morph. 
Acet.  gr.  iss. ;  Conserv.  Rosar.  gr.  xij.     Fiat  massa  in  pilulas  sex  dividenda. 

Progress  of  the  Case. — December  \st. — The  local  apphcation  of  cold  has  afforded 
him  considerable  relief,  so  much  so  that  he  does  not  like  to  be  without  it.  He  is 
unable  to  take  a  sufficient  amount  of  aliment,  and  is  gradually  getting  weaker. 
Dec.  ith. — The  pills  at  night  continue  to  lull  his  pain.  His  diet  consists  of  strong 
beef-tea,  three  half-pints  per  diem ;  bread  and  milk ;  milk  and  rice  pudding ;  with 
six  ounces  of  wine.  Patient  always  vomits  after  eating,  however  httle,  and  conti- 
nues to  sink.     Dec.  5th. — Died  at  10.30  a.m. 

*  Reported  by  Mr.  "William  Guy,  Clinical  Clerk. 


OEGAN'IC   DISEASES   OF   THE   STOMACH.  449 

Sectio  Cadaveris.—  Twenty-eigld  hours  after  death. 

Abdomex.— Permission  could  only  be  obtained  to  examine  the  abdomen.  On 
opening  the  stomach  it  was  seen  to  contain  a  considerable  quantit.v  of  yellow  pulta- 
ceous  s°ubstance,  being  half  digested  food  tinged  with  bUe.  The  pyloric  orifice  was 
compressed  by  a  mass  of  cancerous  exudation,  seated  in  the  smaller  curvature,  and 
projecting  into  the  stomach ;  this  mass  was  about  5  inches  in  diameter,  rounded 
at  the  margins ;  nodulated  internally  with  two  projecting  portions,  so  situated  as  to 
act  as  valves  in  front  of  the  pyloric  orifice,  through  which  a  finger  could  be  easily 
passed  behind  them.  The  thickness  of  this  mass  was  in  one  place  two  inches,  gra- 
dually diminishmg  towards  the  margins  to  half  an  inch.  The  tissue  was  friable, 
easily  breaking  do^vn  under  the  finger,  but  not  yielding  cancerous  juice.  The  pan- 
creas was  generally  healthy,  but  an  inch  of  the  duodenal  extremity  was  involved  in 
the  cancerous  tumour.  The  cardiac  orifice,  which  was  half  an  inch  from  the  margm 
of  the  cancerous  tumour  formerly  described,  was  quite  healthy,  as  was  the  rest  of 
the  stomach  not  involved.  Several  mesenteric  glands  in  the  neighbourhood  of  the 
pancreas  were  enlarged,  nodulated,  and  filled  with  cancerous  exudation.  Ante- 
rioriy  the  stomach  was  strongly  adherent  to  a  portion  of  the  liver,  which  below, 
over  the  tumour  described,  felt  hard  and  nodulated.  In  the  position  of  the  right  kid- 
ney was  a  cyst,  the  size  of  the  human  head,  containing  yellow  serum.  Internally 
it  presented  a  smooth  serous  surface,  here  and  there  interrupted  by  circles  and  frag- 
ments of  circles  leading  into  pouches.  Some  of  these  openings  were  perfectly  circu- 
lar, with  smooth  abrupt  margins,  and  were  about  the  size  of  a  fourpenny  piece ; 
others  were  about  the  size  of  a  half  crown  or  five  shilling  piece.  Here  and  there, 
on  the  surface  of  the  serous  membrane,  were  corrugated  indurated  lines  with  black 
calcareous  plates  upon  them,  the  result  of  cicatrizations.  Externally  the  pouch  was 
smooth,  covered  with  shreds  of  cellular  tissue ;  at  its  mferior  portion  was  an  indura- 
tion, measuring  two  inches  in  length,  and  being  cut  into  four,  was  found  to  consist 
of  cortical  renal  substance  about  one  sixth  of  an  inch  in  thickness.  Immediately 
behind  this  renal  substance  was  a  cyst,  communicating  with  one  of  the  pouches 
previously  described,  about  the  size  of  half  a  crown.  No  trace  of  tubercular  struc- 
ture could  anywhere  be  seen. 

A  portion  of  lung  was  also  removed  about  two  inches  square ;  it  was  spongy 
throughout,  but  presented  gelatinous-looking  masses,  about  one-sixth  of  an  inch  in 
diameter,  scattered  through  its  substance.  They  could  be  squeezed  and  compressed 
between  the  fingers,  but  had  a  certain  amount  of  firmness.  On  section  they  pre- 
sented a  smooth  surface  of  grey  colour. 

Microscopic  Esamixatiox. — The  cancerous  mass  in  the  stomach  presented 
cancer  cells  in  all  stages  of  formation,  with  granule  cells  here  and  there  embedded  m 
masses  of  molecular  substance.  The  mesenteric  and  epigastric  glands  on  being  cut 
presented  a  fragile  surface,  from  which  a  glutinous  substance  could  readily  be 
scraped.  This  contained,  when  examined  microscopically,  large  cancer  cells  multi- 
plying endogenously ;  here  and  there  granule  cells,  with  a  few  filjres  and  numerous 
molecules.     The  rounded  masses  m  the  lung  were  of  the  same  structure. 


Case  LXI.* — Colloid  Cancer,  with  Perforating  Ulcer  of  Stomach — Peritonitis. 

History. — James  Douglas,  ret.  55,  a  porter — admitted  Sept  15,  1854.  About 
fourteen  weeks  ago,  being  previously  quite  healthy,  he  began  to  experience  a  burn- 
ing pain  in  the  epigastrium,  more  severe  after  taking  food,  and  also  a  sensation  as  of 

*  Reported  bv  Mr.  Robert  Rhind,  Clinical  Clerk. 
29 


450  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

a  ball  rising  in  his  throat.  For  three  weeks  he  continued  to  work,  but  gradually  grew 
worse ;  eight  weeks  ago,  he  vomited,  for  two  daj^s,  dark  coloured  matter  like  coffee 
grounds.  Has  since  been  troubled  with  pyrosis,  has  lost  his  appetite,  and  become 
weaker  and  thinner. 

Symptoms  on  Admission. — Is  greatly  emaciated.  Tongue  moist,  slightly  furred ; 
appetite  bad ;  no  d3^sphagia ;  feels  pain  in  the  epigastric  region  constantly  of  a 
burning  character,  more  severe  after  taking  food ;  no  vomiting,  but  has  eructations 
of  a  thin  watery  fluid.  The  epigastrium  feels  hard  on  palpation ;  in  the  region  of 
the  umbilicus  there  is  a  distinct  tumour  stretching  across  the  abdomen;  movable 
under  the  integument;  not  very  tender  to  the  touch.  Bowels  habitually  costive. 
Has  no  cough.  Pulse  56,  weak.  Urine  not  coagulable,  of  sp.  gr.  1019.  Other 
systems  normal. 

Progress  of  the  Case. — September  IbiJi  to  October  9ih. — The  patient  has  been 
treated  by  the  administration  of  antacids,  bismuth  and  magnesia ;  by  the  injection 
of  nutritive  enemata ;  b}^  occasional  opiates  at  night ;  by  suitable  aperients,  and 
careful  regulation  of  the  diet.  He  has  gained  no  strength ;  is  indeed  much  weaker  ; 
at  present  he  has  a  burning  sensation  along  whole  course  of  the  oesophagus.  Oct 
13th. — This  morning  experienced  acute  pain  in  the  abdomen,  which  is  now  dis- 
tended, and  generally  painful  on  pressure  and  deep  inspiration.  Pulse  84,  pretty 
firm.  Eight  leeches  were  applied  to  the  abdomen,  followed  by  warm  fomentations, 
and  opium  in  grain  doses.  Oct.  lith. — Has  had  much  vomiting,  this  morning,  of 
dark  cotfee-coloured  fluid ;  pulse  is  feeble,  and  extremities  are  cold.  While  eating 
his  dinner  to  day,  he  fell  forward,  and  immediately  expired. 

Scctio  Cadaveris. —  Twenty-two  hows  after  death. 

Body  very  much  emaciated. 

Thorax. — Thoracic  organs  normal. 

Abdomen. — On  opening  the  abdomen  a  large  quantity  of  dark  coloured  fluid  was 
found,  in  which  were  suspended  flakes  of  white  lymph.  To  the  inner  surface  of  the 
peritoneum  pieces  of  soft  recent  lymph  were  attached,  but  it  was  quite  free  of  small 
round  nodules.  The  stomach  and  the  intestines  were  loosely  glued  to  each  other, 
and  to  the  parietal  peritoneum,  by  soft  lymph.  The  fingers  alone  were  sufficient  to 
separate  the  bowels.  On  examining  attentively  the  anterior  surface  of  the  stomach 
two  or  three  small  perforations  could  be  detected.  The  largest  was  nearly  an  inch 
long  on  the  outer  surface  of  the  stomach,  and  corresponded  to  an  ulceration  about 
2-^  inches  in  extent  internally.  The  pyloric  half  of  the  stomach  was  transformed 
into  a  large,  intensely  hard,  glue-like  mass,  and  was  about  the  size  of  a  cocoa-nut,  or 
two  closed  fists.  On  opening  the  stomach,  the  mucous  membrane,  towards  the  car- 
diac extremity,  was  perfectl}^  sound,  but  at  the  pyloric  end  it  had  undergone  ulcera- 
tion at  several  points,  especially  near  the  smaller  curvature  and  the  pylorus.  The 
pyloric  orifice  was  of  sufficient  diameter  to  admit  easily  the  little  finger.  The  pan- 
creas, liver,  and  surrounding  organs  were  healthJ^  The  texture  of  the  growth  was 
as  hard  as  cartilage,  and  creaked  under  the  knife,  but  on  section  presented  the  usual 
characters  of  colloid  cancer.  (See  p.  136.)  The  mucous  membrane  of  the  intestines 
was  perfectly  healthy.     The  other  abdominal  organs  were  normal. 

Microscopic  Examination. — The  colloid  cancer  presented  the  characteristic 
structure  described  and  figured  p.  136. 

Commentary. — An  indurated  swelling  in  the  epigastric  region,  pain 
and  vomiting  after  food,  are  the  usual  symptoms  of  cancer  in  the 
stomach  ;  and  they  were  all  present  in  the  two  cases  just  noticed.  There 
was,  besides,  ha^matemesis,  indicating  ulceration  in  Case  LX.,  and,  in 


ORGANIC  DISEASES   OF   THE   STOMACH. 


451 


addition,  sudi^n  pain,  with  peritonitis,  in  Case  LXI.,  pointing  out  the 
occurrence  of  perforation.  The  vomiting  did  not  appear  so  soon  in  the 
last  as  in  the  first  case,  and  it  will  be  noticed  that  in  it  the  pyloric  con- 
striction was  not  great.  On  the  other  hand,  ulceration  was  more  exten 
sive  with  pyrosis,  and  led  to  perforation  with  fatal  peritonitis.  The 
atrophy  of  the  right  kidney,  which  was  converted  into  a  fibrous  sac, 
had  not  apparently  in  Gaffney  produced  any  complaint  whatever  during 
life.  All  the  symptoms  observed  in  this  man,  with  the  exception  of 
hsematemesis,  may  be  produced  by  a  tumour  outside  the  stomach,  as 
well  as  by  disease  of  the  stomach  itself,  pressing  on  the  organ,  and 
nothing  is"  more  difficult  (if  indeed  it  be  ever  possible)  than  to  diagnose 
the  former  condition  from  the  latter,  which,  however,  occurs  rarely. 
(See  p.  474.) 

In  manv  cases  the  lesion  hitherto  described  as  scirrhus  of  the  pylorus 
or  stomach  seems  to  be  a  simple  hypertrophy  of  their  muscular  and 
fibrous  coats,  which  may  or  may  not  be  associated  with  cancer  of  the 
neiofhbouring  glands.  A  simple  stricture  of  the  pylorus  may  in  this  way 
produce  more  or  less  thickening  of  the  stomach,  in  consequence  of  the 
chronic  vomiting  excited  by  it ;  or  by  increasing  the  muscular  power 


Wimi^xM 


Fis. 


Fig.  393. 


Fis.  S99. 


necessary  to  overcome  the  obstruction,  just  as  happens  in  the  intestines, 
bladder,  and  other  hollow  viscera,  when  the  parts  below  them  are  stric- 


Fig.  397.  Appearance  of  the  gastric  glands  in  recent  catarrh  of  the  stomach. 
Their  external  outline  is  irregular,  and  they  are  filled  with  enlarged  secreting  cells. — 
{Wilson  Fox.) 

Fig.  398.  Commencing  cystic  formation  in  a  gastric  follicle,  which  is  constricted  in 
some  places  {b,  c,)  and  swollen  at  others,  a.  Shows  the  thickening  of  the  limitary 
membrane,  and  d,  slight  fatty  degeneration  of  the  epitheUum. — {Wilso/i  Fox.) 

Fig.  399.  A  cyst  in  the  pyloric  portion  of  the  stomach,  composed  of  a  fibrous 
envefope,  and  contents  wholly  composed  of  cylindrical  epithelium.  At  a,  the  limitary 
membrane  of  the  gastric  glands  commences  to  be  thickened ;  and  at  b,  their  contents 
have  undergone  the  fatty  degeneration,  so  common  in  chronic  catarrh. — ( Wilson  lox.) 

340  diam. 


452 


DISEASES   OF  THE   DIGESTIVE   SYSTEM. 


turcd.  (See  Figs.  146  to  148,  p.  153.)  I  have  recorde(4,  four  cases  of 
this  kind  in  my  work  on  "Cancerous  and  Cancroid  Growths."  (Edin- 
burgh, 1848,  p.  46,  et  seq.)  In  all  such  cases  it  is  observable,  that  the 
same  emaciation  and  cachectic  appearances  are  present  as  in  instances 
of  undoubted  cancer — a  circumstance  which  is  attributable  to  the 
impeded  nutrition  of  the  body  rather  than  to  a  supposed  cancerous 
diathesis.  On  this  account  I  have  long  ceased  to  place  any  confidence 
in  the  so-called  "cachectic  appearance"  as  diagnostic  of  cancer,  attribut- 
inp-  it  either  to  imperfect  nutrition,  or  to  wearing  down  of  the  body  from 
excessive  pain.  This  cachexia  is  often  present  in  many  other  forms  of 
morbid  growth,  and  frequently  absent  when  the  disease  has  been  proved 
to  be  cancerous  by  a  microscopic  examination. 

Of  all  forms  of  cancerous  disease,  that  of  the  stomach  is  perhaps  the 
most  distressing;  it  cuts  off  the  supply  of  nourishment  which  should 
enter  the  system,  and  induces  (in  addition  to  the  wearing-down  pain) 
loss  of  sleep,  loss  of  blood,  and  more  or  less  constant  vomiting.  Our 
duty  in  such  cases  is  to  relieve  and  support  the  system ;  and  to  this  end 
opiates  in  large  doses,  nutritive  enemata,  careful  regulation  of  the  diet, 
and  ice  allowed  to  dissolve  in  the  mouth,  are  the  best  remedies.  A  local 
frio-orific  mixture,  as  recommended  by  Dr.  J.  Arnott,  and  the  application 
of  a  few  leeches  to  the  epigastrium,  are  also  occasionally  beneficial.  In 
Case  LX.  the  cold  application  was  of  marked  service. 

The   histological   changes   which   occur  in   various   disorders  of  the 


ft 

w 


v~Z 


i^vg       [ 


i      ]^^^^4^^y 


d 


Fig.  400. 


Fig.  402. 


stomach  were  first  investigated  by  Dr.  Handfield  Jones,  who  lias 
described  and  figured  the  appearances  presented  by  the  follicles,  their 
contained  cells,  and  other  minute  structures  under  a  variety  of  circum- 


Fig.  400.  The  gastric  glands  in  chronic  catarrh  of  the  stomach,  the  breaking  down 
of  tlie  upper  portion  being  proljably  due  to  post  mortem  change,  a,  A  mass  of  pig- 
ment ;  5,  h,  free  fat  drops ;  c,  tliickened  limitary  membrane ;  d,  d,  d,  complete  fatty 
degeneration  of  the  epithelium. — {Wilson  Fox.)  240  diam. 

Fig.  401.  Chronic  catarrh  of  the  stomach,  with  hypertrophy  of  the  fibrous  tissue 
between  the  glands.  The  section  has  been  treated  with  acetic  acid,  which  exhibits 
more  distinctly  the  nuclei  of  the  nervous  tissue,  and  gives  a  cloudy  appearance  to  the 
follicular  epithelium. — ( Wilsoyi  Fox.) 

Fig.  402.  Fatty  degeneration  affecting  the  upper  layer  of  the  follicular  epithelium, 
c,  and  fibrous  connective  tissue,  a,  a,  producing  erosion  of  the  surface ;  h,  fatty 
degeneration  of  the  epithelium  and  sub-mucous  fibrous  tissue. — ( Wilson  Fox.) 

340  diam. 


DISEASES   OF   THE    LIVER.  *i53 

stances.*  There  may  be  hypertrophy  and  atrophy  of  the  sohtary 
glands;  atrophy  of  the  glandular  tubes;  fatty  degeneration;  wasting 
and  black  discoloration  o"f  their  epithelial  contents ;  fibroid  thickening, 
etc.  His  researches  have  been  for  the  most  part  confirmed  by  Dr.  F. 
Schlapferf  and  Dr.  Wilson  Fox.J  The  latter  observer  has  added  some 
important  facts  connected  with  chronic  catarrh  of  the  stomach,  thicken- 
ing of  the  limitary  membrane,  and  cystic  degeneration  of  the  glands. 
Dr.  Habershon,§  as  well  as  Dr.  Fox,  points  out  the  rapid  changes  which 
take  place  in  the  glands  of  tlie  stomach  after  death,  and  the  great  cau- 
tion therefore  required  in  forming  conclusions,  when  examination  of  the 
minute  structure  is  too  long  delayed.  As  a  guide  to  the  clinical  student 
and  practitioner,  I  give  the  more  important  morbid  changes  which  have 
been  observed  in  the  gastric  glands,  from  the  excellent  representations 
of  Dr.  Fox.  Dr.  Jones  has  the  great  merit  of  having  laid  the  founda- 
tion for  a  clinical  history  of  these  lesions,  although  the  observations  are 
as  yet  far  too  few  to  enable  us  to  connect  them  with  diagnosis  and 
treatment  at  the  bed-side.  From  what  is  known  on  this  subject,  I  must 
refer  to  the  works  I  have  named,  hoping  that  before  long  these  researches 
may  be  extended  by  clinical  histologists,  and  uUimately  lead  to  a  more 
exact  knowledge  of  the  dyspeptic  and  organic  diseases  of  this  important 
organ. 


DISEASES  OF  THE  LIVER. 

Notwithstanding  the  obscurity  which  still  rests  upon  the  functions  of 
the  liver,  the  progress  of  histological  pathology  has  tended  to  make  ns 
better  acquainted  with  the  minute  changes  which  occur  in  many  dis- 
eases of  the  organ.  The  nature  of  fatty  enlargement,  of  cirrhosis,  and 
of  the  disintegration  of  cell-texture  following  obstruction  of  the  bile- 
ducts,  is  now  understood,  but  much  reseai'ch  is  still  necessary.  A  care- 
ful comparison  of  the  structural  changes  observed  in  the  liver  after 
death,  with  the  clinical  history  and  symptoms  observed  during  life,  is 
what  is  o-reatly  desired  to  advance  our  knowledge  of  hepatic  diseases. 
This  knowledore,  however,  can  scarcely  be  hoped  for,  until  medical  men, 
and  especially  such  as  practise  in  the  East,  become  efficient  histologists. 
It  is  the  application  of  therapeutics  to  these  diseases,  however,  and  a 
correct  appreciation  of  the  class  of  remedies  called  cholagogues,  which, 
in  the  present  state  of  medicine,  requires  most  to  be  determined.  Such 
an  investigation  necessitates  physiological,  histological,  and  chemical 
knowledge,  added  to  good  powers  of  clinical  observation.  But  of  all  the 
subjects  of  research  now  open  to  the  young  investigator,  I  know  of  none 
in  which  patience  and  exactitude,  based  on  a  scientific  rather  than  an 
empirical  svstem  of  inquiry,  is  likely  to  yield  more  useful  results. 

*  Pathological  and  Clinical  Observations  respecting  Morbid  Coaditions  of  the 
Stomach.     London,  1845. 

\  Yirchow's  Archiv.  B.  7,  p.  158.     185-1. 

X  Medico-Chir.  Trans,  of  London.     Vol.  XLI.     1858. 

§  On  Diseases  ol  the  Alimentary  Canal,  p.  52.     8vo,  bound.     1857. 


45-i  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 


Case  LXII.* — Acute  Congestion  of  the  Liver — Hepatitis  ? — Eecovery. 

History. — Thomas  Eussell,  ffit.  38,  labourer  at  a  gas  work — admitted  January 
26th,  1855.  States  that  about  three  weeks  ago,  after  indulging  freely  in  the  use  of 
ardent  spirits,  he  experienced  general  shivering  and  pain  in  the  right  hypochon- 
drium,  with  tinnitus  and  a  sense  of  faintness.  Subsequently  he  lelt  pain  in  the 
right  shoulder,  and  at  length  was  obliged  to  leave  off  work.  His  comrades,  who 
went  home  with  him,  told  him  that  he  looked  yellow  in  the  face.  At  night  he 
became  very  hot.  He  returned  to  his  work  on  the  following  day,  and  continued  at  his 
employment  for  a  fortnight,  but  was  very  weak,  and  suffered  much  from  tlie  pain  in  his 
side,  and  in  the  shoulder.  Since  then  he  has  been  confined  to  bed,  under  medical  care, 
applying  counter-irritants  locally,  and  taking  pills  which  have  made  his  mouth  sore. 

Symptoms  ox  Admission. — On  admission,  he  complains  of  pain  in  the  right  hypo- 
chondrium  and  right  shoulder,  in  the  former  of  which  situations  it  is  permanent  and 
increased  by  pressure,  while  in  the  latter  it  is  only  occasional.  The  tongue  is  covered 
with  a  moist,  white  fur;  the  breath  has  a  mercurial  foetor;  the  gums  are  painful; 
appetite  good.  Bowels  open.  Pressure  and  percussion  over  the  liver  painful.  Yer- 
tical  hepatic  dulness  4i  inches.  Pulse  72,  soft.  Sleeps  little  in  consequence  of  the  pain. 
Urine  normal ;  no  jaundice.  Other  functions  well  performed.  To  apply  six  leeches 
to  the  7-ight  hypochondrium,  and  the  parts  afterwards  to  he  fomented.  To  take  two  com- 
pound rhubarb  jiills  every  night. 

Progress  of  the  Case. — February  1st. — The  leeches  and  fomentations  have 
in  no  way  benefited  the  pain,  which  to-day  is  as  severe  as  on  admission.  Bowels 
still  open.  Stools  darker  than  formerly,  but  healthy.  Feb.  3d. — Since  last  report 
all  pain  has  left  him ;  he  declares  himself  to  be  well,  and  at  his  own  request  was 
discharged. 


Case  LXIII.f — Acute  Jaundice — Albuminuria — Recovery. 

History. — "Walter  HaUiday,  set.  51,  tailor — admitted  July  6th,  1857.  States  that 
he  has  generally  been  a  temperate  man,  although,  occasionally,  he  has  taken  spirits 
moderately.  On  the  first  of  this  month,  when  working  below  an  open  window,  he 
was  suddenly  seized  with  rigors,  followed  by  great  thirst,  heat  of  skin,  and  headache. 
Next  morning  he  went  to  work  as  usual,  but  was  obliged  to  desist  in  the  middle  of 
the  day,  and  go  home.  The  rigors  have  returned  occasionally  ever  since,  and  he  has 
experienced  obscure  pain  in  the  lumbar  region.  The  skin  became  jaundiced  on  the 
second  day  of  his  illness,  and  the  yellow  tint  has  been  increasing  in  intensity  since. 
He  has  also  occasionally  vomited. 

Sy'mptoms  on  Admission. — The  tongue  is  moist  and  covered  with  a  whitish  fur. 
No  difiQcult}^  in  taking  food  nor  pain  afterwards.  No  tenderness  or  pain  in  abdomen  ; 
but  feels  a  pain  in  the  lumbar  region,  which  sometimes  darts  round  the  right  side 
towards  the  umbilicus.  Appetite  impaired.  Bowels  costive.  Yertical  dulness  of 
liver,  on  percussion  4  inches.  The  skin  over  the  whole  body  is  of  a  deep  yellow  tint, 
dotted  with  spots  of  purpura  the  size  of  pin  heads :  but  is  cool  and  moist.  The 
urine  is  deep  coloured,  hke  Madeira  wine.  It  is  very  albuminous  on  the  addition  of 
heat,  and  contains  a  large  quantity  of  bile.  Pulse  88,  small  and  weak.  Other  organs 
healthy.  5  Potass.  Acet.  3  ij ;  Sp.  jFther.  Nit.  f  ss ;  Aquce,  §  vi.  M.  One  ounce 
to  be  taken  every  three  hours.     July  Sth. — Bowels  were  freely  opened  yesterday  in  con- 

*  Reported  by  Mr.  W.  J.  Marshall,  Clinical  Clerk. 
\  Reported  by  Mr.  W.  H.  Davies,  Clinical  Clerk. 


DISEASES   OF   THE   LIVER,  455 

sequence  of  a  Calomel  and  Jalap  powder  which  was  given.     Stools  were  fluid  and  of 
a  dark  brown  color. 

Progress  of  the  Case. — July  9(h. — On  microscopic  examination  of  the  urine,  it 
was  seen  to  contain  numerous  casts,  with  delicate  walls,  having  in  their  interior  large 
epithelial  cells.  Passes  more  urine  than  formerly.  To  Imve  pidv.  Doveri  gr.  x.  at  bed 
time,  folloiued  hy  a  diaphoretic  draught.  Tioo  compound  rhubarb  pills  to  be  taken  every 
night  Julyl2th. — The  urine  and  skin  are  now  of  a  healthy  colour.  The  pulse,  how- 
ever, remains  low,  and  the  patient  weak  and  languid.  Nutrients,  tonics,  and  wine, 
with  gentle  exercise,  were  now  given,  under  which  he  became  thoroughly  well,  and 
was  discharged  August  3d. 

Commentary/. — These  two  cases  are  examples  of  the  slighter  forms  of 
hepatic  disease,  although  what  that  disease  is  it  becomes  no  easy  matter 
to  determine.  In  the  first  case  we  have  pain,  increased  on  pressure  in 
the  right  hypochondrium,  and  in  the  right  shoulder,  ushered  in  by  rigor 
and  febrile  symptoms.  On  percussion  the  liver  is  found  to  be  slightly 
enlarged.  After  coming  into  the  house  the  disease  subsides  in  a  few- 
days.  The  leeches  and  fomentations  did  not  seem  to  alleviate  the  pain, 
but  the  purgative  produced  a  more  healthy  intestinal  discharge.  In  the 
second  case  there  was  little  local  pain,  but  evidently  something  had 
caused  interference  with  the  secretion  of  bile.  The  skin  was  deeply 
jaundiced,  the  stools  of  a  dark  clay  or  leaden  colour,  and  the  urine  loaded. 
This  condition  was  also  ushered  in  with  rigors  and  febrile  symptoms. 
Ptyalism  was  produced  before  he  entered  the  house,  without  occasioning 
the  slightest  benefit.  On  the  contrarv,  the  disease  increased.  But  under 
the  action  of  diuretics  and  diaphoretics,  to  fa\'our  secretion  of  the  bile 
already  absorbed,  as  well  as  of  mercurial  purgatives  to  rouse  the  duode- 
num and  upper  parts  of  the  alimentary  canal  to  a  more  healthy  action,  he 
rapidly  recovered.  Whether  the  disorder  in  these  cases  was  congestive 
or  inflammatory,  or  both,  cannot  be  determined.  ^Yhatever  the  lesion, 
it  so  operated  in  the  one  case  as  to  induce  great  pain,  and  in  the  other 
to  obstruct  the  gall  ducts  and  occasion  jaundice. 

In  jaundice  the  diminished  excretion  of  bile  by  the  intestines  is  at- 
tempted to  be  compensated  for  by  its  entering  more  or  less  largely  into 
the  secretions  of  the  kidney  and  skin — especially  the  former.  In  intense 
forms  of  the  disease,  casts  of  the  renal  tubes  are  frequently  seen  in  the 
urine,  their  contained  cells  deeply  tinged  with  bile  pigment.  Frerichs 
has  carefully  described  and  figured  the  histological  changes  which  occur 
in  the  kidneys  and  skin  under  such  circumstances.  These  consist  in  the 
accumulation  of  yellow,  brown,  and  green  pigment,  in  the  cells  of  the 
ttibuli  uriiiiferi,  and  not  unfrequently  the  pigment  is  infiltrated  through 
the  parenchymatous  tissue  of  the  kidney.  He  has  even  seen  it  assume 
the  form  of  hard  coal-like  masses,  which  must  have  greatly  inteifered 
with  the  functions  of  the  organ.  In  the  skin  the  deeper  layer  of  round 
epidermic  cells  contains  a  yellowish  or  deeply  brown  granular  pigment, 
and  the  secreting  cells  of  the  sudoriferous  glands  are  similarly  affected, 
but  never  to  the  extent  which  may  be  observed  in  the  kidney.*  Such 
observations  indicate  the  importance  of  diuretics  and  sudorifics  in  the 
treatment  of  jaundice,  in  addition  to  the  means  usually  adopted  for 
stimulating  the  upper  part  of  the  ahmentary  canal. 

*  Frerichs,  Klinik  der  Leber  Krankheiten,  185S,  pp.  lOT-8,  and  plate  I. 


456  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


Case    LXIV.-)- — Impaction  of  a  Gail-Stone  in  the  Common  Bik-Dud — Jaundice — 

Death. 

HiSTOET. — Mary  Duncan,  jet.  36,  married — admitted  November  24,  1851.  She 
has  lived  in  India  some  time,  and  returned  only  a  few  months  since.  Three  weeks 
ago,  when  recovering  from  a  severe  attack  of  lumbago,  she  experienced  great  pain 
in  the  epigastric  and  right  hj'pochondiiac  regions.  This  Avas  ushered  in  by  rigors  and 
feverishness,  and  lasted  three  or  four  days.  Its  severitj-  then  dimuiislied ;  but  jaun- 
dice appeared,  and  has  since  become  more  intense. 

Symptoms  on  Admission. — On  admission,  the  whole  integumentary  surface  pre- 
sents a  deep  yellow  colour.  Pulse  100,  full.  The  tongue  is  dry,  with  a  dark-brown 
coat.  There  is  a  disagreeable  taste  in  the  mouth,  impairment  of  appetite,  but  no 
nausea  or  sickness.  The  liver  ou  percussion  presents  the  normal  dulness  of  four 
inches  on  the  right  side.  Pressure  in  the  neighbourhood  of  the  gall  bladder  elicits 
pain,  and  there  is  permanent  soreness  diffused  over  the  anterior  portion  of  the  liver 
and  epigastric  region.  The  pain  is  not  spasmodic  in  its  character,  nor  more  severe 
at  one  time  than  at  another.  The  bowels  are  generally  costive ;  skin  hot  and  dry, 
urine  like  porter,  staining  linen  yellow,  and  becoming  green,  and  then  red  on  the 
addition  of  nitric  acid.  The  abdomen  is  enlarged.  She  has  had  a  child  pre- 
viously, and  saj's  she  is  now  six  or  seven  months  pregnant.  The  treatment  consisted 
of  purgatives  {Pil.  Rhei  comp.);  leeches  and  fomentations  to  the  tender  spot  over  the 
liver,  and  diuretics  of  acetate  of  potass  and  sp.  oither.  nit. 

Progress  of  the  Case. — December  M. — The  bowels  have  been  kept  open  by 
purgatives,  and  the  stools  have  been  well  coloured  with  bile.  Leeches  have  been 
applied  tmoe,  and  the  hepatic  pain  has  been  much  relieved.  She  has  also  been 
taking  small  doses  of  tartrate  of  antimony,  and  muriate  of  morphia.  The  skin, 
however,  continues  dry,  and  is  now  more  deeply  tinged  yellow  than  on  her  admis- 
sion. The  urine  also  is  still  loaded  with  bile.  To-day  vomiting  came  on,  and  she 
rejects  her  food  and  medicine.  Tlie  lips  and  teeth  are  covered  with  sordes,  and  she 
complains  of  great  languor  and  depression.  Diuretics  to  be  continued;  a  blister  to  the 
right  hypochondriac  region ;  and  a  powder,  containing  four  grains  of  calomel  and  one- 
third  of  a  grain  of  opium^  to  he  taken  every  hour  for  six  doses.  The  mercury  produced 
no  physiological  action,  although  continued  in  smaller  doses  and  at  longer  intervals 
for  several  days,  assisted  by  mercurial  frictions  over  the  right  hypochondrium.  Dec. 
\lth. — ^There  was  slight  diarrhoea,  which  was  checked  by  an  aromatic  cretaceous 
mixture.  Mercurials  were  suspended.  On  the  13i/i  she  was  evidently  worse ;  the 
skin  assumed  a  greenish  hue  ;  she  is  very  feeble,  and  passes  her  stools  in  bed ;  pulse 
120,  small.  On  the  15!l/i,  the  skin  assumed  a  tawny  colour;  the  stools  are  passed 
in  bed,  are  green,  of  a  dark  colour,  and  of  a  very  offensive  cadaveric  smell ;  great 
prostration  of  strength  ,  urine  still  loaded  with  bile ;  low  delirium  at  night.  Died 
on  tlie  18^/i. 

Sectio  Cadaveris. —  Thirty  hours  after  death. 

Thorax. — Thoracic  organs  healthy. 

Abdomen. — On  opening  the  abdomen,  bands  of  recently-exuded  lymph  are  found 
firmly  uniting  together,  the  peritoneal  surfaces  of  the  gall-bladder,  the  anterior  mar- 
gin of  the  liver,  and  a  portion  of  the  omentum,  over  an  extent  the  size  of  the  palm  of 
the  hand.  On  separating  these  adliesions,  the  gall-bladder  and  omentum  were 
found  so  firmly  united,  that  an  aperture  was  formed  in  the  former  the  size  of  a  pea; 

*  Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


DISEASES   OF   THE   LIVEK.  457 

through  which  a  quantitj-  of  dark-green  bile  escaped.  The  hver  was  of  its  normal 
size,  and  presented  externally  a  dark  olive-green  colour.  On  cutting  into  its  sub- 
stance, the  gall  ducts  were  everywhere  dilated  and  thickened.  Some  were  distended 
into  elongated  cavities  above  half  an  inch  in  calibre,  and  they  were  all  filled  with 
thick  dark-green  bile.  The  tissue  of  the  liver  throughout  was  unusually  soft,  readOy 
breaking  down  under  the  fingers,  and  uniformly  of  the  same  olive-green  colour  as  the 
external  surface.  In  the  common  bile-duct,  about  half  an  inch  from  its  duodenal 
extremity,  a  hard  light-yellow  gall-stone,  the  size  of  a  small  hazel-nut,  was  firmly 
impacted,  the  duct  both  above  and  below  being  somewhat  thickened  and  dilated. 
No  other  gall-stones  could  be  anywhere  discovered.  The  uterus  and  rectum  were 
adherent,  and  in  separating  them  about  a  teaspoonful  of  yellow  pus  escaped.  The 
vagina  was  shortened  and  constricted  about  two  inches  from  the  vulva,  so  as 
scarcely  to  admit  a  common  quill.  About  an  inch  width  in  the  vagina,  on  its  inferior 
wall,  was  a  round  aperture,  the  size  of  a  shilling-piece,  with  ragged  edges,  and  com- 
municating with  the  rectum.  On  the  superior  wall  of  the  vagina,  about  half  an  inch 
from  the  clitoris,  was  another  rounded  opening,  about  the 

size  of  a  sixpenny-piece,  into  which  the  point  of  the  little  '"^    "^  " "  ^oo 

finger  could  be  pushed  and  passed  into  the  bladder.    The     !.  /^a 

natural  meatus  urinarius  was  occluded.  „  ~'  " 

Microscopic  Examination. — On    crushing    a    small     o 
piece  of  the  liver  between  glasses,  and  examining  it  under  ~'  °  O  °  ° 

a  power  of  250  diameters  linear,  it  was  found  to  consist  ^'"  '*'^*'- 

of  a  multitude  of  iatty  molecules  and  granules,  with  larger  globules  of  loose  oil. 
Many  of  the  cells  seemed  to  be  broken  down  and  disintegrated,  but  such  as  were 
entire  were  more  or  less  distended  with  bile  pigment. — Fig.  403. 

Commentary/. — The  symptoms  present  in  this  case  on  admission,  viz., 
the  jaundice,  local  pain,  the  rigors,  and  fever,  were  indicative  of  obstruc- 
tion in  the  common  bile-duct  connected  with  some  inflammatory  action 
going  on  in  the  liver  or  its  neighbourhood.  Hence  the  topical  applica- 
tion of  leeches,  and  afterwards  wai'm  fomentations,  were  ordered.  As  the 
blood  and  urine  were  evidently  loaded  with  bile,  diuretics  and  purgatives 
were  also  given  to  assist  the  excretion  of  that  product.  These  remedies 
proving  of  no  avail,  and  the  constitutional  symptoms  increasing,  mercury, 
conjoined  with  opium,  was  actively  administered,  but  failed  to  produce 
its  physiological  or  any  useful  therapeutical  result.  After  death,  perito- 
nitis surrounding  the  gall-bladder  and  common  duct  was  discovered ;  but 
death  evidently  resulted  from  the  poisoning  of  the  system  through  the 
absorption  of  bile,  the  excretion  of  which  was  prevented  by  the  firm 
impaction  of  a  calculus  in  the  common  bile  duct.  The  benefit  of  mer- 
cury in  such  cases,  though  sti'ongly  recommended  as  a  means  of  altering 
the  constitution  of  the  bile,  appeals  to  me  very  doubtful ;  for,  supposing 
it  to  possess  the  eff"ect  ascribed  to  it,  and  to  act  as  an  alterative  and 
*  cholagogue,  its  action  in  obstruction  of  the  gall-ducts  must  be  to  distend 
them  still  furthei',  and  thus  increase  the  pressure  on  the  hepatic  cells, 
and  consequently  the  disintegration  of  the  hepatic  texture.  Most  of  the 
examining  class  were  in  favour  of  the  trial  of  mercury  in  this  case ; 
and  considering  how  uniformly  it  has  hitherto  been  recommended  by 
experienced  practitioners,  I  did  not  think  it  right  to  deprive  the  patient 

Fig.  403.     Disintegration  of  the  hepatic  structure  following  obstruction  of  the 
biliary  ducts.  250  diani. 


458  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

of  any  chance  wliich  miglit  arise  from  its  use.  At  the  time,  I  expressed 
my  want  of  confidence  in  its  virtues,  an  opinion  which  the  progress  of 
the  case  fully  justified.  In  the  present  state  of  science  and  art  of  medi- 
cine, there  is  no  one  point  in  therapeutics  which  so  urgently  requires 
thoi'ough  re-investigation  as  the  real  value  of  the  medical  properties 
attributed  to  mercury. 

'  The  effect  of  the  long-continued  over-distension  of  the  gall-ducts  on 
the  liver  was  a  partial  disintegration  of  its  cell  elements,  and  an  accu- 
mulation of  bile  in  such  of  the  cells  as  remained  perfect.  This  lesion  is 
remarkablv  well  described  by  Dr.  Budd,  in  the  third  chapter  of  his  work 
on  the  liver,  where  he  treats  of  fatal  jaundice.  It  admits  of  question  how 
far  this  destruction  of  the  hepatic  cells  may  not,  by  impeding  the  secreting 
power  of  the  organ,  at  length  induce  that  condition  described  by  Dr.  Al- 
lison, where  the  biliary  principles  are  not  eliminated.  It  must,  I  think, 
be  certain  that  jaundice,  produced  primarily,  as  in  the  present  case,  by 
a  mechanical  obstruction,  must  be  kept  up  by  the  altered  condition  of 
the  cell-structure  afterwards  induced. 

This  case  was  instructive  to  all  who  observed  it,  with  regard  to  a  sup- 
posed pregnancv  she  laboured  under.  The  abdomen  was  certainly  some- 
what prominent ;  but  the  investigation  of  the  existence  of  this  state  was 
never  gone  into,  for  the  simple  reason,  that  it  no  way  aft'ected  the  diag- 
nosis or  treatment.  When  the  woman  was  dying,  however,  the  husband 
applied  to  me,  with  a  view  of  ascertaining  whether  it  might  not  be  pos- 
sible to  save  the  child.  On  this  point  I  requested  the  opinion  of  Dr. 
Simpson,  who,  on  examining  the  woman,  declared  her  not  to  be  pregnant. 
This  circumstance  then  is  an  illustration  of  how  women  who  have  pre- 
viouslv  had  children  may  be  deceived  as  to  the  existence  of  a  subsequent 
pregnancy,  and  how  important  it  is  for  the  practitioner,  as  a  general  rule, 
to  satisfy  himself  of  the  reality  or  falsity  of  such  a  state  in  all  cases. 
When  formerly  delivered  in  India,  she  said  instruments  were  employed, 
and  that  she  sustained  some  injury.  This  account  is  rendered  highly 
probable  by  the  existence  of  the  recto-vaginal  and  urethro-vaginal  fistulse, 
and  the  remarkable  vaginal  stricture,  found  after  death. 


Case  LXY.* — Jaundice — Compression  of  the  Ductus  Communis  Choledochus  from  a 
Cancerous  Tumour,  composed  of  Epigastric  and  Lumbar  Glands — Occlusion  of 
Cystic  Duct — Enlargement  of  Gall  Bladder — Cancer  of  the  Pancrecbs — Biliary 
Congestion  of  the  Liver — Cancej-ous  Exudation  into  various  organs — Slight  Leu- 
cocythemia. 

History. — William  Dodds,  set.  23,  ploughman — admitted  December  Stli,  1854. 
He  states  that  four  weeks  ago  he  was  seized  with  pain  in  tlie  lower  part  of  the  abdo- 
men, accompanied  by  unusual  eostiveness.  Some  days  afterwards  he  commenced 
to  vomit  his  food  a  few  hours  after  taking  it.  The  vomiting  continued  for  a  fortnight, 
and  then  suddenly  ceased.  But  it  returned  about  four  days  ago  as  before,  and  has 
continued  up  to  the  time  of  admission. 

Si'MPTOMs  ON  Admission. — The  tongue  is  loaded  with  a  thick  white  coat,  but 
moist.  Appetite  bad.  After  taking  food  he  has  feeling  of  a  great  load  and  dis- 
tension m  his  stomach.     No  flatulence,  but  has  frequent  eructations  of  a  watery 

*  Reported  by  Mr.  Robert  Rhind,  Clinical  Clerk. 


DISEASES   OF   THE    LIVEK.  459 

fluid,  which  is  neither  acid  nor  of  disagreeable  taste.  Usually  vomits  it  about  4 
o'clock,  A.ir.,  and  for  some  time  afterwards  experiences  considerable  relief;  has  con- 
stant severe  pain  and  considerable  tenderness  over  the  epigastrium.  A  tumour  can 
be  felt  towards  the  pjioric  end  of  the  stomach,  of  a  rounded  form.  It  measures  two 
and  a  half  inches  vertically,  its  upper  and  lower  margins  being  distinctly  tangible, 
its  lateral  margins,  however,  cannot  be  determined.  The  hepatic  duluess  in  the 
right  hypochondrium  was  normal.  All  the  other  functions  are  healthy.  Diet  to  be 
carefully  regulated. 

Progress  of  the  Case. — December  10th. — Has  been  much  better  since  admis- 
sion, not  having  vomited  till  this  morning  at  five  o'clock.  He  then  brought  np  a 
large  quantity  of  brownish  pultaceous  matter,  which,  on  microscopic  observation, 
was  found  to  consist  of  half-digested  muscular  fibres,  starch  and  oil  globules,  and 
epithelial  cells.  Has  considerable  pain  and  tenderness  in  the  epigastrium.  Eight 
leeches  to  be  applied,  followed  by  tvarm  fomentations.  Dec.  IStli. — There  have  been 
remissions  in  the  epigastric  pain,  which,  however,  still  continues.  The  vomiting 
also  has  not  been  permanent,  having  been  suspended  for  two  days  by  eating  ice,  and 
again  on  the  16th,  by  a  morphia  draught.  The  constipation  has  been  relieved  by 
domestic  enemata.  It  was  observed  to-day  for  the  first  time,  that  the  skin  has  a 
decided  though  very  slight  yellow  tinge.  I>ec.  23d— Since  last  report  has  expe- 
rienced great  pain  at  times  in  the  abdomen  generally,  for  which  he  was  ordered  a 
draught  at  night  with  Tr.  Cannabis  Ind.  3ss.  Six  more  leeches  were  also  applied 
on  the  20th,  but  without  lessening  his  sufferings.  There  has  been  considerable  fever, 
with  thirst  and  loss  of  appetite.  Iced  Lemonade  for  drink,  and  tvarm  fomentations 
to  the  abdomen,  give  most  relief!  Yesterday  the  jaundice  was  decidedly  more  pro- 
nounced, and  has  increased  still  more  to-day.  There  has  latterly  been  constant 
vomiting,  shortly  after  taking  food."  He  is  more  emaciated,  and  the  tumour  formerly 
alluded  to  can  now  be  felt  hard  and  nodulated  through  the  integuments.  The  stools 
are  of  a  clay  colour,  and  the  urine  loaded  with  bile  so  as  to  resemble  porter.  Pulse 
120,  very  weak.  Vf.  Pil.  Opii  vj.  One  to  be  taken  immediately,  and  repeated  in  four 
hours  if  there  be  no  alleviation  of  the  pain.  To  have  wine  §  iv  daily,  and  ice  to  dissolve 
in  the  mouth.  Continue  the  tuarm  fomentations  to  the  abdomen,  and  to  inject  slowly 
5  iv  of  strong  beef  tea  into  the  rectum.  From  this  time  he  continued  sinking.  The 
skin  assumed  a  greenish  tinge.  On  the  2J:th  he  vomited  blood,  and  passed  black 
tarry  matter  by  stool.  Brandy  and  stimulants  were  freely  administered,  but  he  died 
Dec.  26th. 

Sectio  Cadaveris. — Fifty -one  hours  after  death. 

The  body  considerably  emaciated.  The  whole  surface,  and  all  the  tissues,  includ- 
ing the  cartilages,  were  stained  of  a  greenish-yellow  colour. 

Thorax. — Both  lungs  were  emphysematous  anteriorly,  especially  the  left.  Pos- 
teriorly they  were  engorged,  and  on  section  were  cedematous,  with  scattered 
nodules  of  cancerous  matter  in  their  substance,  of  cheesy  consistence,  but  occasion- 
ally very  soft,  and  varying  in  size  from  a  pepper-corn  to  that  of  a  small  hazel-nut. 
A  continuous  layer  of  cancerous  matter  also  here  and  there  surrounded  the  bronchial 
tubes  From  the  universal  predominance  of  bile-pigment,  these  cancerous  masses 
closely  resembled  to  the  eye  tubercular  matter.  Immediately  under  the  upper  part 
of  the  sternum,  and  over  the  ascending  aorta,  was  a  mass  of  lymphatic  glands, 
about  three  inches  long  and  two  inches  thick,  of  a  fleshy  colour  and  pulpy  consist- 
ence, easily  breaking  down  under  the  finger,  and  infiltrated  here  and  there  with 
a  yellowish-white  cheesy  deposit,  exactly  resembling  tubercle.  The  bronchial 
glands  at  the  root  of  the  lungs  were  greatly  enlarged,  and  presented  a  similar 


460  DISEASES   OF   THE   DIGESTIVE    SYSTEil. 

appearance.  The  heart  was  healthy.  The  ventricles  contained  semi-coagulated 
blood,  the  veins  black  fluid  blood. 

ABDOifEX. — In  the  cavity  of  the  peritoneum  there  was  about  8  oz.  of  dark  brown 
clear  serum.  The  liver  weighed  .3  ll3s.  12  oz.,  was  of  a  light  olive-green  colour, 
approaching  to  brown,  soft  in  texture,  and  on  section  was  seen  to  contain  a  few 
whitish  yellow  masses,  varying  in  size  from  a  millet-seed  to  that  of  a  small  pea,  of 
tolerably  firm  consistence.  The  gall-bladder  projected  about  an  inch  and  a  half 
below  the  lower  margin  of  the  liver.  It  was  considerably  enlarged,  and  was  dis- 
tended with  thick  black  bile.  Tlie  cystic  duct  was  completely  closed  a  little  above 
its  junction  with  the  hepatic,  which  was  quite  free.  The  calibre  of  the  common 
duct  was  much  diminished;  and  although  a  probe  could  be  pushed  through  it,  it 
was  evidently  compressed  by  the  tumour  to  be  described  immediately.  The  spleen 
weighed  5  oz ,  and  was  healthy,  with  the  exception  of  a  cancerous  mass  in  its 
centre,  about  the  size  of  a  coftee-bean,  similar  to  those  in  the  lung.  Surrounding 
the  pyloric  end  of  the  stomach,  and  projecting  from  below  the  liver  towards  the 
left  side,  was  an  agglomerated,  indurated,  and  nodulated  mass  of  enlarged  and  can- 
cerous lymphatic  glands,  of  the  size  and  form  of  a  cocoa-nut.  This  was  the  tumour 
which,  during  the  life  of  the  individual,  was  felt  in  the  epigastrium.  It  pressed 
upon  and  completely  occluded  the  ductus  communis  choledochus.  The  aorta  passed 
through  the  left  third  of  this  mass,  and  was  so  compressed  as  scarcely  to  admit  the 
little  finger.  On  section,  this  mass  presented  very  much  the  appearance  of  some 
specimens  of  pudding  stone,  consisting  of  rounded  or  oval  yeUo wish- white  masses, 
varying  in  diameter  from  J  to  1^  inches,  and  united  together  by  highly  congested 
areolar  tissue,  of  a  deep  purple  colour,  with  here  and  there  extravasations  of  blood 
in  its  substance.  The  affected  glands  were  friable  and  easily  crushed  between  the 
fingers,  but  yielded  no  juice  on  pressure.  The  mesenteric,  mesocolic,  and  lumbar 
glands  generally  were  similarly  diseased.  The  right  extremity  of  the  pancreas  was 
converted  into  a  firm  mass  by  cancerous  exudation,  and  closely  connected  to  the 
tumour  just  described,  of  which  it  formed  an  integral  part.  On  opening  the 
stomach,  it  was  seen  to  contain  a  quantity  of  tenacious,  brown,  glairy  mucus, 
closely  coherent  to  the  mucous  membrane.  Its  walls  at  the  pylorus  were  found  thick- 
ened ;  and  from  this  point  the  thickening  gradually  diminished,  until  it  ceased  at  a 
convex  margin,  somewhat  irregularly  nodulated,  and  elevated  above  the  rest  of  the 
mucous  surface.  The  diseased  portion  occupied  about  one-third  of  the  area  of  the 
organ.  The  mucous  surface  covering  it  was  of  a  dirty-white  colour,  and  was  ulcer- 
ated at  one  point  with  softened  ragged  edges  over  a  space  the  size  of  a  shilling- 
piece.  The  healthy  two-thirds  of  the  mucous  surface  was  of  bright  rose-pink 
colour,  from  vascular  congestion.  The  cut  edge  of  the  pylorus  was  a  quarter  of  an 
inch  thick,  dependent  on  hypertrophy  of  the  muscular  coat  to  the  extent  of  one- 
sixth  of  an  inch,  and  of  an  infiltration  of  firm  whitish  exudation,  in  the  submucous 
areolar  tissue.     The  intestines,  kidneys,  and  other  organs,  were  healthy. 

Microscopic  Examination. — The  whitish-yellow  masses  in  the  lungs  were  prin- 
cipally composed  of  molecular  matter,  but  with  numerous  delicate  nucleated  cells 
apparently  forming.  In  the  bronchial  glands,  the  whitish-yellow  matter  was  com- 
posed of  a  few  cancer  cells  only,  evidently  in  a  state  of  disintegration,  associated 
with  multitudes  of  fatty  molecules  and  granules.  The  fluid  squeezed  from  the 
fleshy  and  pulpy  matter  from  the  same  glands,  contained,  1st,  numerous  round  and 
oval  nucleated  cells,  about  one-thousandth  of  an  inch  in  diameter ;  2d,  many  gra- 
nule cells  of  varying  size;  3d,  multitudes  of  gland  nuclei;  4th,  blood  corpuscles;  5th, 
a  large  quantity  of  molecular  matter.  The  pulp  of  the  epigastric  glands  contained, 
1st,  large  cancer  cells,  some  containing  three  included  cells ;  2d,  a  very  few  granule 
cells ;  3d,  numerous  molecules.     The  blood  contained  a  decided  increase  of  colour- 


DISEASES   OF   THE   LIVER.  461 

less  corpuscles.     The  cells  of  the  liver  contained  a  quantity  of  biliary  matter,  giving 
them,  under  the  microscope,  a  bright  yellow  colour. 

Commentari/. — The  nature  of  this  case  was  tolerably  evident  from  the 
first ;  the  epioastric  tumour,  pain,  and  vomiting  after  taking  food,  indi- 
cated obstruction  of  the  pylorus  produced  by  a  cancerous  growth. 
Later,  when  jaundice  appeared,  it  became  clear  that  the  common  duct 
was  obstructed.  Treatment  could,  of  course,  only  be  palliative.  On 
dissection,  it  was  singular  to  observe  the  resemblance  which  the  can- 
cerous masses  in  the  lungs  and  in  the  glands  bore  to  tubercle.  Some 
persons  who  were  present,  indeed,  judging  from  the  youth  of  the  patient, 
their  friable  consistence  and  yellow  colour,  maintained  that  the  glands 
were  scrofulous ;  and  it  would  have  been  difficult  to  undeceive  them 
•without  the  assistance  of  the  microscope.  All  the  tissues  were  tinged 
of  a  deep  yellow,  and  the  hepatic  cells  were  goi'ged  with  bile,  so  that 
the  absorption  of  this  excretion  into  the  blood  must  have  been  very 
great.  The  insensible  manner  in  which  so  much  cancerous  matter 
developed  itself  is  worthy  of  observation,  as  it  was  only  four  weeks 
before  admission  that  he  experienced  any  inconvenience.  Then  came 
on  the  effects  of  obstruction — first,  of  the  pylorus,  and,  secondly,  of  the 
common  duct — from  the  combined  effects  of  which  lie  died. 

Case  LXVl.*— Jaundice— Cancerous  Tumour  of  the  Pancreas,  comprising  the 
Ductus  Communis  Choledochus— Dilatation  of  the  Gall-bladder,  and  passage  of 
Gall-stones  into  the  Gall-bladder— Cancer  of  the  Liver  and  Kidneys. 

History.— John  M'Donald,  ait.  50,  tailor— admitted  November  29,  1853.  Four 
weeks  ago  he  was  seized  with  a  gnawing  pain  in  the  epigastrium.  On  the  1.3th 
he  was  over- worked,  and  went  liome  mucli  exliausted.  On  the  following  day,  there 
was  drowsiness,  loss  of  appetite,  and  anorexia.  On  the  27th,  the  skin  was  slightly 
tinged  yellow.  He  applied  at  one  of  the  dispensaries,  and  was  then  suffering  from 
intense  grinding  pain  in  the  right  hypochondrium.  One  of  the  clinical  students  who 
saw  him  there  advised  him  to  come  into  the  Infirmary. 

Symptoms  on  Admission. — He  has  no  pain,  no  difficulty  in  taking  food,  though 
it  excites  nausea.  Tongue  slightly  furred;  moist.  No  appetite.  Considerable 
thirst.  Vertical  dulness  of  liver  is  3f  niches.  No  abdominal  tenderness.  No 
tumour  to  be  felt  in  epigastrium.  Bowels  constipated.  Stools  of  a  dark  green 
colour ;  but  he  says  they  were  white  when  tlie  attack  came  on.  Urine  is  of  a  dark 
brown  colour,  like  weak  porter,  from  the  presence  of  bile ;  unaffected  by  heat.  Pulse 
60,  regular.  Skin  of  a  deep  yellow  colour.  Other  organs  and  functions  normal. 
'^  Pit.  Hydrarg. ;  Pil.  Hhcei  Co.  aa  3  ss.  M.  et  divide  in  pil.  xii.  Two  to  be  taken 
every  night. 

Progress  of  the  Case. — December  3d.— The  stools  are  now  of  a  lead  colour.  To 
have  gr.  v.  of  Pil.  Hydrarg.,  and  of  Ext.  Taraxaci  every  night  Dec.  lOth — Com- 
plains of  acute  grinding  pain  in  the  region  of  the  liver.  Bowels  have  not  been  open 
for  some  days.  Skin  of  a  deeper  yellow.  To  have  gr.  v.  of  Pil.  Bhcei  Co.  in  addi- 
tion to  the  others.  Dec.  Uih—Had  an  asafcetida  enema  yesterday.  The  bowels 
have  been  well  opened ;  pain  much  relieved.  Stools  still  of  a  lead  colour.  Omitiant. 
Pil.      IJ  Pil.  Phcei  Co.   3j;    Calomel,  3j;    Olei  Cinnamomi,  gutias  iv.      31.  et  divide 

*  Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


462  DISEASES   OF   THE   DIGESTIVE   SYSTE;M. 

in  pil.  xij.  Two  to  be  taken  every  night.  Dec.  lith. — Is  now  free  from  pain,  but  feels 
very  weak.  Stools  of  a  dark  green  colour.  Otherwise  the  same.  Cannot  take  food. 
5  Liq.  Potasses  3  ij ;  Sp.  JSther.  Kit.  §  ss ;  Infus.  Gentian.  Co.  §  v.  M.  Two  table 
spoonfuls  to  be  taken  three  times  a  day.  Dec.  11  th. — Much  weaker.  Takes  no  nou- 
rishment. Skin  of  a  dark  green  tint.  Tongue  dry,  and  covered  with  a  dark  brown 
crust.  Bowels  open.  Stools  of  a  dark  leaden  tint.  Pulse  120,  very  weak.  To 
have  I  vj  of  wine.  Dec.  I9th. — Whisky  has  been  hberally  administered ;  but  he 
continued  to  sink,  and  died  at  two  o'clock  a.m. 

Sectio  Cadaveris. — Thirty-four  hours  after  death. 

Extreme  jaundiced  appearance  of  the  whole  body,  and  yellowness  of  all  the 
tissues. 

Thorax. — With  the  exception  of  shght  emphysema  of  the  lungs,  all  the  thoracic 
organs  were  healthy. 

ABDOiiEX. — On  opening  the  duodenum,  there  was  seen  at  the  point  where  the 
common  duct  enters  it,  a  tumour  bulging  inwards,  and  compressing  the  duct.  The 
growth  was  the  size  of  a  walnut,  and  presented  aU  the  characters  of  scirrhus.  It 
was  formed  in  the  right  extremity  of  the  pancreas ;  and  the  rest  of  the  organ  was 
indurated,  and  contained  several  small  cysts  filled  with  a  gelatinous  fluid.  The  por- 
tion of  the  common  duct  which  passed  through  the  tumour  was  an  inch  and  a  half 
long,  and  barely  admitted  a  small  probe.  Behind  the  constriction,  the  common, 
cystic,  and  hepatic  ducts  were  greatly  enlarged,  the  common  duct  having  a  cahbre 
nearly  equal  to  the  size  of  the  tliumb.  The  gaU-bladder  was  much  enlarged,  and 
distended  with  dark-coloured  bile.  It  contained  two  small  gaU-stones  of  bile  pig- 
ment, but  none  could  be  found  in  the  ducts.  The  hver  weighed  3  lbs.  9  oz.,  was  of 
a  green  colour,  with  the  centres  of  the  lobules  congested.  The  bile-ducts  were 
everywhere  dilated  throughout  its  substance.  Scattered  throughout  the  liver  were 
white  cancerous  masses,  varying  in  size  from  a  pea  to  that  of  a  hazel-nut.  Similar 
small  cancerous  masses  existed  in  the  cortical  substance  of  the  kidneys.  On  open- 
ing the  intestmes,  a  considerable  quantity  of  black  blood  was  found  mingled  with 
the  foeculent  matter,  both  in  the  smaU  and  large  intestines.     Other  organs  healthy. 

Microscopic  Examination. — The  cancerous  masses  in  the  pancreas,  and  hver, 
and  kidneys,  contained  numerous  characteristic  cells.  The  hepatic  cells  were  loaded 
with  yellow  bile,  which  became  of  a  cherry-red  colour  on  the  application  of  Petten- 
kofer's  test.     They  contained  no  fat. 

Commentary. — It  appeared,  fi-om  careful  examination  of  this  man's 
case,  that  he  had  suffered  from  two  attacks  of  grinding  pain  in  the  right 
hypochondrium,  such  as  are  commonly  felt  during  the  passage  of  gall- 
stones. After  death,  two  biliary  calculi  were  found  in  the  gall-bladder, 
having  all  the  appearance  of  those  which  are  usually  formed  in  the 
liver.  It  is  almost  certain,  therefore,  that  the  painful  attacks  were  coin- 
cident with  the  passage  of  these  calculi  from  the  liver  to  the  gall-blad- 
der, as  their  escape  into  the  intestines  was  prevented  by  the  constriction 
of  the  common  duct,  by  the  cancerous  mass  in  the  pancreas. 

Since  tlie  researches  of  Bernard  as  to  the  functions  of  the  pancreas 
were  made  known,  I  have  carefully  sought,  in  a  great  number  of  cases, 
for  the  passage  of  fatty  matter  in  the  alvine  evacuations,  but  in  vain. 
In  several  instances  of  jaundice,  such  as  the  present,  I  have  found  the 
head  of  the  pancreas  diseased ;  but  in  none  of  them  did  the  stools  pre- 
sent the  characters  described  in  the  cases  of  Bright,  Lloyd,  Elliotson, 
and  others.     It  is  true  that  in  this  case  the  common  duct  Avas  not  abso- 


DISEASES   OF   THE    LIVEK.  463 

lutely  obliterated,  but  it  appeared  to  me  that  the  pancreatic  duct  was  so 
involved  in  the  tumour,  that  its  fluid  secretion  was  incapable  of  passing. 
But  as  no  special  anatomical  investigation  was  made  in  reference  to  this 
point,  we  are  not  entitled  to  suppose  that  the  supply  of  pancreatic  juice 
was  entirely  cut  off".  In  other  cases,  however,  where  the  common  duct 
has  been  obstructed  (Case  LXIV.),  or  where,  from  disease  of  the  head  of 
the  pancreas,  the  pancreatic  duct  has  been  obliterated  (Cases  LX.  and 
LXV.),  there  has  been  no  proof  whatever  that  the  fatty  elements  of  the 
food  have  not  been  emnlsionized.  Such  fiicts  indicate  that  the  function 
attributed  by  Bernard  to  the  pancreas  must  also  be  performed,  under 
certain  circumstances,  by  the  alimentary  canal  alone,  independent  of 
that  organ. 

Case  LXY  11.*— Enlargement  of  the  Liver— Ascites— Albicmmuria— Recovery. 

History.— David  Harper,  a3t.  30,  painter— admitted  into  tlie  clinical  ward  Feb- 
ruary 18th,  1852.  Four  months  ago,  was  seized  with  diarrhoea  and  vomiting, 
whicli  have  continued  more  or  less  ever  since.  The  hver  was  first  observed  to  be 
enlarged  in  the  beginning  of  December  last,  and  it  has  gradually  increased  in  size 
up  to  the  present  time.  He  has  taken  numerous  remedies  to  check  the  diarrhcea 
and  vomiting,  but  with  little  efl'ect. 

Symptoms  ox  Admission.— On  admission,  the  liver  is  found  to  extend  from  one 
inch  below  the  right  nipple  above  to  within  an  inch  and  a  half  of  the  anterior  supe- 
rior spine  of  the  ilium  below— a  depth  of  nine  inches.  From  this  point  its  margin 
could  be  felt  ascending  obliquely  upwards  to  the  most  depending  portion  of  the 
ninth  rib  on  the  left  side,  crossing  about  an  inch  above  the  umbihcus.  There  is 
distinct  fluctuation  to  be  felt  throughout  the  rest  of  the  abdomen,  indicating  ascites. 
In  the  right  lumbar  region  the  enlarged  liver  is  tender  on  pressure.  The  abdomen 
measures  32^  inches  in  circumference  at  its  widest  part.  Spleen  of  normal  size. 
Tongue  moist,  slightly  loaded.  There  has  been  no  vomiting  for  some  days,  but  the 
diarrlioea  is  very  severe.  Says  he  has  frequently  passed  blood  by  stool.  Skin  not 
jaundiced,  but  rather  dry.  Kespiratory,  circulatory,  and  other  systems  normal.  IJ 
Pit.  Plumb,  et  Opii  xij.     Sumat  unam  ter  indies. 

Progress  op  the  Case. — March  ith. — Has  had  occasionally  vomiting  and  diar- 
rhoea since  last  report,  for  which  he  has  been  taking  at  times  the  naphtha  mixture, 
morphia  draughts,  and  gallic  acid.  To-day  the  urine  is  somewhat  scanty,  and 
slightly  coagulable  on  the  addition  of  heat  and  nitric  acid :  spec.  grav.  1024.  $ 
Acetatis  Potassce,  3  j ;  »S/j.  ^th.  Nit.  3  ij ;  Syr.  Aurantii,  §  j ;  Aquce,  |  v.  M.  Sumat  3  j 
ter  indies.  March  I2th. — To-day  the  urine  was  ascertained  with  the  microscope  to 
contain  numerous  casts  of  the  tubes  and  isolated  epithelial  cells  loaded  with  fatty 
granules.  The  vomiting  and  diarrhoea  continue.  Habeat  suppositorium  opiatum 
octavo,  qucique  hord.  April  6th. — The  diarrlioea  was  for  a  few  days  somewhat 
checked  by  the  suppositories,  but  gradually  returned,  and  is  now  very  severe ;  the 
bowels  having  been  opened  twelve  times  yesterday.  The  urine  has  continued 
albuminous,  and  loaded  with  desquamative  casts  and  fatty  tubes.  To-day  its 
spec.  grav.  is  1007.  There  is  now  great  debihty,  and  occasional  stupor  and  drowsi- 
ness. May  11th. — The  drowsiness  has  disappeared.  For  the  last  few  days  has 
been  taking  3  j  of  the  potass,  bitart.  with  the  mixture  of  acetate  of  potash  and  nitric 
aether,  and  he  now  passes  a  larger  amount  of  urine,  which  is  free  of  tubular  casts 
The  abdomen  is  less  tense.     About  the  middle  of  May  the  vomiting  and  diarrhcea 

*  Reported  by  Mr.  J.  A.  Douglas,  Clinical  Clerk. 


464  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

first  abated,  and  was  soon  after  checked.  In  August  his  health  was  so  much 
improved  that  lie  was  allowed  to  go  out  of  the  house  for  the  benefit  of  air  and  exer- 
cise. He  was  re-admitted  September  I3(h,  having  enjoyed  tolerable  health  in  the 
interval,  although  the  hepatic  swelling  is  about  the  same  size.  He  was  now 
ordered,  ^.  Hydrarg.  Proto-iodidi,  gr.  vj;  Pulv.  Opii  gr  ij;  Ext.  2'araxaci,  3ss; 
Coiiserv.  Rosarum,  gr  .v.  fiant.  pil  xx.  Sumat  unam  ter  indies.  These  pills  on  the  20th 
produced  salivation,  when  they  were  discontinued,  and  an  astringent  gargle  was 
ordered.  The  abdomen  now  measures  thirtj'-six  inches  in  its  broadest  circum- 
ference. Oct.  25th. — Complains  of  oppression  on  walking,  of  shooting  pains  through 
the  chest  and  abdomen.  Ascites  seems  once  more  to  be  increasing.  Tr.  lodini  to  be 
painted  over  the  abdominal  surface.  Nov.  2\st. — Since  last  report  the  liver  has 
greatly  diminished  in  size,  and  his  complaints  have  ceased.  The  urine  presents  a 
slight  hazy  albuminous  appearance  on  the  addition  of  heat  and  nitric  acid,  but  is 
voided  in  natural  quantity.  Dec.  13<7i.— The  liver  is  now  so  reduced  in  size  that  its 
lower  margin  is  only  two  inches  below  the  false  ribs  in  front,  and  one  inch  on  the 
rio-ht  side.  All  his  functions  are  apparently  healtliy,  the  urine  healthy,  and  his 
strength  appears  perfectly  re-established.  Dismissed. 
\ 
Commentary. — The  enlargement  of  the  liver  which  existed  in  this 
man  was  probably  simple  hypertrophy,  which,  by  pressing  npon  the 
large  abdominal  veins,  caused  ascites.  It  is  worthy  of  remark,  that  it 
underwent  a  sensible  diminution  after  the  local  application  of  Tr.  of  Iodine, 
having  resisted  mercurial  action  and  various  other  remedies.  The 
occurrence  of  Bright's  disease,  and  the  presence  of  numerous  desqua- 
mative casts  of  the  tubuli  uriniferi,  more  or  less  loaded  with  fat,  and  of 
albumen  in,  with  diminished  density  of,  the  urine,  were  considered  for- 
midable complications.  But  here  also,  under  the  use  of  strong  diuretics, 
the  renal  symptoms  subsided,  the  casts  disappeared,  and  the  urine 
became  perfectly  healthy.  He  has  since  been  seen  by  the  clerks  walk- 
ino-  about  the  town,  and  has  informed  them  that  he  is  quite  well,  and 
carries  on  his  occupation  without  any  inconvenience. 


Case  LXVIII.* — Fatty  Enlargement  of  the  Liver. 

History. — James  Grant,  ast.  29,  blacksmith — admitted  October  14th,  1851.  His 
occupation  consists  of  watching  an  apparatus  worked  by  steam,  in  a  room  of  elevated 
temperature ;  he  has  no  heavy  labour,  though  constantly  standing  on  his  feet ;  he 
drinks  whisky  to  a  large  amount.  Since  September  1849,  he  has  been  three  times 
in  the  house  for  various  periods,  from  which  he  has  been  as  often  dismissed  relieved. 
The  liver  began  to  enlarge  two  j^ears  ago,  and  has  been  very  slowly  increasing  ever 
since. 

Symptoms  on  Admission. — On  admission,  he  labours  under  slight  diarrhoea, 
having  had  two  or  tliree  stools  daily  for  several  weeks  past.  He  has,  moreover,  a 
dull  heavy  pain  in  the  abdomen,  extending  to  the  lumbar  region.  The  belly  is 
evidently  enlarged  at  its  upper  part,  where  a  firm  tumour  exists,  forming  a  protu- 
berance in  the  epigastric  region.  The  girth  of  the  abdomen  at  this  place  during 
expiration,  is  34  inches.  The  hepatic  dulness  extends  from  two  inches  below  the 
right  nipple,  down  to  a  transverse  line  drawn  one  inch  above  the  superior  spine  of 
the  ilium.      The  whole  of  the  right  and  part  of  the  left  hypochondriac  regions  are 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


DISEASES   OF  THE   LIVER.  465 

dull  on  percussion.  The  tympanitic  sound  of  the  stomach  is  audible  in  front,  the 
organ  being  evidently  pushed  forward  by  the  enlarged  liver  behind  it.  The  whole 
surface  of  the  tumour  feels  smooth,  and  presents  no  tenderness.  The  splenic  dulness 
measures  5^  inches  vertically;  skin  dry;  no  oedema  of  the  legs;  general  appear- 
ance pale  and  cachectic ;  occasionally  he  has  frequent  desire  to  micturate,  but  the 
urine  has  alwaj^s  presented  its  normal  cliaracters;  considerable  breathlessness  on 
exertion,  but  the  lungs  and  heart,  on  examination,  were  apparently  quite  healthy; 
other  functions  well  peribrmed.  He  was  ordered  a  mixture  containing  the  Iodide 
of  Putimium,  six  grains  of  which  were  to  be  taken  three  times  a  day.  Frictions 
with  the  Unguent.  lodinii  were  also  to  be  employed  daily. 

Progress  of  the  Case. — Towards  the  end  of  October,  the  bowels  became  reg-ular, 
and  his  general  health  was  somewhat  improved.  Frequent  micturition,  with  dis- 
charge of  pus  in  the  urine,  now  came  on,  which  subsided  in  a  few  days.  From  this 
time,  altliough  the  size  of  the  liver  underwent  no  diminution,  his  bodily  strength 
gradually  improved.  He  occasionally  had  slight  return  of  looseness  in  the  bowels, 
which  was  checked  by  appropriate  remedies.  The  difficulty  of  breathing  after  exer- 
tion also  slowly  left  him;  and  lie  was  dismissed  greatly  relieved,  January  26th,  1852. 

Commentary. — Fatty  liver  was  first  shown  by  Mr.  Bowman  to 
depend  on  the  secretion  of  a  large 
quantity  of  oil,  which  is  stored  up 
in  the  hepatic  cells.  These  cells  are, 
under  such  circumstances,  frequently 
enlarged,  and  contain  oil  varying  in 
amount  from  a  few  granules  to  a 
large  mass,  which  occupies  the  whole 
of  their  cavities.  Not  unfrequently 
livers,  which  to  the  naked  eye  appear 
healthy  enough,  may  still  be  demon- 
strated under  the  microscope  to  con-  Fig.  404. 
tain  an  unusual  number  of  tat  granules,  and  there  can  be  little  doubt 
that  considerable  variations  may  exist  in  this  respect  quite  compatible 
with  a  state  of  health.  Almost*  all  stall-fed  animals  that  do  not  labour, 
possess  a  large  amount  of  fat  in  their  hepatic  cells.  It  is  only  where  the 
organ  is  much  enlarged,  altered  in  colour,  and  pressing  upon  neigh- 
bouring viscera,  that  its  fatty  degeneration  can  be  said  to  interfere  with 
the  vital  processes. 

Fatty  degeneratiou  of  the  liver  has  been  observed  to  be  very  common 
in  drunkards  who  are  continually  taking  alcoholic  liquids.  Of  13  indi- 
viduals who  died  from  DeliriuraTremens,  6  had  very  fatty  liver,  in  3  the 
organ  contained  little,  in  2  none  at  all,  atid  in  2  there  was  cirrhosis 
(Frerichs).  In  such  cases,  the  quantity  of  carbon  taken  in  the  form  of 
spirits  being  too  great  in  amount  to  be  excreted  from  the  lungs  as  car- 
bonic acid,  and  fi-om  the  liver  as  bile,  is  stored  up  in  the  liver  as  fat.  In 
tropical  climates,  the  same  pathological  condition  comes  on  under  differ- 
ent cii-cumstances.  A  high  temperature,  and  a  rarified  atmosphere, 
indispose  persons  to  take  bodily  exercise;  and  Europeans,  instead  of 
living  according  to  the  simple  manner  of  the  natives,  too  often  continue 


Fig.  404.  Hepatic  cells  in  various  stages  of  fatty  degeneration.  On  the  right 
of  tlie  tigure,  yellow  granular  pigment  is  also  contained  in  the  cells,  which  were 
taken  from  a  cirrhosed  liver.  -50  diam. 

30 


466  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

to  consume  the  food  habitual  to  them  in  their  native  country.  But  the 
excretory  power  of  the  lungs  being,  at  the  sante  time,  diminished,  the 
excess  of  carbon  in  the  tissues  and  food  is  thrown  upon  the  liver,  and 
there  converted  into  fat.  Dr.  Macnamara*  found  that,  among  the  first 
regiment  of  European  Bengal  Fusileers,  during  seven  years,  tlie  morta- 
lity among  the  officers  was  11  per  cent.,  and  among  the  men  80  per  cent., 
so  that  the  whole  of  the  fighting  men  in  the  regiment  were  changed 
about  once  in  every  ten  years.  From  the  circumstance  that  the  great 
majorit}^  of  these  men  were  young,  healthy,  and  vigorous,  when  they 
left  home,  and  other  circumstances,  he  attributes  the  deaths  to  high 
feeding,  indulgence  in  spirits,  and  to  slothful  habits,  causing  fatty  degene- 
ration of  the  textures. 

The  manner  in  which  the  livers  of  geese  are  made  fatty  at  Strasburg 
is  as  follows : — The  geese  are  confined  in  close  cages,  in  a  heated  atmo- 
sphere, and  largely  supplied  with  food.  Want  of  exercise  and  lieat 
diminish  the  respiratory  functions,  and  cause  that  of  the  liver  to  be  dis- 
ordered, and  the  result  is  an  enlargement  of  the  organ  from  accumula- 
tion of  fat.  In  the  case  before  us,  the  cause  of  the  disease  seems  to  have 
been  exactly  the  same.  A  man  is  kept  stationarv  watching  a  steam- 
engine,  in  an  elevated  temperature,  consuming  his  usual  food,  and  indulg- 
ing in  alcoholic  drinks.  Fatty  liver  is  also  common  in  cases  of  phthisis 
pulmonalis.  Here  the  excreting  function  of  the  lungs  is  more  or  less 
interfered  with,  and  the  carbonaceous  matters,  not  separated  as  usual  by 
this  channel,  are  stored  up  in  the  liver  in  the  form  of  fat.  The  hepatic 
disease  is  especially  observed  in  those  consumptive  patients  who,  while 
they  are  capable  of  assimilating  a  certain  amount  of  food,  are  prevented 
by  languor,  breathlessness,  or  other  causes,  from  taking  exercise. 
According  to  Frerichs,  of  117  cases  of  pulmonary  tuberculosis,  examined 
after  death,  there  were  17  which  presented  fatty  liver  in  the  highest 
degree,  whilst  there  were  62  others  with  the  hepatic  cells  loaded  with 
oil  globules.  On  the  contrary,  in  other  diseases  of  the  pulmonary  organs, 
he  found  fatty  liver  to  occur  very  seldom. 

This  view  of  tlie  pathology  of  fatty  liver  has  been  objected  to  on  the 
following  grounds: — 1st,  That  the  connection  between  fatty  liver  and 
disease  of  the  lungs  is  not  general ;  2d,  That  there  is  no  evidence  that  a 
fatty  liver  does  not  excrete  bile  as  usual ;  and  3d,  That  as  a  considerable 
portion  of  bile  is  absorbed  into  the  blood  to  be  excreted  from  the  lungs, 
the  liver  must  be  considered  as  preparing  material  for  these  organs. 
Hence  it  is  argued,  that  it  would  be  a  strange  compensation  if  the  func- 
tions of  the  liver  were  to  be  increased,  while  that  of  the  lung  is  dimi- 
nished by  disease  (Budd).  But  if  fatty  liver  be  not  always  conjoined 
with  diseased  lung,  it  will  be  found  associated  with  some  circumstance 
which  diminishes  the  function  of  that  organ,  in  relation  to  the  Avork  it 
is  called  upon  to  perform ;  for  instance,  the  diminished  exercise  and 
great  heat  of  tropical  climates.  Further,  although  it  be  granted  that  the 
liver  may  in  health  prepare  carbonaceous  matters  for  pulmonary  excre- 
tion, it  must  be  cleai',  that  if  the  lungs  cannot  accomplish  this  function, 
such  matters  must  be  thrown  back  or  retained  in  the  liver,  and  consti- 
tute a  powerful   cause  of  fatty  degeneration   of  that  organ.     On   the 

*  Indian  Annals  of  Medical  Science,  1855,  p.  170. 


DISEASES   OF   THE   LIVER.  467 

whole,  therefore,  we  must  regard  excess  of  carbonaceous  matters  in  the 
system,  and  the  diminution  of  pulmonary  action,  as  the  chief  causes  of 
fatty  degeneration  of  the  liver;  a  view  which  has  the  merit  of  pointing 
out  to  us  as  remedies  a  diminished  diet,  a  temperate  climate,  appropriat-e 
exercise,  and  an  endeavour  to  promote  the  functions  of  the  lungs  and  of 
the  skin. 

There  is  another  structural  alteration  of  the  liver,  which,  from  its 
colour  and  general  resemblance  to  bees'- wax,  has  been  called  "  waxy,'' 
and  sometimes  "  brawny  "  liver.  This  disease  has  been  confounded  with 
fatty  liver,  but  an  examination  of  their  minute  structure  shows  that  the 
hepatic  cells  present  a  verv  different  character  in  this  condition.  Instead 
of  being  enlarged  and  filled  more  or  less  with  oil  globules,  they  are 
colourless,  shrunken,  and  for  the  most  part  destitute  of  contents,  and 
the  nucleus  disappears.  (See  Fig.  295.)  I  have  previously  described 
this  lesion  as  one  of  the  forms  of  albuminous  degeneration.  (See  p. 
214.)  Its  clinical  history  will  be  given  under  the  head  of  Phthisis. 
(See  case  of  Margaret  Clark.) 


Case  LXIX.* — Cirrhosis  with  Atrophy  of  the  Liver — Ascites. 

History. — John  Harper,  xt.  28,  farmer,  from  Caithness — admitted  June  24th, 
1852.  Six  years  ago,  after  recovering  from  measles,  his  health  was  greatly  deranged. 
He  was  weak,  and  perspired  profusely  at  night,  or  when  performing  any  unusual 
exertion.  A  short  time  afterwards,  he  was  exposed  to  cold  and  wet,  and  he 
observed  that  the  abdomen  gradually  enlarged,  and  dyspnoea  supervened.  On  two 
occasions  paracentesis  abdominis  was  performed ;  at  the  first  operation  a  quart,  and 
at  the  second  a  pint,  of  fluid  was  removed,  without  producing  much  relief  He  has 
had  considerable  pain  in  the  epigastric  region  at  times,  and  latterly  the  appetite  has 
been  diminished,  and  the  bowels  costiva 

SviiPTOMS  ON*  Admission'. — On  admission,  the  abdomen  is  shghtly  swollen,  and 
evidently  contains  fluid.  Round  the  umbilicus  it  measures  39  inches.  Xo  anasarca. 
The  hepatic  dulness  extends  three  inches  downwards  on  the  right  side,  commencing 
two  inches  under  the  nipple.  Tongue  is  furred ;  appetite  diminished ;  no  epigastric 
pain  or  uneasiness ;  bowels  irregular,  but  at  present  costive.  There  is  slight  dulness 
on  percussion  under  the  right  clavicle,  with  harsh  inspiration,  prolonged  expiration, 
and  increased  vocal  resonance :  urine  scanty,  depositing  lithates.  The  other  func- 
tions are  well  performed,  and  he  appears  to  be  a  strong,  well-nourished  person. 

Progress  of  the  Case. — The  treatment  consisted  of  diuretics  {Sjx  ^ther.  Nit. 
and  Tr.  Digitalis)  and  sudorifics  {Pulv.  JDoveri) ;  but  feehug  the  confinement  of  the 
Hospital  to  disagree  witli  him  after  his  usual  active  occupations,  he  insisted  on 
going  out,  which  he  did  July  6th. 

Commentary, — The  diminished  extent  of  the  hepatic  dulness,  the 
ascites,  and  the  chronic  nature  of  the  disease,  point  out  this  case  to  be 
one  of  cirrhosis.  This  morbid  change  in  the  liver  consists  of  the  forma- 
tion of  fibrous  tissue  between  the  lobules  of  the  organ,  wherebv  its 
secreting  cells  are  compressed  and  atrophied.  As  a  further  result,  the 
large  venous  trunks  are  also  compressed,  and  their  commencing  ramifi- 

*  Reported  by  Mr.  John  Matthews,  Clinical  Clerk. 


468  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

cations  so  congested  that  effusion  into,  or  dropsy  of,  tLe  peritoneal  cavity 
is  induced.  Notwithstanding  the  extensive  organic  changes  which  are 
frequently  observed  in  this  disease,  danger  is  not  so  much  to  be  appre- 
hended from  them  as  from  the  ascites,  which,  by  distending  the  abdomen 
and  compressing  the  lungs  and  liver,  so  interferes  with  those  important 
oro;ans  as  to  destroy  life. 


Case  LXX.* — Cirrhosis  with  Enlargement  of  Liver — Hypertrophy  of  Spleen — Slight 
Leucocythemia — Jaundice — Constriction  of  Arch  and  descending  Aorta. 

History.— James  Kerr,  ret.  28,  a  labourer — admitted  July  22,  1852.  This  man 
first  had  jaundice,  with  swelling  of  the  abdomen,  between  four  and  five  years  ago  : 
and  since  then  he  has  been  several  times  in  the  Infirmary.  The  treatment  has  con- 
sisted of  various  alteratives  internally,  with  the  occasional  application  of  the  Tr. 
lodinii,  bUsters,  and  leeches  externally.  The  swelling,  however,  has  continued  to 
increase  verj-^  slowly,  and  for  the  last  two  years  he  has  been  incapacitated  from  work- 
ing. The  blood  for  some  time  has  contained  an  excess  of  fibrin,  and  a  slight  increase 
of  the  colourless  corpuscles;  and  he  has  been  troubled  at  intervals  with  attacks  of 
epistaxis  and  occasional  diarrhoea.  For  two  years  past  there  has  been  an  increased 
impulse,  with  a  rough  blowing  murmur,  loudest  with  the  first  sound  under  the  manu- 
brium of  the  sternum. 

SYMPTOiis  ON  Anjiissiox. — On  admission  the  hepatic  duLness  commences  an  inch 
below  the  right  nipple,  and  extends  down  to  the  umbilicus,  measuring  twelve  inches 
vertically.  The  splenic  dulness  reaches  from  the  lower  margin  of  the  fifth  rib  to  a 
transverse  line  drawn  an  inch  below  the  umbilicus,  and  measures  eight  inches  verti- 
cally. The  liver  presents  a  protuberance  anteriorly,  which  extends  in  the  form  of  a 
ridge,  four  inches  broad,  from  the  epigastrium  backwards  towards  the  false  ribs. 
The  girth  of  the  abdomen  over  this  ridge  is  42  inches.  The  inferior  border  of  the 
spleen  and  liver  can  be  distinctly  felt  through  the  parietes  of  the  abdomen.  The 
heart's  action  and  sounds  are  normal.  An  increased  pulsation  is  distinctly  visible 
at  the  root  of  the  neck,  and  can  be  felt  above  the  clavicles  and  under  the  top  of  the 
sternum.  Here  there  is  a  loud  rough  murmur  synchronous  with  the  systole  of  the 
heart,  and  accompanied  by  a  distmct  impulse.  There  is  a  slight  cough,  with  a  little 
mucous  expectoration,  but  auscultation  and  percussion  of  the  lungs  reveal  nothing 
abnormal  Urine  rather  scanty,  high  coloured,  spec.  grav.  1026,  contains  some  biliary 
matter,  and  deposits  on  cooling  a  pretty  copious  pinkish  sediment  of  lithates.  The 
integuments  and  conjunctivae  are  still  tinged  of  a  light  bile  yellow  colour.  There  is 
considerable  tenderness  over  the  Hver  in  the  right  hypochondi'ium.  He  says  slight 
epistaxis  returns  about  once  a  week.  The  bowels  are  open  daily;  no  diarrhoea. 
After  walking  or  unusual  exercise  oedema  of  the  legs  comes  on.  On  examining  the 
blood  microscopically,  the  colourless  corpuscles  are  not  so  numerous  as  when  he  was 
last  in  the  house.     Four  leeches  to  be  applied  to  the  right  hypochondrium. 

Progress  of  the  Case  — This  man  left  the  house  in  August.  He  was  re- 
admitted November  9th,  having  in  the  interval  suffered  from  an  attack  of  pleurisy 
on  the  right  side.  Latterly  he  has  been  in  the  Dundee  Hospital,  and  says  that  five 
weeks  ago  he  passed  considerable  quantities  of  dark  grumous  matter  from  the  bowels. 
In  other  respects  his  condition  is  the  same  as  formerly  reported.  Xoiemier  Wth. — 
Vomited  about  nine  or  ten  ounces  of  blood.  29^/i. — Hematemesis  returned  yesterday 
afternoon  with  great  violence,  and  at  intervals  he  brought  up  in  all  132  ounces  of 
blood.     His  strength  is  now  greatly  diminished;  pulse  104,  full.     The  abdominal 

*  Eeported  by  Messrs.  Douglas  and  Dewar.  Clinical  Clerks. 


DISEASES   OF   THE   LIVER. 


469 


swelling  and  aortic  signs  as  formerly  reported ;  but  the  breathing  is  laboured,  with 
dyspnoea  at  night,  considerable  cough,  and  muco-purulent  expectoration.  No  dul- 
ness  on  percussion  over  lungs ;  but  sibilant  and  sonorous  rales  are  heard  at  the  base 
of  the  right  lung  on  auscultation.  From  this  period  his  general  health  evidently 
began  to  fail.  Ascites  first  came  on,  followed  by  oedema  of  the  legs  and  general 
anasarca.  The  dyspnoea  became  more  urgent,  with  a  sense  of  oppression  in  the 
chest,  and  there  was  occasional  vomiting  of  blood.  On  the  21st  of  December  there 
was  considerable  hematemesis,  and  discharge  of  blood  by  stool,  which  was  followed 
by  exliausting  diarrhoea.     lie  died  December  25th. 

Secfio  Cadaveris. — Fifty-three  hours  after  death. 

Body  generally  anasarcous. 

Thorax.— Extensive  chronic  adhesions  between  the  pleura  on  the  right  side. 
On  the  left  side  about  four  ounces  of  serum  in  the  pleural  cavit.y.  Lungs  oedematous. 
Slight  emphysema  of  the  left  lung  anteriorly.  Posteriorly  both  lungs  congested,  and 
here  and  there  compressed.  The  ascending  portion  of  the  aortic  arch  was  of  normal 
size,  but  its  transverse  and  descending  portions,  as  well  as  the  descending  aorta 
generally,  were  unusually  small  in  calibre,  so  that  the  little  finger  could  with  diffi- 
culty be  introduced.  In  structure  the  vessel  was  healthy,  but  in  consequence  of  this 
formation  a  pouch  was  formed  immediately  above  the  sigmoid  valves.  About  two 
ounces  of  serum  in  the  pericardium.     The  heart  healthy. 

Abdomen. — About  twenty  ounces  of  serum  in  the  peritoneal  cavity.  The 
stomach  was  about  half  full  of  brownisli-black  blood,  containing  soft  coagula. 
Mucous  coat  healthy.  Brunner's  glands  much  enlarged,  about  the  size  of  millet 
seeds.  The  intestines  everywhere  healthy.  Mesenteric  glands  slightly  enlarged. 
Liver  weighed  nine  pounds  one  ounce,  was  of  a  pale  gamboge  colour  throughout, 
speckled  here  and  there  with  rounded  masses,  the  size  of  a  pea,  liaving  a  darker 
ochrey  tint.  On  section,  it  offered  considerable  resistance  to  the  knife,  and  the  fresh 
cut  surftice  presented  a  dense,  whitish-yellow  fibrous  structure,  with  the  lobules  of 
the  organ  atrophied  and  embedded  in  it,  and  of  various  tints  of  yellow,  varying 
towards  white.  In  short,  the  last  stage  of  cirrliosis.  Spleen  weighed  3  lb.  6  oz., 
and  is  enlarged  from  simple  hypertrophy.  Kidneys,  larynx,  oisophagus,  and  other 
organs  healthy. 


FiK.  405. 


Fig.  405.     Structure  of  a  thiu  section  of  liver  in  the  last  stage  of  cirrhosis.     250  diam. 


470  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

Microscopic  Examixatiox. — On  making  a  thin  section  of  the  liver  with  a  Valen- 
tin's knife,  and  examining  it  with  a  power  of  250  diameters,  the  appearance  was 
seen  represented  in  the  woodcut.  (Fig.  405.)  The  stroma  of  the  organ  was  com- 
posed of  fibrous  substance,  surrounding  and  compressing  the  hepatic  lobules,  many 
of  which  presented  pale  cells,  more  or  less  filled  with  yellowish  pigment ;  in  some 
the  cells  were  more  or  less  fatty,  and  in  others  waxy.  Here  and  there  the  spaces 
were  empty,  the  contents  having  apparently  lost  their  cohesion,  or  having  been 
dragged  out  by  the  knife. 

Co7nmentary. — The  lesion  which  I  presumed  to  exist  in  the  liver  of 
this  man  during  his  life  was  that  of  a  simple  hj-pertrophy,  a  disease  fre- 
quently associated  with  enlarged  spleen  and  excess  of  colourless  cor- 
puscles in  the  blood.  But  on  dissection,  the  liver  presented  all  the 
structural  characters  of  the  last  stage  of  cirrhosis,  associated  with  great 
increase  of  size  in  the  organ.  The  fibrous  structure  especially  Avas  very 
large  in  amount,  the  lobules  much  compressed,  and  so  altered,  that, 
while  the  cells  in  many  of  them  were  loaded  with  pigment,  some  had 
undergone  the  fatty,  and  others  the  waxy,  degeneration.  The  cirrhosis 
must  have  occasioned  some  obstruction  to  the  perfect  excretion  of  bile, 
as  the  jaundice,  though  slight,  was  uniform  for  more  than  four  years. 
There  had  also  been  epistaxis,  haematemesis,  and  frequent  diarrhoea, 
symptoms  very  common  in  connection  with  enlarged  liver  and  spleen, 
and  probably  dependent  on  the  congested  condition  of  the  gastro-intes- 
tinal  mucous  membrane,  produced  by  pressure  on  the  portal  veins.  For 
a  long  time  he  suffered  no  inconvenience  from  the  abdominal  swelling, 
except  from  its  bulk  and  occasional  tenderness,  unless  indeed  dyspnaa 
be  taken  into  consideration,  which  was  attributed  partly  to  an  aneuris- 
mal  dilatation  of  the  aortic  arch.  A  dilatation  in  point  of  fact  did  exist, 
and  a  certain  obstruction  was  occasioned  from  the  state  of  the  parts 
described,  sufficient  to  produce  all  the  physical  signs  and  functional 
symptoms  of  aneurism  of  the  aorta.  The  origin  of  the  excessive  hemor- 
rhages is  involved  in  mystery,  the  most  careful  examination  of  the  body 
having  failed  to  detect  lesion  of  any  vessel,  or  of  any  part  of  the  mucous 
membrane.  Some  years  ago  I  opened  the  body  of  a  man  whose  stomach 
was  found  filled  with  a  firm  coagulum  of  blood,  so  that,  when  the  organ 
was  opened,  it  could  be  turned  out,  presenting  a  cast  of  its  interior, 
weighing  between  two  and  three  pounds.  Yet  the  most  minute  inspec- 
tion did  not  enable  me  to  discover  the  slightest  lesion  to  which  such 
extensive  hemorrhage  could  be  attributed.  Such  lesion,  however,  must 
have  existed  ;  for  no  one  can  now  conceive  the  possibility  of  blood  cor- 
puscles passing  through  the  vascular  walls  by  transudation,  as  was  for- 
merly imagined.  AVe  may,  I  think,  theoretically  ascribe  them  to  the 
excessive  congestions  occasioned,  and  to  the  rupture  of  capillaries  which 
escape  detection  after  death.  Another  fact  worth}"  of  observation  in  the 
case  of  Kerr  was,  that  the  excess  of  colourless  corpuscles  in  the  blood 
(leucocythemia),  which  existed  when  he  first  came  under  my  notice,  had 
entirely  disappeared  during  the  last  few  months  of  his  life. 

The  treatment  in  cirrhosis  must  be  purely  palliative,  and  directed  to 
diminish  the  ascites  by  means  of  diuretics  and  diaphoretics.  The  ques- 
tion of  drawing  ofi"  the  fluid  by  paracentesis  is  one  which  may  arise,  in 
case  the  swelling  is  very  great,  and  the  embarrassment  to  the  pulmonary 


DISEASES   OF   THE    LIVER. 


471 


and  renal  organs  extreme.  Even  then,  althongh  temporary  relief  may  be 
obtained  by  the  operation,  there  is  every  reason  to  believe  that,  in  the 
majority  of  cases,  life  is 
in  no  way  prolonged. 

A  condition  of  the 
liver  is  frequently  seen, 
and  which  has  been  call- 
ed the  nutmeg  liver,  from 
the  resemblance  it  pre- 
sents to  the  fresh-cnt  sur- 
face of  a  nutmeg.  That 
is  to  say,  it  exhibits  bright 
red  or  brown  points,  sur- 
rounded by  a  whitish  or 
slightly  yellow^  substance. 
On  making  thin  sections 
of  such  a  liver,  it  will  be 
seen,  that  whilst  the  ves- 
sels of  the  lobules,  and 
especially  their  central  parts,  are  distended  with  blood,  the  cells  at  the  mar- 
gins of  the  lobules  have  undergone  the  fatty  degeneration.  It  has  been 
supposed  by  some  that  this  condition  is  an  incipient  cirrhosis,  by  others  an 
incipient  fatty  degeneration  of  the  organ.  Certain  it  is,  that  in  such  cases 
the  fatty  cells  are  form- 
ed at  the  circumference 
of  the  lobule,  in  im- 
mediate relation  to  + 
the  portal  capillaries, 
which  are  loaded  with 
blood.  It  has  been 
called  interlobular  fat- 
ty degeneration,  but  is 
in  fact  fatty  degenera- 
tion of  the  cells  at  the 
circumference  of  the 
lobule.  Wedl  has 
pointed  out  that  in 
some  rare  forms  of  this 
lesion  there  is  a  deposit 
of  pigment  in  the  cells 
nearest  the  hepatic  ca- 
pillaries, and  occupy- 
ing the  centre  of  the 
lobule,  without   any  fatty  degeneration  whatever.     Pigment  may  also 


Fiir.  407. 


Pig  406.  Peri-lobular  fsitty  or  nutmeg  liver.  «,  Fatty  degeneration  around  the 
lobules;  h  and  c,  Centres  of  the  lobules  with  tlie  vessels  congested — {Wedl.) 

Fig.  407.  Pigmented  nutmeg  liver,  a,  Lobule  with  the  central  vein  divided  at  -f- , 
containing  amorphous  pigment;  6,  Lobule  with  the  central  vein  healthy;  c,  The 
central  vein  filled  with  pigment.  The  radiated  central  pigment  is  owing  to  its  being 
deposited  in  that  portion  of  the  hepatic  cells  nearest  the  capillaries. — ( Wedl.)  90  diam. 


472  DISEASES    OF   THE    DIGESTIVE    SYSTEM, 

occur  in  tlie  veins  themselves.  At  otlier  times  the  fatty  and  pigmentary 
degenerations  of  the  liver  may  be  more  or  less  combined,  the  former 
existing  at  the  periphery,  and  the  latter  at  the  centre  of  the  lobule. 
We  have  no  clinical  history  of  these  forms  of  nutmeg  liver,  nor,  so  far 
as  is  yet  known,  do  they  occasion  any  symptoms,  susceptible  of  being 
recoonised  in  the  livino-  bodv. 


Case  LXXI.* — Cancerous  Exudation  into  the  Livtr — Cancerous  Ulceration  of  (Esopha- 
gus— Simple  Stricture  of  Pylorus — Profuse  Hematemesis — Aneurism  of  Ihoracic 
Am  ta,  bursting  into  the  left  Pleura. 

History. — Thomas  Stewart,  xt.  54,  bookseller — admitted  Xovember  28,  1849. 
States  that  about  six  years  ago  he  had  an  attack  of  hemoptysis,  but,  with  this  ex- 
ception, he  always  enjoyed  good  health,  tUl  about  four  months  ago.  At  that  time 
his  appetite  began  to  fail,  and  he  felt  sick  after  eating,  occasionally  vomiting  his  food. 
Since  then  the  sickness  has  been  increasing,  and  about  three  or  four  weeks  ago,  be 
began  to  vomit  blood.  He  has  also  been  affected  with  paiu  in  the  throat  on  attempt- 
ing to  swallow,  and  a  sense  of  constriction  in  the  oesophagus,  opposite  the  superior 
border  of  the  sternum.  He  states,  that  he  can  very  seldom  take  food  without  excit- 
ing vomiting ;  but  occasionally,  when  he  succeeds  in  retaining  it  for  half  an  hour, 
the  sense  of  sickness  passes  off.  He  further  states  that  he  vomits  blood  mixed  with 
clots  of  dark -brown  masses.  This  does  not  occur  after  eating,  but  generally  between 
three  and  five  in  the  morning ;  occasionally,  however,  it  occurs  during  the  day,  and 
is  then  preceded  by  a  fit  of  coughing.  He  has  been  losing  flesh  lately  to  a  great  ex- 
tent, and  is  now  very  thin,  having  formerly  been  of  a  stout  and  robust  habit  of  body. 

Symptoms  ox  Admission. — On  admission  he  appears  pale  and  emaciated.  Com- 
plains of  great  general  weakness.  Tongue  much  furred,  and  the  superior  surface 
fissured.  He  has  pain  and  constriction  on  attempting  to  swallow.  Is  sick,  and 
generally  vomits  after  every  meal,  and  this  whether  his  diet  be  solid  or  fluid.  Vo- 
mits a  great  deal  of  florid  blood,  mixed  with  dark  grumous  masses,  and  clots  of  a  black 
colour.  Ou  examining  this  fluid  under  a  microscope,  it  is  seen  to  consist  chiefly  of 
blood  corpuscles  and  epithelial  scales ;  no  cancer  cells  can  be  detected.  He  states 
that  on  Friday  last  (Nov.  23),  he  vomited  about  half  a  gallon  of  blood,  and  on  the 
following  day  even  a  larger  quantity.  There  is  great  tenderness  over  the  region  of 
the  stomach ;  and  on  examination,  a  hard  lobulated  oval  tumour  is  discovered  on  the 
right  side  of  the  epigastric  region,  measuring  four  inches  transversely,  and  two 
inches  from  above  downwards.  The  appetite  is  bad.  and  has  been  getting  worse  of 
late.  Bowels  usually  regular.  He  complains  of  cough,  which  has  existed  for  about 
four  months ;  no  dyspnoea.  On  percussion,  the  chest  sounds  well,  except  that  there 
is  dulness  over  the  lower  third  of  the  left  lung  posteriorly.  On  auscultation,  the 
expiration  is  prolonged  anteriorly,  and  crepitation  is  heard  over  the  part  where 
dulness  is  elicited  on  percussion.  Pulse  90,  of  tolerable  strength.  Complains  of 
occasional  palpitation,  and  the  impulse  of  the  heart  is  somewhat  increased ;  but  on 
auscultation,  the  heart's  sounds  are  normal.  Urine,  sp.gr.  1020,  natural  in  quantity, 
not  coagulable;  deposits,  on  cooling,  an  abundant  lateritious  sediment  of  lithate  of 
ammonia.  Complains  of  giddiness,  and  is  unable  to  walk  well,  owing  to  weakness. 
Four  leecJies  to  be  applied  over  the  tumour  in  epigastrium.  IJ.  Pulv.  Opii  gr.  ij  ; 
Extract.  Hyoscyam.  gr.  xii.  M.  et  divide  in  jnl.  iv.  One  to  be  taken  morning  and 
evening.  5-  ^aphthce  Medicin.  3i;  Mist.  Camphxyra,  §  iij.  M.  Half  an  ounce  to  be 
taken  every  three  hours. 

*  Reported  by  Mr.  Hugh  Balfour,  Clinical  Clerk. 


DISEASES   OF   THE   LIVEE.  473 

Progress  of  the  C>.se.— December  Is/.— Pain  and  tenderness  are  somewhat 
relieved  by  the  leeches.  Still  vomits,  but  not  to  so  great  an  extent  as  formerly. 
From  this" time  he  went  on  with  occasional  exacerbations  and  remissions,  but  on 
the  whole  became  manifestly  weaker.  Every  now  and  then  he  vomited  large  quan- 
tities of  florid  blood,  and  on  one  occasion  the  quantity  amounted  to  thirty-six  ounces. 
Gallic  acid  and  acetate  of  kad  and  opium  were  given  at  these  times.  After  each 
attack  of  hematemesis,  for  some  hours  small  quantities  of  blood  came  welling  up  into 
his  moulh,  and  were  expectorated.  On  December  liih,  it  is  noted  that  the  weakness 
is  increasing,  and  appetite  diminishing.  He  was  then  ordered  eight  ounces  of  wine 
and  beef-tea  enemaia.  IT^/i.— Extremely  weak,  and  quite  unable  to  take  food,  evi- 
dently sinking.     IQth. — Died, this  morning  at  four  a.m. 

Sectio  Cadaveris. — Twenty-one  hours  after  death. 

The  body  was  Hvid  and  greatly  emaciated.  On  reflecting  tlie  integuments  from 
tlie  thorax  and  abdomen,  a  nodulated  portion  of  the  liver,  nearly  separated  from  the 
rest,  very  movable,  containing  a  large  mass  of  cancerous  exudation,  and  measuring 
four  by  two  inches  across,  projected  as  a  distinct  tumour  into  the  epigastrium,  and 
was  evidently  the  same  swelling  as  had  been  felt  during  hfe,  through  the  iu- 
tegumenls. 

Thorax. — The  cavity  of  the  left  pleura  contained  about  a  pound  and  a  half  of 
recently  coagulated  blood.  The  pericardium  contained  about  six  ounces  of  clear 
straw-coloured  serum.  Heart  much  contracted.  The  whole  of  the  thoracic  viscera, 
together  with  the  trachea,  and  great  vessels,  were  removed  en  masse.  The  blood  in 
the  pleura  was  then  seen  to  have  issued  from  between  the  lobes  of  the  left  lung, 
through  a  laceration  of  the  pleura,  at  the  external  and  back  part  of  that  organ.  The 
aorta  "being  sUt  up,  was  found  to  be  somewhat  rough  internally.  At  the  outer  part 
of  the  arch,  where  it  joins  the  descending  aorta,  the  left  side  of  the  vessel  was  perfo- 
rated by  a  nearly  circular  aperture,  two  inches  in  diameter,  with  smooth  edges, 
which  led  into  an  aneurismal  sac,  the  size  of  a  large  cocoa-nut,  filled  with  a  soft 
coagulum.  The  aneurismal  sac  pressed  and  encroached  on  the  left  lung  inferiorly, 
and  communicated  with  the  pleural  cavity  through  a  recent  ragged  laceration  in  the 
pleura  costalis,  three  inches  in  length.  Here  and  there,  immediately  round  the  sac, 
the  lung  was  infiltrated  with  blood,  and  greatly  softened.  In  these  places  it  was 
very  thin,  and  presented  several  perforations,  through  which  hemorrhage  into  the 
luno-  must  have  taken  place.  Xo  communication  could  be  discovered  between  the 
aneurismal  sac  and  the  stomach  or  oesophagus.  The  whole  arch  of  aorta  was 
shghtly  dilated;  the  valves  healthy.  Between  the  thoracic  aorta  and  the  oesophagus 
there  were  two  masses  of  glands,  greatly  enlarged  from  cancerous  infiltration.  The 
oesophagus  itself  was  ulcerated  about  its  middle,  and  the  enlarged  glands  before 
mentioned  projected  into  its  cavity.  This  ulceration  surrounded  the  tube  internally, 
and  extended  about  three  inches  from  above  do\\Tiwards,  presenting  a  soft  pulta- 
ceous  surface,  the  result  of  disintegrated  cancerous  exudation.  The  lung  presented 
throughout  a  number  of  small  irregularly-shaped  masses  of  exudation,  not  langer,  in 
most  instances,  than  four  or  five  lines  in  diameter,  and  resembling  masses  of  crude 
tubercle,  but  somewhat  softer,  and  slightly  redder  in  colour.  There  were  also  one 
or  two  larger  masses,  nearly  globular  in  form,  from  one-fourth  to  three-fourths  of  an 
inch  in  diameter,  of  soft  consistence,  yielding  a  cream-coloured  juice,  and  marked 
with  one  or  two  red  vessels  and  reddish  points.  The  bronchial  glands  were  infil- 
trated with  black  matter,  and  mostly  contained  masses  of  cancerous  exudation 
similar  to,  but  smaller  tlian,  those  in  the  lung. 

Abdomex. — The  peritoneum  covering  the  diaphragm,  as  weU  as  that  in  the  pelvis 
and  several  other  places,  showed  fungus-Uke  projections  and  nodules  of  irregular 


474  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

form — the  largest  two  inches  in  diameter,  flattened  on  their  surface,  of  a  yellowisli- 
white-colour,  mottled  with  numerous  red  vessels  externally.  Internally  they  were 
of  a  similar  colour  and  appearance — crossed  by  fibres,  which  included  matter  of  the 
consistence  and  general  appearance  of  boiled  ground  rice.  In  the  pelvic  cavity,  at  its 
most  depending  parts,  there  were  about  two  ounces  of  bloody  pus  and  lymph,  infil- 
trated with  blood,  and  here  and  there  these  existed  in  small  patches  on  the  surface 
of  the  intestines  and  parietal  peritoneum.  The  liver  was  much  enlarged,  and 
weighed  six  pounds  ten  ounces.  It  contained  numerous  nodular  masses,  which  on 
the  surfoce  were  cup-shaped.  The  largest  were  nearly  four  inches  across,  and  were 
usually  softened  in  their  centre.  On  section,  they  presented  the  ordinary  appearance 
of  encephaloma  of  the  liver,  with  the  exception,  that  in  many  places  their  substance 
was  partly  diffluent,  and  on  section  excavations  or  cavities  were  left  in  the  ma.ss. 
Some  of  them  contained  a  creamy  yellowish  fluid,  mixed  with  red,  and  others  olive- 
coloured  serum,  with  a  large  amount  of  flocculent  and  granular  pinkish  debris. 
Here  and  there,  also,  masses  of  reticulum  were  infiltrated  among  the  whitish  and 
greyish  cancerous  exudation.  The  liver  itself  was  pale  fawn  coloured  and  very 
fatty.  The  stomach  was  perfectly  healthy ;  but  there  was  a  simple  stricture  at  the 
pylorus,  which  with  difficulty  admitted  the  introduction  of  the  little  finger,  and 
which  depended  on  hypertroph}'  of  tlie  areolar  tissue  between  the  muscular  and 
mucous  coats.  The  intestines  were  extremely  contracted ;  the  colon  not  being 
above  one-half  inch  in  diameter.  Kidneys  pale,  containing  numerous  small  cysts. 
The  epithelium,  however,  was  nearly  healthy,  exhibiting  under  the  microscope  only 
a  small  quantity  of  granular  matter.  The  mesenteric  and  lumbar  glands  were 
healthy. 

Microscopic  Examixatiox. — A  small  portion  of  the  white  and  tolerably  con- 
sistent cancerous  exudation  in  the  liver  presented  numerous  cancer  cells,  varying 
greatly  in  size  and  shape,  but  none  exceeding  the  l-50th  of  a  millimetre  in  its 
longest  diameter.  Many  were  nucleated,  and  several  were  evidently  breaking  up 
and  disintegrating.  They  were  associated  with  some  free  nuclei,  and  a  multitude  of 
molecules  and  granules — (Fig  323).  The  reticulum  was  wholly  composed  of  fatty 
molecules  and  granules — (Fig.  324).  The  broken-down  matter  on  the  surface  of  the 
oesophagus,  where  it  was  ulcerated,  closely  resembled  that  represented  in  Fig.  322, 
but  was  even  more  disintegrated.  The  milky  juice  squeezed  from  the  glands 
between  the  thoracic  aorta  and  the  oesophagus,  presented  large  cancer  cells,  which 
presented  the  various  appearances  characteristic  of  their  undergoing  the  fatty  dege- 
neration.— (Fig.  323). 

Commentary. — During  life,  the  pain  in  the  stomach,  the  vomitino-  after 
food,  the  black  bloody  coagula  rendered,  and  the  distinct  nodulated  and 
somewhat  movable  tumour  in  the  epigastrium,  left  little  doubt  in  the 
minds  of  all  those  who  examined  the  case,  that  we  had  to  do  with  cancer 
of  the  pylorus.  On  examination  after  death,  however,  the  tumour 
which  had  previously  been  felt,  was  found  to  be  a  nodule  of  cancerous 
exudation  developing  itself  in  the  liver,  a  part  of  which  had  been 
pushed  forward  so  as  to  occasion  the  swelling.  As  the  rest  of  the  liver 
was  entirely  hid  under  the  ribs,  it  was  not  possible  to  have  suspected 
this  occurrence  during  life.  The  simple  structure,  however,  that  really 
existed  in  the  pylorus,  conjoined  with  the  pressure  exercised  bv  the 
tumour  on  the  valve,  caused  the  vomiting  that  formed  the  principal  fea- 
ture of  the  disease. 

The  appearance  of  the  matters  rendered  by  the  mouth  proved  that 
they   must  have   come  from   the  stomach  ;    because,   although   a  con- 


DISEASES   OF   THE   LIVER. 


475 


siderable  quantity  of  red  blood  was  evacuated,  this  was  commonly 
mino-led  with  rusty  brown,  and  even  perfectly  black,  coagula.  Besides, 
on  one  occasion,  he  was  actually  seen  by  the  clerk  to  render  the  blood 
by  the  act  of  vomiting ;  and  the  same  thing  was  repeatedly  observed  by 
the  nurse.  At  first,  ■then,  I  considered  that  the  cancer  of  the  stomach 
liad  ulcerated  internally,  and  poured  out  the  blood  evacuated  ;  but 
latterly,  from  the  large  quantities  discharged,  my  suspicions  were  fixed  on 
the  presence  of  an  aneurism  pressing  on  the  lung,  and  communicating 
witli  the  trachea,  in  which  case  he  must  have  swallowed  the  blood. 
This  supposition  seemed  to  be  confirmed  by  the  existence  of  limited  dul- 
ness  on  the  left  side,  and  by  crepitation — an  almost  invariable  concomi- 
tant of  aneurism  so  situated. 

On  attempting,  after  death,  to  ascertain  by  Avhat  means  the  blood 
entered  the  stomach,  I  could  not  find  any  direct  communication  between 
the  aneurism  and  that  viscus,  or  the  oesophagus.  It  may  have  resulted 
from  the  blood,  in  the  first  instance,  having  been  infiltrated  into  the  sub- 
stance of  the  lung,  then  passed  through  the  bronchi,  trachea,  and  larynx, 
into  the  pharynx,  and  so  been  swallowed.  More  probably,  however,  it 
was  caused  by  intense  portal  congestion,  producing  hemorrhage  from  the 
capillaries. 

This  man  presented  in  a  very  marked  degree  the  so-called  peculiar 


Tis.  40S. 


cachectic  aspect  of   malignant   disease.      I    have   alwavs  noticed  that 
this  aspect  is  best  marked  in  individuals  labouring  under  cancer  of  the 


Fig.  40S.     Remarkable  carcinomatous  cyst  in  the  liver ;  a,  part  of  diaphragm. — 
(Ogh.)  Half  the  real  size. 


476  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

stomach,  so  situated  as  to  interfere  Avith  tbe  process  of  nutrition.  It 
is  stated  in  the  report  that  he  had  previously  been  stout  and  fat — a 
condition  I  have  pointed  out  in  another  place*  to  be  favourable  to  the 
development  of  cancer  generally.  I  am  inclined  to  think  that  this 
maliornant  aspect,  so  much  dwelt  on  bv  practitioners,  is  the  mere 
result  of  emaciation  from  interference  with  the  nutritive  processes,  or 
from  pain  and  want  of  sleep,  and  is  in  no  way  distincti\e  of  cancer  in 
organs  where  such  effects  are  not  occasioned. 

Cancer  of  the  liver  may  occur  in  two  forms — 1st,  That  of  distinct 
nodules,  which  have  been  so  well  described  by  Baillie  and  Farre  ;  2d, 
More  or  less  infiltrated  in  minute  grains  throughout  the  hepatic  tissue. 
The  former  is  by  far  the  most  common,  and  when  it  presents  projections 
from  the  surface  of  the  organ,  these  constitute  the  only  positive  proof 
during  life  of  its  being  affected  with  cancer.  In  some  rare  cases  I  have 
seen  these  two  forms  run  into  one  another.  Softening  of  the  cancerous 
masses  was  well  observed  in  the  case  just  recorded,  as  well  as  its 
transformation  into  the  fatty  substance  wliich  forms  the  so-called  reti- 
culum. Dr.  Oglef  has  recorded  a  case  in  which  a  cancerous  mass  in 
the  liver  presented  on  section  the  remarkable  form  of  a  cvst  with 
thick  walls,  closely  resembling  a  small  cocoa-nut  full  of  fluid.  The 
walls  exhibited  the  usual  appearance  and  structure  of  encephaloma, 
and  the  fluid  which  occupied  the  centre  was  slightly  turbid  and  con- 
tained shreddy  particles  of  cancer  and  some  fatty  matter.  In  the 
majority  of  cases  of  cancerous  liver,  other  organs  of  the  body  are 
similarly  affected,  rendering  the  disease  more  or  less  complicated.  (See 
Cases  LXV,  and  LXXVI.)     The  treatment  must  be  entirely  palliative. 


DISEASES  OF  THE  INTESTINES. 

Case  LXXII.  J — Diarrhaa — Recovery. 

History.— Mary  Gordon,  £et.  21,  a  thin  weak-looking  woman,  lately  employed 
as  a  herring-curer — admitted  in  the  afternoon  of  July  25th,  1855.  She  has  for  the 
last  two  days  been  much  exposed  to  cold  and  wet,  and  early  this  morning  was 
seized  with  violent  pain  in  the  epigastric  and  lumbar  regions,  accompanied  by 
shivering,  sickness,  and  vomiting.  At  nine  o'clock  the  bowels  were  freely  opened, 
and  since  then  she  has  had  several  fluid  stools,  with  griping  pain  in  the  abdomen, 
and  violent  tenesmus.  The  matters  discharged  from  the  bowels  she  describes  as 
watery,  mingled  with  slime.     She  has  taken  some  brandy,  which  caused  slight  relief. 

Symptoms  ox  Admission'. — On  admission  the  tongue  is  white,  appetite  impaired, 
great  thirst,  no  nausea  nor  vomiting  at  present,  no  tenderness  over  stomach  or 
abdomen.  Bowels  still  loose ;  the  matter  discharged  consists  of  a  dirty  yellow 
fluid,  in  which  masses  of  mucus  are  floating.  Xo  blood  nor  pus.  Pulse  84,  fuU. 
Says  she  has  occasional  palpitations.  Countenance  slightly  flushed.  Considerable 
lumbar  pain.  Urine  healthy.  Other  functions  well  performed.  ^  Tr.  Opii  3  j ; 
Conf.  Aroinat.  3j ;  Mist.  Creke  comp.  ?  iij ;  M.  Half  an  ounce  to  be  taken  every 
three  hours. 

*  On  Cancerous  and  Cancroid  Growths.     Edinburgh,  1849. 
f  Trans,  of  Patholog.  Society.     Yol.  ix..  p.  238. 
\.  Reported  by  Mr.  Simon  Mutakisna,  CUuical  Clerk. 


DISEASES   OF  THE   INTESTINES.  477 

Progress  of  the  Case.— July  26</t.— To-day  feels  weak,  but  the  diarrlioea 
ceased  after  the  second  dose  of  the  mixture.  July  27</t.— Still  very  exhausted. 
To  have  nutrients  with  wine  §  ij.  daily.  She  rapidly  recovered,  and  was  discharged 
August  2d. 

Case  LXXIII.* — Diarrlioea — Recovery. 

History.— Frederick  Lyons,  set.  4— admitted  December  19th,  1854.  Tlie  mother 
says  he  has  been  fed  regularly,  if  not  plentifully,  and  up  to  two  months  ago 
he  was  quite  healthy.  He  was  then  sent  to  school,  ever  since  which  he  has  had 
diarrhoea,  the  bowels  being  generally  open  five  or  six  times  a  day.  He  has  been 
losing  strength  uj)  to  the  present  time. 

Symptoms  on  Admission.— The  cliild  is  now  very  thin,  is  always  picking  his 
nose.  Tongue  clean.  Abdomen  tumid  and  tender  on  pressure.  Has  had  six 
stools  within  the  last  twenty-four  hours,  of  fluid  consistence  and  clay  colour.  Pulse 
96,  weak.  Has  never  been  known  to  pass  worms.  Other  systems  normal.  Haheat 
01.  Ricini  3  ij.     Nutritious  diet.     To  remain  in  bed. 

Progress  of  the  Case. — Diarrhoea  diminished.  Stools  of  a  more  healthy 
colour.  Takes  rice  and  milk  greedily.  From  this  time  he  rapidly  recovered.  All 
diarrhoea  had  ceased  on  the  24:th.  On  the  27th  he  was  allowed  to  get  up;  there 
was  then  no  tenderness  of  abdomen,  and  the  tumidity  had  nearly  disappeared. 
Discharged  well,  January  8th. 

Commentary. — The  cases  of  diarrhoea  here  recorded  are  examples  of 
the  two  most  common  forms  of  this  disorder,  the  one  originating  from 
exposure  to  wet  and  cold,  the  other  from  irregularities  in  diet.  In  the 
first  case  the  discharge  was  checked  by  opium  and  chalk,  in  the  second 
by  a  mild  aperient,  proper  nourishment,  and  rest. 

Many  varieties  of  diarrhoea,  or  excessive  discharge  from  the  bowels, 
have  been  described  by  systematic  writers,  but  pathologically  they  may 
all  be  referred  to  two  causes,  namely: — 1st,  A  disturbance  of  the  healthy 
conditions  of  the  blood,  leading  to  increased  eliminating  action  of  the 
intestinal  mucous  membrane,  in  various  acute  inflammatory  diseases — 
when  it  may  be  critical — as  after  exposure  to  cold  or  wet,  occasioning 
suppressed  "transpiration;  in  cholera;  in  leucocythemia ;  and  so  on. 
2d,  From  irritating  substances  in  the  canal  itself  derived  fi'om  food  or 
drink ;  from  an  increased  amount  of  bile  or  other  secretion  ;  from  struc- 
tural disease  of  the  mucous  membrane,  as  in  dysenteric,  tubercular,  or 
typhoid  ulcerations;  from  worms  or  foreign  bodies  impacted  in  the  gut, 
etc.,  etc.  The  indications  for  treating  those  two  forms  of  diarrhoea  are 
very  different.  In  the  first  it  may  be  sanative  in  itselt^  and  only  symp- 
tomatic, or  the  natural  termination  of  a  general  disorder  which  it  would 
sometimes  be  injurious  and  even  dangerous  to  check.  In  the  second, 
the  diarrhoea  is  always  hurtful  if  long  continued,  and  our  hopes  of  cor- 
recting it  will  mainly  depend  on  our  capability  of  removing  the  local 
irritating  cause. 

Thus  if,  as  very  commonly  happens,  improper  diet  be  the  cause,  this 
must  of  course  be  better  regulated.  If  any  special  irritating  substance 
has  been  taken,  and  occasions  griping  with  tenesmus,  a  simple  warm- 

*  Reported  by  Mr.  Arthur  W.  Moore,  Clinical  Clerk. 


478  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

water  injection,  slowly  introduced,  so  as  to  distend  and  wasli  out  the 
rectum,  may  at  once  remove  it.  If  not,  a  dose  of  castor  oil,  followed 
by  an  antacid  and  anodyne  mixture,  such  as  the  compound  chalk  mix- 
ture, with  a  little  Tr.  opii,  generally  succeeds.  To  this,  if  the  discharge 
continue,  the  various  astringents  may  be  added,  and  given  by  the  mouth 
or  by  the  rectum.  Quietude  is  a  very  necessary  part  of  the  treatment, 
and  confinement  to  bed  in  all  severe  cases  is  of  the  greatest  importance. 
When  diarrhcEa  is  symptomatic  of  deranged  liver,  of  intestinal  ulcera- 
tions, of  worms,  or  other  irritating  cause,  the  treatment  resolves  itself 
into  the  appropriate  method  of  removing  the  original  disorder. 

The  opposite  disease  to  diarrhoea  is  constipation,  which  is  diminished, 
difficult,  or  suspended  discharge  from  the  bowels.  This  also  may  be  the 
result  of  constitutional  or  local  causes,  and  give  rise  to  indications  for 
treatment  directed  to  overcome  the  one  and  remove  the  other.  In  most 
cases,  however,  there  is  torpor  and  diminished  nervous  energy  afteeting 
the  contractility  of  the  intestinal  muscular  coat.  All  that  I  think  it 
necessary  to  say  here  is,  that  purgatives,  although  necessary  to  over- 
come temporary  obstructions  and  give  immediate  ease,  do  not  tend  in 
themselves  to  remove  the  causes  of,  and  therefore  seldom  permanently 
cure,  a  constipation.  The  best  means  for  accomplishing  this  are  appro- 
pi'iate  diet,  the  use  of  particular  kinds  of  food,  such  as  brown  bread, 
stewed  fi-uits,  etc. ;  exercise,  baths,  pleasure-excursions,  a  course  of  saline 
waters,  etc.,  etc.  In  constipation,  as  in  diarrhoea,  should  any  structural 
disease  or  mechanical  impediment  exist,  its  treatment  must  be  regulated 
according  to  the  circumstances  of  the  disease  of  which  it  is  sympto- 
matic. 

The  use  of  purgatives  in  intestinal  disease  is  a  subject  of  great  import- 
ance, and  one  which  appears  to  me  to  have  been  much  misunderstood. 
It  has  been  supposed,  for  instance,  that  a  good  alvine  evacuation  once  a 
day  is  necessary  to  tbe  healthy  state  of  the  body,  and  that  an  individual 
who  only  has  such  an  evacuation  once  in  two  days,  and  sometimes  in 
three,  is  constipated.  This  idea  has  led  to  the  habitu.d  use  of  purgatives, 
and  is  the  principal  cause  of  the  enormous  number  of  aperient  pills 
annually  sold  with  government  stamps  in  this  country.  The  fact  is,  that 
many  persons  naturally  never  have  a  motion  above  once  in  two  or  three 
days,  and  retain  their  health  quite  well.  The  rule  ought  to  he  that  in 
all  such  cases  purgatives  are  unnecessary  unless  inconvenience,  or  some 
decided  symptom,  follow  retention  of  the  foeces.  Again,  it  has  been  sup- 
posed that  purgatives  are  antiphlogistic,  and  so  far  has  their  administra- 
tion been  deemed  beneficial,  that  there  is  scarcely  a  disease,  the  treatment 
of  which  at  one  time  was  not  commenced  by  a  smart  aperient,  with  a 
view  of  cleansing  out  the  bowels,  in  order  to  have  a  clear  field,  as  it 
were,  for  future  operations.  But  purgation  can  in  no  way  benefit  a 
distant  part  actually  inflamed,  whilst  its  employment  at  the  commence- 
ment of  many  diseases,  and  more  especially  of  typhus  and  peritonitis,  is 
positively  injurious.  The  chief  uses  of  purgatives  are  to  overcome  tem- 
porary obstructions,  to  remove  irritating  substances;  to  solicit  the  flow 
of  bile  and  other  secretions  at  the  upper  part  of  tlie  canal,  and  to  excite 
watery  discharges  in  certain  cases  of  dropsy.  For  this  purpose  the 
practitioner  must  be  acquainted  with  the  properties  of  the  difl:erent  kinds 
of  pui'gatives,  and  choose  such  only  as,  when  pi-operly  administered,  will 


DISEASES    OF   THE   INTESTINES.  -179 

best  effect   bis  object.      Everything  Hke    routine    practice   should   be 
avoided. 

Case  LXXIV.* — Acute  Dysentery — Recovery. 

History. — Timothy  Flinn,  aet.  14,  a  hawker — admitted  November  26th,  1852. 
States  that  on  the  22d  inst.,  when  in  Perth,  he  was  suddenly  seized  with  looseness 
of  the  bowels,  griping  pains  in  the  abdomen,  and  tenesmus  not  preceded  by  sliiver- 
ing.  He  attributes  the  attack  to  having  breakfasted  on  oatmeal  porridge,  a  kind  of 
food  to  whicli  he  was  not  accustomed,  althougli  he  had  been  much  exposed  to  wet, 
cold,  and  fatigue.  On  the  first  day  of  his  illness,  the  calls  to  stool  occurred  several 
times  in  an  hour.  On  the  following  day  he  observed  that  he  was  passing  blood  with 
the  foeces,  and  sometimes  nothing  but  small  quantities  of  thick  bloody  matter  of 
tough  consistence  like  glue.  Notwithstanding  these  symptoms,  he  walked  from 
Perth  to  Edinburgh,  the  frequent  bloody  stools  continuing,  but  the  pain  gradually 
abating. 

Symptoms  on  Admission.— Tongue  is  dry  in  the  centre,  the  tip  and  edges  being 
clean  and  moist.  Appetite  much  impaired;  thirst  moderate.  Thinks  he  has  had 
twelve  stools  during  the  last  twenty-four  hours,  which  were  mixed  with  blood.  Has 
still  tenesmus  and  much  straining,  complains  of  a  constant  and  rather  sharp  pain  at 
the  lower  part  of  the  abdomen,  which  is  greatly  increased  on  pressure,  and  follows 
the  course  of  the  sigmoid  flexure  and  rectum.  This  pain,  he  says,  appeared  on  the 
second  day  of  his  illness,  a  few  hours  before  the  appearance  of  the  blood.  Pulse  92, 
small  and  soft.  Urine  diminislied  in  quantity,  but  healthy.  Other  functions  well 
performed.  B  TV.  Catechu  =  ss  ;  Sol  Mur.  Morph.  2  j ;  J^i*<-  CrttcK  comp.  ad  3  viij. 
M.     Sumat  3  j  ieiiid  qudque  hord. 

Progress  of  the  Case. — The  bowels  have  been  opened  twelve  or  fourteen  times 
since  yesterday's  visit.  Pain  stOl  very  severe  in  the  left  iliac  fossa.  A  considerable 
quantity  of  blood  and  mucus  in  the  stools.  Applicent.  hirudines  xij  parti  dolenti. 
Injiciaiur  Enema  Amyli  cum  Tr.  Opii  I  i.  November  28//i.— Six  stools  since  yester- 
day, very  watery,  with  traces  of  blood.  No  tenesmus.  Continuetur  Mist.  Nov.  ^Qth. 
—Six  stools,  more  foeculent,  and  Avithout  blood.  From  this  time  he  rapidly  reco- 
vered, and  was  dismissed  quite  well,  December  9th. 


Case  'LX'^X.]— Sub- Acute  Dysentery— Recovery. 

History. — John  M'Gee,  a?t.  38,  a  mason's  labourer— admitted  June  29th.  1853, 
Says  that  last  summer  he  was  confined  to  his  house  for  twenty-six  weeks,  in  conse- 
quence of  severe  bowel  complaint,  and  has  been  subject  to  diarrhoea  every  now  and 
then  ever  since.  He  returned  to  his  work  last  February,  but  was  again  obliged  to 
desist  nine  weeks  ago  in  consequence  of  the  severity  of  the  bowel  complaint  and 
weakness.  Three  weeks  since  he  observed  the  stools  to  be  tinged  with  blood.  Six 
days  ago  he  vomited  a  tenacious  mass  of  the  appearance  of  white  of  egg.  He  has 
been  much  addicted  to  the  use  of  ardent  spirits,  and  is  very  intemperate.  The  medi- 
cines he  has  taken  have  been  of  little  benefit 

Symptoms  on  Admission.— Tongue  smooth  and  moist  anteriorly,  but  somewhat 
loaded  at  the  base.  Appetite  tolerably  good.  No  fever.  There  is  tenderness  on 
pressure   over  the   abdomen  generally,  and  frequently  griping  pains.     Has  about 

*  Reported  by  Mr.  Wm.  Calder,  Clinical  Clerk. 
f  Reported  by  Mr.  J.  D.  Maclaren,  Clinical  Clerk. 


480  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

thirteen  stools  a  day,  which  are  thin,  of  pale  yellow  colour,  containing  a  quantity  of 
pus.  Pulse  80,  weak.  Other  systems  healthy.  !^  Pil.  Flumb.  Acet.  Sumat  unam 
quarto,  qudque  liord.  Hdbeat  suppositor.  cum  Mur.  Morph.  gr.  ss  vespere.  Jvly  \st. — 
Increased  pain  in  the  abdomen.  Applictnt.  hirudines  vj.  July  2d. — No  change. 
Complains  of  thirst.  Initrmit.  Pil.  Plumb.  5  Confect.  Aromat.  3  ss ;  Sol.  Mur.  Marph. 
3  iss ;  Tr.  Catechu  3  vj ;  Mist.  Cretce  ^v.  M.  A  table-spoonful  to  be  taken  every  four 
hours.  Habeat.  Enema  Amyli  cum  lY.  Opii.  min.  XL.  5  Lactis  recentis  §  x ;  Aq. 
Calais  3  viij.  M.  To  be  used  as  drink.  July  4th. — Has  now  only  six  stools  in  the 
twenty- four  hours.  Complains  of  dj-snria,  and  has  only  passed  nineteen  ounces  of 
urine  daily  for  three  days.  IJ .  /S/j.  ^ther.  Mt.  §  ss ;  Pot.  Acet.  3  ij ;  Syr.  Aurant. 
Ij;  Aquce  §  ivss.  M.  A  iable-.<t2M0»ful  to  be  taken  three  times  a  day.  July  1th. —  < 
Has  now  only  three  or  four  stools  daily,  which  are  fceculent.  No  dj'suria.  Urine 
more  copious.  Considerable  uneasiness  in  the  epigastric  region.  Omit.  mist,  diure- 
tica.  Applied  Emp.  Lyttce  (3  x  4)  epigastrio.  Habeat  Enema.  Opiatum  vespere.  July 
2oth. — Since  last  report  has  had  about  three  stools  on  an  average  daily.  He  feels 
much  stronger.  Aug  1st. — Has  had  occasional  exacerbations  of  fever,  with  thirst, 
accompanied  by  increased  looseness,  which  have  been  checked  by  the  Pil.  Pluvib. 
Opiat.  From  this  date  he  continued  slowly  gaining  strength,  taking  occasional 
exercise,  but  subject  every  now  and  then  to  relapses,  for  which  he  was  ordered  tannin 
with  opium,  and  occasional  suppositories.  Gradually  the  pus  disappeared  from  the 
stools,  which  became  more  fceculent  and  regular.  He  was  dismissed  quite  well, 
September  20th. 


Case  LXXVI.* — Chronic  Dysente^-y — Ascites  and  (Edema  of  the  Legs — Leucocythe- 
mia — Cirrhosis  of  the  Liver — Cancer  of  the  Lung. 

History. — Thomas  Crease,  set.  28,  single — admitted  May  27th,  1857.  Has  been 
of  intemperate  habits.  Since  November  1856  has  been  troubled  with  violent  cough 
— sputum  being  tinged  with  blood ;  voice  hoarse ;  feet  and  legs  more  or  less  swollen, 
hot  and  tender,  especiall}'  around  the  ankles.  This  attack  dated  from  a  definite  day 
which  he  could  not  name  in  November  1856,  after  expcsure  to  cold  while  crossing  at 
Queensferry.  He  was  under  treatment  in  the  Infirmary  from  March  6th  to  April 
28th,  1857 ;  there  were  present  during  that  time  cough,  with  bloody  or  rusty  sputum, 
which,  however,  occasionally  became  frothy  and  mucous ;  a  doughy  and  cjedematous 
condition  of  the  feet,  and  latterly  of  the  bauds;  an  unusual  temperature  of  skin,  and 
a  pulse  more  or  less  tlirilling  and  hard.  There  was  no  diarrhoea.  After  leaving 
hospital  he  was  for  four  weeks  under  quack  treatment ;  getting  steaks,  ale,  and  brandy 
almost  ad  libiturn.  No  relief  was  obtained ;  the  heat  of  skin,  ihirst,  and  exhaustion 
continued,  and  the  bowels  became  loose.  The  cough  became-less  troublesome,  and 
the  expectoration  scanty. 

Symptoms  on  Admission. — Percussion  note  is  rather  flat  on  the  right  side  of 
thorax  anteriorly  and  over  the  upper  half  on  same  side  posteriorly.  The  respiratory 
murmurs  are  very  feeble.  "When  audible  they  are  harsh ;  no  sibilus  nor  moist  rale  ; 
vocal  resonance  increased  under  right  clavicle ;  no  dyspnoea ;  no  cough  nor  sputum 
to-daj'.  Cardiac  impulse  weak ;  the  transverse  dulness  is  normal ;  the  sounds  are 
normal,  but  a  systolic  blowing  murmur  is  said  by  the  clerk  to  have  occurred  for- 
merly at  night.  It  is  not  now  audible.  The  pulse  136,  rather  full  and  hard.  The 
tongue  is  covered  with  fur;  thirst  great,  appetite  bad.  Abdomen  on  palpation  is 
natural;  no  dulness  on  percussion,  nor  tenderness  on  pressure.  The  bowels  are  re- 
ported loose,  but  patient  does  not  complain  of  their  frequency.     Urine  is  quite  natural. 

*  Reported  by  Messrs.  John  Lowe  and  Stewart  Lockie,  Clmical  Clerks. 


DISEASES  OF  THE   INTESTINES.  481 

The  skin  over  the  body  generally  is  of  an  unusually  high  temperature  and  dry.  No 
lesion  of  the  nervous  system;  is  exliausted,  and  is  mentally  despondent.  Is  ordered 
vnne  (  §  iij)  and  saline  diaphwetics. 

PR0GEES3  OF  THE  Case. — May  3l5<. — Sputum  rather  frothy,  semi-transparent, 
gelatinous,  slightly  tinged  with  blood ;  pulse  1 14  ;  febrile  condition  the  same  ;  the 
diarrhoea  has  not  ceased.  June  3d — Diarrhoea  continues ;  foeces  of  a  hght  yellow 
colour  and  pea  soup  consistence,  of  an  extremely  fceculent  odour,  presenting  on  micro- 
scopic examination  no  blood  discs  nor  other  abnormal  bodies.  Ordered  an  astringent 
and  chalk  mixture.  Jane  ~ith. — FebrUe  symptoms  continue ;  ordered  3  grains  of  qui- 
nine thrice  daily.  The  diarrhoea  slightly  abated;  continue  the  astringent  mixture. 
June  11th. — Diarrhoea  continues  with  much  tenesmus;  frequent  calls  (from  6  to  8 
times)  at  night  to  stool ;  evacuations  at  eacla  time  are  scanty ;  stools  watery.  Let 
him  have  an  opiate  suppository  at  night.,  and  after  every  stool  let  the  folloicing  enema  be 
administered :  IJ  Plumb.  Acetat.  9 j ;  Aq.  Distill  5  iss ;  Sol.  Mur.  Morph.  3  ss.  June 
loth. — Patient  expresses  himself  as  better,  and  the  febrile  excitement  is  diminished. 
June  2Ath. — The  diarrhoea  has  not  ceased ;  the  injections  cause  pain,  and  are  speedily 
ejected ;  they  are  now  discontinued ;  ordered  half  ounce  of  the  decoction  of  the  Indian 
Bael  thrice  daily.  June  2~fh. — In  addition  to  the  decoction,  let  him  have,  thrice  daily, 
one  of  the  foUoiving  powders :  ^  Pulv.  Cretoe  prep.  3ij;  Coiifect.  Aroinat.  "Q'y.  Fulv. 
opii,  gr.  iij.  M.  et  divide  in  chartulas  duodecem.  July  2d. — Febrile  symptoms  and 
diarrhcea  much  diminished;  skin  cooler;  pulse  86,  of  moderate  strength;  oedema  of 
the  legs  is  much  less  than  formerly.  On  the  Hh,  he  becomes  worse ;  on  the  5tk,  feels 
better ;  on  the  8th,  diarrhoea  again  more  severe,  and  febrile  symptoms  renewed.  On 
the  dth,  the  blood  was  microscopically  examined,  and  an  increase  of  white  corpus. 
cles  was  detected  (from  20  to  25  being  visible  in  one  field),  and  the  red  discs  arranged 
themselves  in  irregular  masses.  On  the  11th,  the  powders  and  decoctions  are  dis- 
continued, and  a  mixture  of  Kino,  Catechu,  and  Simarouba  was  given.  On  the  IMh, 
the  diarrhoea  being  persistent,  the  use  of  the  powders  is  resumed,  and  at  night  an 
astringent  injection.  On  the  loth  and  11th,  is  better;  on  the  2Qth,  is  worse  and 
seldom  oft"  the  stool;  on  the  2\st,  is  better,  having  had  only  three  stools ;  on  the  2ith 
has  six  stools,  skin  beiijg  burning  hot,  pulse  120,  hard,  and  apparently  strong,  but 
patient  complains  of  great  debility.  July  26th. — Great  thiret :  pain  over  abdomen, 
which  is  relieved  by  a  turpentine  epithem.  Abdomen  is  tense,  with  skin  white.  gUs- 
tening,  and  dry;  percussion  verj- tympanitic  anteriorly;  is  slightly  dull  over  the  flanks. 
Juiy  2Sth. — Patient  is  extremely  weak  ;  foeces  are  passed  in  bed.  Urine  is  examined 
and  found  non-albuminous ;  has  been  delirious  this  morning.  July  29th. — No  return 
of  the  delirium ;  swelling  of  abdomen  increased  ;  the  diarrhoea  and  febrile  state  con- 
tinue; pulse  112;  very  weak;  great  thirst.    July  30th. — Died  this  morning  at  9.30  a.m. 

Sectio  Cadaver  is. — Forty-eight  hours  after  death. 

Body. — Moderately  emaciated ;  oedema  of  feet  and  legs ;  face  with  a  peculiar 
feverish  expression. 

Thorax. — Heart  was  quite  natural.  The  two  upper  lobes  of  right  lung  healthy: 
the  lower  lobe  felt  heavy,  presenting  a  rounded  prominence  about  thi-ee  inches 
in  diameter,  projecting  from  its  surface.  On  section  it  was  foiuid  to  be  a  mass  of  soft 
cancer,  of  an  oval  form,  about  the  size  of  a  fist ;  greyish  or  pinkish- white  in  colour, 
with  some  opaque  yellow  patches  (reticulum)  intermixed  with  it.  It  readily  broke 
down  under  pressure,  and  part  had  already  undergone  softening.  In  its  neighbour- 
hood were  two  other  masses  of  similar  character,  about  the  size  of  small  marbles. 
In  the  lower  lobe  of  the  left  lung  there  was  a  cancerous  mass  of  the  size  of  a  filbert ; 
otherwise  the  lung  was  healthy.     The  bronchial  glands  were  natural. 

Abdomen. — The  peritoneum  contained  nearlv  a  gallon  of  a  somewhat  opalescent 

31 


482  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

serum.  The  liver  was  of  small  size,  and  presented  a  coarsely  granular  surface.  On 
section  it  was  found  in  a  moderately  advanced  state  of  cirrhosis ;  it  weighed  2  lbs. 
8  oz.  The  spleen  was  quite  natural,  and  weighed  6  ounces.  Kidneys  healtliy. 
Stomach  normal.  The  coats  of  the  small  intestines  were  generally  thickened  and 
cedematous,  but  there  was  no  trace  of  ulceration.  The  mucous  membrane  of  the 
large  intestines  was  found  extensively  ulcerated,  chiefly  in  the  transverse  and 
descending  colon.  There  were  a  few  in  the  caecum  and  upper  part  of  the  rectum ; 
they  ceased  altogether  about  3  inches  above  the  anus.  The  calibre  of  the  intestine 
was  diminished.  The  ulcerations  were  of  a  very  clironic  character,  there  being  no 
increased  vascularity  of  the  surrounding  mucous  membrane.  They  were  generally 
arranged  in  a  linear  direction,  parallel  to  the  long  axis  of  the  gut.  Many  were  nearly 
cicatrized,  presenting  in  the  base  and  margin  an  accumulation  of  dark-coloured  pig- 
ment. There  were  pretty  numerous  slate-coloured  cicatrices,  indicating  the  posi- 
tion of  former  ulcers.     No  other  lesion  was  found. 

Microscopic  Examination. — The  cancerous  exudation  in  the  lungs  contained 
numerous  cancer  cells  in  all  stages  of  development.  Some  of  them  were  very  large, 
and  contained  from  three  to  five  secondary  cells.  Several  of  them  contained  clear 
collections  of  fluid,  as  represented  Fig.  126. 

Commentary. — The  three  cases  now  related  present  the  same  disease 
in  different  degrees  of  severity.  In  the  first  there  is  every  reason  to  sup- 
pose that,  though  severe,  it  was  not  extensive.  In  the  second  it  was 
more  chronic,  hut  ultimately  the  patient  got  well.  In  the  third,  it  went 
on  to  such  extensive  ulceration,  kept  up  such  constant  irritative  lever,  and 
so  interfered  with  nutrition,  as,  conjoined  witli  the  otlier  lesions  under 
Avhich  the  man  lahoured,  to  cause  death;  on  dissection  afterwards  it  was 
seen  that  he  had  had  chronic  disease  of  the  liver,  which  had  caused 
ascites  and  oedema  of  the  extremities.  On  this  had  supervened  the 
inflammation  of  the  lower  bowel,  especially  of  the  colon,  which  had 
proceeded  to  ulceration,  extending  over  a  considei-able  portion  of  the 
mucous  membrane.  In  many  places  the  ulcers  had  healed,  while  in 
others  there  was  exhibited  a  tendency  to  cicatrization  ;  and  it  is  very 
possible  that  a  recovery  miglit  have  occurred  in  this  case,  as  in  the  one 
wdiich  preceded  it,  but  for  the  hepatic  disease,  which,  by  keeping  up 
constant  congestion  of  the  portal  system,  and  therefore  of  the^  intestinal 
venous  capillaries,  must  have  opposed  itself  to  all  successful  efforts  at  cui-e 
of  the  ulcers.  The  masses  of  cancer  developed  in  the  lower  portion  of 
the  lungs,  and  which  gave  rise  to  many  of  the  symptoms  of  pneumonia, 
especially  cough  and  bloody  expectoration,  cannot  be  said  to  have  had 
any  influence  in  producing  the  fatal  termination 

In  the  case  of  Crease  I  employed,  as  an  astringent,  a  decoction  of  the 
unripe  fruit  of  the  Indian  Bael,  commonly  called  the  Bengal  Quince.  It 
is  said  to  contain  tannin,  both  free  and  in  a  combined  state,  aromatic 
principle,  mucilage,  and  a  small  amount  of  bitter  principle  supposed  to 
be  sedative.  The  decoction  must  be  used  fresh,  and  is  prepared  by  sim- 
mering two  ounces  of  the  unripe  fruit  in  a  pint  of  water  down  to  a 
fourth,  of  -which  from  one  to  three  table-spoonfuls  constitute  a  dose.  In 
the  case  of  a  gentleman  under  my  care,  whose  obstinate  diarrhoea  had 
resisted  all  the  usual  means,  this  decoction  checked  the  disorder  perma- 
nently after  a  few  doses ;  and  I  have  since  given  it  with  great  advantage 
in  similar  cases.  In  the  case  of  Crease  it  was  of  no  benefit  whatever. 
Indeed  it  cannot  be  supposed  that  where  actual  ulcerations  exist  over  a 


DISEASES  OF   THE   INTESTINES.  483 

considerable  portion  of  the  mucous  surface  of  the  colon,  any  remedies  can 
produce  an  impression  on  the  alvine  discharges.  These  are  the  result  of 
the  organic  lesion,  so  that  medicines  merely  directed  to  the  symptoms, 
unlesslhev  favour  cicatrization,  cannot  operate  with  effect.  This  requires 
time,  fjeneral  health  of  body,  avoidance  of  irritating  food  and  mental 
excitement,  quietude,  a  good  atmosphere,  pure  water,  etc.  etc. — in  short, 
local  ao-ents  must  be  combined  with  all  those  general  remedies  and 
hvo-ienic  conditions  calculated  to  improve  the  vital  powers,  and  favour 
regeneration  of  tissue. 

Diarrhoea  and  dysentery  pass  into  one  another;  a  great  variety  of 
lesions  mav  induce"  the  first,  but  the  last  is  considered  to  be  a  true 
inflammation  of  the  large  intestines.  Hence  the  symptoms  of  dysentery 
are  local  pain,  accompanied  by  fever,  and  attended  with  a  discharge 
from  the  bowels,  first  of  blood,  and  then  of  pus.  The  blood  results  from 
rupture  of  the  capillaries  consequent  upon  their  congestion,  and  is  min- 
gled with  the  mucous  discharge.  Fluid  exudation  is  at  fii-st  poured  out 
on  the  surface  and  passes  away  from  the  bowels  with  the  excess  of  mucus 
and  blood,  but  subsequently  purulent  matter  is  thrown  off  from  the 
ulcerated  surface  of  the  mucous  membrane. 

The  character  of  the  foecal  evacuations  should  be  carefully  attended 
to,  not  only  in  dvsentery,  but  in  all  forms  of  intestinal  disease.  In 
health  the  foecal  evacuation  consists  of  a  soft  solid  mass,  forming  a  mould 
of  the  outlet  at  the  anus.  It  is  mingled  with  bile,  and  presents  a  dark 
brown  colour.  Its  odour,  though  foecal,  is  not  putrid.  As  a  general  rule, 
the  more  the  alvine  evacuation  departs  from  its  normal  consistence, 
colour,  and  odour,  the  more  violent  is  the  cause  which  occasions  the 
chano-e.  Thus,  as  regards  consistence,  the  discharge  from  the  bowels 
mav%e  fluid,  though  foeculent,  sometimes  resembling  pea-soup,  the 
characteristic  stools  of  active  typhus.  The  discharge,  again,  may  be 
watery  through  an  excessive  amount  of  serum,  resulting  from  congestion 
of  the  vessels^  or  occasioned  by  saline  and  drastic  cathartics.  In  cholera 
the  discharge  resembles  rice-water,  and  is  largely  mingled  with  pure 
desquamated  epithelium.  It  may  consist  of  shreds  of  glairy  mucus, 
which  is  veiT  common  in  females  with  uterine  disease,  and  sometimes  of 
masses  of  recently  coagulated  exudation,  or  a  substance  like  white  of  egg. 
In  colour  it  may  be  paler  than  natural,  to  such  a  degree  as  to  be  clay- 
coloured  or  almost  white,  indicating  a  diminished  quantity  of  bile.  It 
may  be  red,  reddish-brown,  grass-green,  or  absolutely  black,  from  the 
presence  of  blood,  and  according  as  blood  has  been  poired  into  the 
intestine  more  or  less  near  its  outlet,  or  as  chemical  changes  have 
occurred  in  it  before  being  discharged.  In  other  cases  it  may  be  of  a 
dark  leaden  hue,  or  of  a  dirty  yellow  more  or  less  resembling  pus.  If 
pus  and  blood  appear  in  the  stools  almost  pure,  then  these  fluids  have 
been  poured  out  not  far  from  the  orifice ;  the  more  they  are  mingled 
with  foeculent  or  fluid  matter,  the  more  is  their  origin  distant.  Constant 
fluid  stools  of  a  uniform  colour  are  generally  derived  from  the  small 
intestines.  As  to  odour,  the  more  offensive  and  putrid,  the  greater 
is  the  indication  of  absence  of  bile  in  some  cases,  and  prostration  of  the 
vital  powers  in  others.  In  the  examination  of  the  foeces  the  microscope 
will  be  found  of  the  greatest  service.     (See  p.  83.) 


484 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


The  morbid  anatomy  of  dysentery  and  of  enteritis  generally  is  a  most 
extensive  subject,  for  which  1  must  refer  you  to  the  various  special  works 
which  treat  of  it.  It  will  suffice  to  say  that  the  seat  of  the  exudation  is 
for  the  most  part  the  areolar  texture  below  the  baseinent  membrane,  but 
pressing  principally  on  the  mucous  surface,  and  giving  rise  to  hemorrhages, 
ulcerations,  purulent  discharges,  etc.  If  the  disease  be  chronic,  the 
muscular  coat  becomes  hypertrophied,  causing  thickening  and  rigidity 
of  the  intestinal  tube.  If  violent  gangrene  occur,  the  mucous  surface 
after  death  presents  a  deep  red  colour,  which  is  caused  by  congestion  of 
the  vessels;  sometimes  bright  green  patches  are  mingled  with  the  red, 
and  result  from  alteration  in  the  colour  of  extravasated  blood ;  then 
again,  brown  or  blackish  sloughs  may  be  obsers-ed  from  decomposition 
of  the  injured  texture.  Typhoid  enteritis  will  be  subsequently  described. 
(See  Fever.)  Tubercular  enteritis  is  a  common  complication  of  phthisis, 
generally  hurrying  on  the  fatal  result.  Cancerous  enteritis  is  by  no 
means  uncommon. 

The  structural  changes  observed  in  the  mucous  membrane  in  cases  of 
diarrhoea  and  dysentery  are — 1st,  Degeneration  of  the  epithelium;  2nd, 
Congestion  of  the  vessels  and  hemorrhage ;  3rd,  Exudation ;  4th,  Mor- 
bid changes  in  the  various  glands. 

1.  The  readiness  with  which  the  epithelium  is  separated  from  the 
basement  membrane  of  the  intestinal  mucous  membrane  varies  much  in 
different  animals.  For  instance,  I  have  found  it  to  be  easily  separable  in 
dogs,  while  in  cats  it  is  very  firmly  adherent.  This  circumstance 
explains,  to  a  certain  extent,  the  dift'erent  ideas  put  forth  by  experimen- 
talists as  to  the  function  of  the  epithelium  in  digestion.  Some  maintain 
that  it  is  cast  off  so  as  to  admit  of  endosmose  through  the  naked  villus ; 
whilst  others  maintain  that  endosmose  is  carried  on  through  the  agency 
of  the  epithelial  cells  themselves  in  situ,  which  I  believe  to  be  the  correct 

doctrine.  In  man  the 
epithelial  cells  are  easi- 
ly separated,  and  their 
separation  constitutes 
a  morbid  state  of  great 
importance,  because  if, 
as  I  suppose,  they  be 
t^  the  organs  of  primary 
,^s'■ 


assimilation,  their  re- 
moval must  interfere 
with  nutrition.  This 
I  consider  to  be  one 
of  the  reasons  why 
chronic  diarrhoeas,  and 
more  especially  cho- 
lera, in  which  disorder 
the  rice-water  stools  consist  chiefly  of  serum,  containing  desquamated 


Fig.  409. 


Fig.  409.  Vascular  congestion  and  sugillation  of  the  mucous  membrane  of  the 
small  intestine  in  cholera,  a  and  5,  Congested  tortuous  vessels  in  villi,  which  are 
deprived  of  epithelium  ;  c,  The  veins  only  congested  in  four  viUi ;  d,  Extravasation 
of  )3lood  below  the  basement  membrane,  and  around  the  glands  of  Lieberkuhn 
( Wtdl.)  .  50  diam. 


DISEASES   OF  THE   INTESTINES. 


485 


epitheliura,  are  so  prostrating  to  the  econom)\  Of  course  the  inter- 
ference with  nutrition  so  occasioned  will  be  in  proportion  to  the  extent 
of  mucous  membrane  affected. 

2.  Great  congestion  of  the  vascular  plexus,  which  ramifies  in  the  villi 
and  around  the  glands,  is  one  of  the  most  common  appearances  seen 
after  death  in  the  intestinal  mucous  membrane ;  it  is  often  associated 
with  extravasations  of  blood  more  or  less  extensive.  This  lesion  may  be 
conjoined  with  all  the  others  to  which  this  texture  is  liable,  and  is  at  once 
visible  both  to  the  naked  eye  and  on  mi- 
croscopic observation.  In  all  cases  of  acute 
diarrhtea,  dysentery,  and  in  cholera,  this 
morbid  change  may  be  recognised. 

3.  Exudation  may  occur  below  the  base- 
ment membrane,  infiltrating  the  areolar 
texture  between  it  and  the  mucous  coat,  occu- 
pying the  villus  and  surrounding  the  various 
glan(.ls  ;  or  more  rarely,  it  may  appear  on 
the  surface  of  the  mucous  membrane,  pre- 
senting adherent  coagula.  In  the  former 
case  it  undergoes  the  usual  transformations, 
giving  rise,  according  to  circumstances,  to 
purulent  collections,  fibrous  growths,  or 
ulcerations  varying  in  extent,  which  may 
or  may  not  ultimately  cicatrize.  In  the 
latter  case  the  coagulated  exudation  rarely 
presents  a  fibrillated  structure,  but  rather  a  dense  aggregation  of  fibrinous 
amorphous  substance,  which  disin- 


tegrates or  passes  into  pus.  Within 
the  villi  it  often  assumes  an  opaque 
brownish  colour,  and  passes  into 
gi-anule  cells,  while  the  blood,  which 
has  been  extravasated  or  arrested 
in  the  vessels,  is  transformed  into 
black  pigment  (Fig.  410,  h,  c,  and  d). 
4.  The  morbid  changes  in  the 
various  glands  have  been  more 
especially  studied  in  relation  to  ty- 
phoid fever,  under  which  head  I 
shall  again  refer  to  them.  There 
can  be  no  doubt,  however,  that  the 
glands  of  Brunner  and  Lieberkuhn, 
as  well  as  those  of  Payer,  are  constantly  undergoing  alterations,  pro- 
bably similar  to  those  so  well  described  by  Dr.  Handfield  Jones  in  the 


Fig  410. 


Fio-.  410.  a,  Granular  mass,  in  recent  exudation  on  the  surface  of  the  intestinal 
mucous  membrane;  6,  summit  of  a  villus,  containing  black  pigment,  at  +,  in  a 
vessel;  c,  Summit  of  a  vUlus,  containing  a  brown  exudation;  d,  Another  villus, 
with  the  exudation  transformed  into  granule  cells  and  masses. — (Wedl.)     250  diam. 

Fio-.  411.  An  enlarged  Payerian  sac  from  the  colon  of  a  child,  a,  Glands  of 
Lieberkuhn;  b,  Muscular  layer;  c,  Sub-mucous  tissue;  d,  Transverse  muscles;  e, 
Serous  membrane;  f.  Depression  of  mucous  membrane  over  the  sac,  g.—{KoUiker.) 

50  diam. 


486  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

stomacli,  altliougli  few  histological  and  clinical  researches  have  as  yet 
been  made  regarding  them.  In  children,  in  whom  the  intestinal  mucous 
membrane  is  active  and  easily  irritated,  the  shut  sacs  of  Payer  are  often 
unusually  large,     (Fig.  411.) 

The  treatment  of  ordinary  dysentery,  such  as  we  meet  with  in  this 
country,  may  be  gathered  from  the  cases  recorded.  It  consists,  1st, 
In  careful  regulation  of  the  diet,  which  should  be  imtritivebut  uuirritating; 
2d,  In  confinement  to  bed;  3d,  In  the  use  of  antacids  and  astringents  to 
check  the  discharges ;  and  4th,  In  the  employment  of  leeches,  fomen- 
tations, and  poultices  locally,  and  of  opium  internally  to  relieve  pain 
and  diminish  irritability.  It  should  not  be  forgotten,  however,  that, 
although  in  consequence  of  inflammation  there  may  be  abundant 
diarihoea,  this  may  be  conjoined  with  a  true  constipation ;  in  other 
words,  the  excrement  which  it  is  necessary  for  the  body  to  throw  out, 
may  be  retained  in  the  coecum  or  upper  part  of  the  canal,  in  con- 
sequence of  the  contraction  or  irritability  of  the  canal  lower  down. 
Hence  it  is  necessary  occasionally  to  administer  a  small  dose  of  castor 
oil  or  other  mild  aperient,  to  secure  the  passage  of  effete  matter  from 
the  system,  a  point  in  practice  requiring  great  care  and  experience. 

Derangements  of  the  alimentary  canal  constitute  the  great  majority 
of  children's  diseases.  In  them  this  portion  of  the  economy  is  actively 
engaged,  not  only  in  developing  itself,  but  in  producing,  by  means  of 
digestion  and  assimilation,  an  excess  of  nutritive  materials  for  the  blood. 
During  these  processes  of  evolution,  the  functions  of  the  alimentary 
canal  are  especially  liable  to  be  disordered,  and  frequently,  as  a  result  of 
the  irritations  thereby  occasioned,  various  convulsive  or  diastaltic  affec- 
tions arise.  In  all  such  cases  the  practitioner  should  endeavour  to 
remove  local  irritations  and  support  nutrition.  The  former  object  is 
best  accomplished  by  antacid  medicines,  especially  chalk  and  magnesia, 
and  occasionally  a  mild  aperient,  such  as  castor  oil ;  the  latter,  by  careful 
attention  to  the  diet,  procuring  a  healthy  nurse,  etc.  The  constant  flow 
of  saliva  during  dentition,  the  vomitings  from  over-distension  of  the 
stomach,  and  occasional  diarrhoea  in  weak  children,  are  often  salutary 
discharges,  which  only  require  watching  and  hygienic  regulation,  and 
will,  it  is  hoped,  no  longer  be  mistaken  for  symptoms  of  an  active 
inflammation  which  require  antiphlogistic  remedies. 


Case   LXXVII.* — Obstruction  of  the   Large   Intestine — Cancer  of  Stomach,   Liver, 
Peritoneum  generally,  and  Mesenteric  Glands. 

History. — James  Sturgeon,  a;t.  21,  tax  collector — admitted  into  the  Clinical 
"Ward  of  the  Royal  Infirmary,  September  14,  1853.  He  noticed  for  the  first  time 
last  January  tliat  his  appetite  had  diminished,  and  that  he  was  greatly  troubled  with 
flatulence,  vomiting,  and  constipation.  These  symptoms  continued  until  three 
months  ago,  when  the  abdomen  became  swollen,  and  gradually  so  distended,  that 
he  applied  to  Dr.  Alison,  under  whose  treatment  the  vomiting  nearly  disappeared. 
He  then  noticed  several  hard  lumps  in  the  abdomen,  varying  in  size  from  a  walnut 

*  Reported  by  Mr.  "Wm.  Calder,  Chnical  Clerk. 


DISEASES   OF   THE   INTESTIXES.  487 

to  a  hen's  egg.     These,  since  then,  have  continued  to  increase  in  size,  and  have 
become  very  painful  on  pressure. 

Progress  of  the  Case. —  October  2Qlh. — Since  his  admission  the  appetite  has 
been  gradually  failing,  and  he  has  become  daily  thinner  and  weaker.  He  has  expe- 
rienced considerable  pain  in  the  abdomen,  combined  with  a  feehng  of  tightness  and 
constriction  there.  It  has  always  felt  tense,  and  contained  more  or  less  fluid,  but 
until  a  fortnight  ago,  the  tumours  formerly  mentioned  could  be  felt  veiy  distinctly, 
separated  from  the  walls  of  the  abdomen  by  a  thin  layer  of  fluid.  The  bowels  have 
been  greatly  constipated.  Tlie  treatment  has  consisted  in  the  administration  of 
diuretics  of  every  kind,  with  strong  purgatives,  enemata,  warm  fomentations  to  the 
abdomen,  and  occasionally  anodyne  draughts  at  night.  On  taking  charge  of  this 
patient  to-day  I  found  his  condition  as  follows : — Great  emaciation ;  complexion  of  a 
cachectic  waxy  appearance;  skin  cold  and  dry;  tongue  moist,  with  a  browTiish  fur; 
breath  offensive;  very  little  appetite;  only  occasional  vomiting;  and  no  thirst. 
Bowels  have  not  been  opened  for  four  days,  a  draught  of  castor-oU  with  a  drop  of 
croton-oil  having  merely  brought  away  a  few  hard  lumps  of  foeces  of  a  dark  colour. 
Purgatives  do  not  cause  griping.  The  abdomen  is  greatly  enlarged,  and  tense,  but 
with  a  distinct  feeling  of  fluctuation.  Xo  tumours  can  now  be  felt,  but  during 
inspiration  distinct  friction  can  be  felt  by  the  hand,  and  heard  by  means  of  the 
stethoscope.  Pressure  only  causes  a  trifling  obscure  amount  of  pain,  but  his  chief 
complaint  is  from  the  sense  of  constriction.  The  pulse  is  70 ;  regular  and  feeble. 
A  murmur  is  audible  with  the  first  sound  of  the  heart,  at  the  base ;  action  is  regu- 
lar; no  palpitation.  There  is  dry  cough  and  slight  dyspnoea.  The  respiratory 
sounds  are  feeble,  but  otherwise  seem  natural.  Urine  healthy.  From  this  time  he 
gradually  sank.  (Edema  appeared  in  the  inferior  extremities ;  vomiting  became 
more  severe,  and  at  length  constant,  whenever  food  or  drink  was  taken.  AU  kinds 
of  medicines  failed  even  as  palliatives ;  emaciation  became  extreme,  and  he  sank 
November  5,  the  bowels  having  been  obstinately  closed  for  ten  days. 

Sectio   Cadaveris. — Forty  hours  after  death. 

Thorax. — Pulmonary  tissue  everj^-here  spongy  and  crepitant.  On  the  superior 
lobe  of  the  left  lung  there  were  two  cicatrices,  and  on  the  right  pulmonary  pleura 
there  were  similar  patches,  more  widely  scattered,  extending  over  the  whole  of 
superior,  middle,  and  inferior  lobes.  Purulent  mucus  was  easily  pressed  from  seve- 
ral of  the  bronchi.  No  carcinomatous  nodules  were  found  in  tlie  pulmonary  tissue 
but  the  whole  intercostal  pleura  was  studded  over  with  small  irregular  plates  of 
cancerous  exudation,  bearing  a  considerable  resemblance  to  the  eruption  of  small- 
pox. Heart  small ;  muscular  substance  pale  fawn-coloured.  The  pericardium 
shows  on  its  external  surface  numerous  cancerous  nodules  from  the  size  of  a  pin's 
head  to  that  of  a  smaU  flattened  coffee  bean.  Bronchial  glands  at  the  root  of  luno- 
swollen,  some  of  them  the  size  of  a  pigeon's  egg ;  all  infiltrated  with  cancer,  and 
some  mingled  with  black  pigment. 

Abdomen. — The  hver  was  smooth  on  its  surface.  Inferiorly  and  laterally  it  was 
closely  adherent  to  the  diaphragm,  the  pleural  surface  of  which  was  covered  by 
laminae  of  cancerous  matter.  On  stripping  off  the  diaphragm  tlie  peritoneal  coverino- 
of  the  liver  was  seen  infiltrated  with  cancer,  in  some  places  to  the  depth  of  half  an 
inch.  Substance  of  liver  presented  the  usual  appearance  of  the  white  tubercle  of 
Farre ;  it  was  pale,  soft,  and  very  fatty.  The  spigelian  lobe  of  the  liver,  the  omen- 
tum, epigastric  glands,  spleen,  and  pancreas  were  united  together,  and  formed  a 
large  irregular  whitish  mass  extending  across  the  abdomen,  and  weigliing  4  lbs. 
This  mass  formed,  on  the  right  side,  a  dense  wedge  pressing  in  the  right  iliac  fossa 
upon  the  ascending  colon  immediately  as  it  leaves  the  coecum ;  this  bowel  was  fiUed, 


DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

but  not  distended,  with  firm  yellow  feces,  but  the  ascending,  descending,  and  trans- 
verse colon  were  empty  and  collapsed.  The  peritoneum  covering  the  intestine  was 
dotted  all  over  with  nodular  projecting  masses,  varying  in  size  from  a  millet  seed  to 
a  hazel  nut,  in  colour  from  white  to  deep  red,  and  even  almost  black,  and  in  con- 
sistence from  soft  pulpy  matter  to  nodules  considerably  indurated.  The  whole  of 
the  abdominal  peritoneum  was  closely  covered  with  similar  irregular  nodules,  for 
the  most  part  of  soft  consistence,  with  here  and  there  a  little  coagulated  blood. 
There  were  two  gallons  of  sanguineous  serum  in  the  peritoneal  cavity.  Spleen 
small,  but  healthy;  it  was  closely  adherent  to  the  diaphragm  above  and  the  can- 
cerous mass  below,  and  on  section  seemed  to  be  surrounded  by  a  thin  layer  of  cancer 
infiltrated  in  the  peritoneum  superiorly,  while  mferiorly  the  cancerous  mass  all  round 
it  is  1-J  inch  in  tliickness.  Stomach  imbedded,  and  also  compressed,  in  the  cancerous 
mass  which  was  everywhere  adherent  to  its  peritoneal  surface.  Its  mucous  mem- 
brane, as  well  as  that  of  the  alimentary  canal,  was  quite  healthy.  On  section  of 
the  mass  it  presented  the  uniform  appearance  of  white  lard,  giving  to  the  finger  a 
feeling  of  considerable  firnmess.  It  yielded  no  cancerous  juice,  but  was  friable,  rea- 
dily breaking  down  under  pressure. 

Microscopic  Examination. — The  whole  of  the  cancerous  exudation  on  the  peri- 
toneum exhibited  numerous  cancer  cells  in  some  places  mingled  witii  fibres,  in  others 
associated  with  numerous  oil  granules  and  granular  cells.  The  wliite  masses  on  the 
pleuraj  were  principally  composed  of  fibres,  but  on  the  addition  of  acetic  acid  might 
be  seen  to  be  crowded  with  cancer  nuclei. 

Commentary. — In  tins  case  it  was  observable  that  the  vomiting  did 
not  occur  regularly  after  taking  food,  and  that  the  ejected  matters  con- 
sisted of  the  ingesta,  and  were  never  mixed  with  recently  extravasated 
or  altered  blood.  This  indicated  tliat  no  ulcer  or  erosion  of  the  stomach 
had  taken  place.  That  the  peritoneum  and  mesenteric  glands  were  the 
principal  textures  involved,  was  indicated  by  the  nodular  swellings  felt, 
and  the  friction  sound  audible  over  the  peritoneum,  and  the  abdominal 
distension  from  accumulation  of  fluid.  The  continued  constipation  also 
indicated  some  mechanical  contraction  of  the  gut,  obviously  owing  to 
cancerous  deposition  in  some  way  pressing  on  or  constricting  it, — all 
which  suppositions  were  proved  to  be  correct  on  examination  of  the 
body  after  death. 

Case  LXXVIII.* — Strangulation  of  the  Small  Intestine  from  Inguinal  Hernia — Gan- 
grene, Ulceration,  and  Perforation  of  the  Intestine — Peritoriitis. 

History. — Margaret  Bruce,  set.  47 — admitted  September  25th,  1848.  Says  that 
she  has  occasionally  had  a  swelling  in  the  left  groin  for  the  last  nine  years,  that  has 
always  gone  away  on  Ipng  down  and  applying  warm  fomentations.  On  the  18th, 
while  carrying  a  large  bucket  of  water  up  stairs,  she  felt  something  give  way  in  the 
left  groin.  On  the  following  morning  she  suddenly  awoke  with  rigors,  shortly  fol- 
lowed by  nausea  and  vomiting.  The  left  groin  also  felt  painftd,  and  she  perceived 
a  tumour  there  the  size  of  a  man's  fist.  Purgatives  were  now  taken  without  causing 
any  action  of  the  bowels.  The  vomiting,  iiowever,  became  more  intense,  and  the 
matter  ejected  more  of  a  dark  brown  colour.  In  this  condition  she  has  continued 
ever  since. 

Symptoms  on  Aumission. — On  admission  she  lay  on  her  back,  with  the  thighs 

*  Reported  by  Mr.  T.  N.  Fanning,  Clinical  Clerk. 


DISEASES   OF   THE   INTESTINES.  489 

flexed  on  the  abdomen.  The  countenance  was  sharp,  sallow,  and  expressive  of 
great  suffering.  Extremities  cold.  Pulse  120,  small  and  weak.  Respiration  diflQ- 
cult,  especially  during  inspiration.  Percussion  and  auscultation  of  the  chest  elicit 
nothing  abnormal.  Tongue  white,  but  red  at  the  top  and  edges.  Bowels  have  not 
been  opened  for  eight  days,  and  there  is  frequent  vomiting  of  matter  like  coffee. 
Skin  of  abdomen  is  hot  and  distended,  and  she  complams  of  great  pain  in  the  umbiU- 
cal  and  left  ihac  regions  on  the  slightest  touch.  A  fluctuating  tumour,  the  size  of  an 
orange,  occupies  the  left  groin,  over  Poupart's  ligament.  Urine  scanty  but  normal. 
Menstruation  has  been  irregular.  Other  functions  normal.  Mr.  Sj-me  was  consulted, 
who  opened  the  tumour,  from  which  there  was  evacuated  about  3  v.  of  foetid  serum, 
mixed  with  dirty  yellow  purulent  matter.  Warm  fomentations  to  he  applied  to  the 
abdomen.  To  have  one  grain  of  opium  in  the  form  of  pill,  immediately.  In  the  even- 
ing the  symptoms  were  the  same,  with  the  exception  of  tlie  abdominal  pain,  which 
is  more  violent,  and  appears  as  if  she  was  cut  with  a  sharp  instrument.  Has  had 
three  injections  of  warm  water,  which  return  unaltered.  To  have  Pulv.  Opii,  gr.  ij. 
every  hour. 

Progress  of  the  Case. — September  26ih. — No  change.  The  opium  produces  no 
effect  whatever.  Strong  beef  tea  to  be  taken  in  small  quantities.  To  eat  as  much  ice 
as  she  pleases.  Sept.  Tith. — Vomiting,  abdominal  pain,  and  intestinal  obstruction,  con- 
tinue. Abdomen  considerably  swollen.  Sore  in  the  left  groin  looks  very  unhealthy. 
Thirst  and  dryness  of  the  lips  and  fauces  are  much  reheved  by  the  pieces  of  sohd  ice. 
Has  taken  opium  in  three  grain  doses  every  second  or  third  hour,  which  has  caused 
apparently  no  effect  whatever,  Sept.  29tt.— Vomited  matters  to-day  are  distmctly 
foeculent.  The  abdomen  above  the  umbilicus  and  in  left  flank  is  greatly  swollen, 
very  tender,  and  tympanitic ;  over  the  right  lower  third  it  is  collapsed.  A  dirty 
sanious  discharge  is  poured  from  the  wound  in  left  groin.  Pulse  110,  very  small  and 
weak.  Tongue  brown  and  dry.  Quite  sensible,  but  much  exliausted.  Utters  low 
moans,  and  complains  principally  of  dryness  of  mouth  and  throat,  which  continues  to 
be  relieved  by  the  ice.  Bowels  continue  closed.  To  have  a  tablespoonful  of  wine  and 
beef-tea  every  hour,  and  §  viij  of  beef-tea  injected  into  the  boivels  slowly,  night  and  morn- 
ing. Pulv.  Opii,  gr.  iij.  to  be  given  only  at  night.  Sept.  30!'ft.— The  discharge  from 
the  groin  to-day  is  foeculent,  as  well  as  the  vomited  matters.  Complains  of  no  pam, 
but  there  is  commencing  dehrium.  Pulse  100,  scarcely  to  be  felt.  Prostration 
extreme.     Distension  of  abdomen,  and  other  symptoms  the  same.     Died  October  1st. 

Sectio  Cadaver  is. —  Thirty-six  hours  after  death. 

Body  pale  and  emaciated.  Over  Poupart's  ligament  was  an  oval  ulcer,  measuring 
an  inch  and  a  half  in  its  longest  diameter,  which  was  slightly  oblique  from  above 
downwards.  Its  base  was  superficial,  of  a  brownish-black  colour,  and  foeculent 
odour. 

Thorax. — Slight  chronic  adhesions  between  pleurje  on  right  side.  Lungs  some- 
what emphysematous  anteriorly.     Thoracic  organs  otherwise  healthy. 

Abdo-VIEX.— On  opening  the  abdominal  cavity,  the  hver,  stomach,  and  intestines 
superiorly,  were  seen  to  be  covered  by  a  uniform  membranous  expansion  of  lymph. 
The  remainder  of  the  intestines  and  the  uterus  were  matted  together,  and  bound 
down  to  the  left  side  of  the  pelvis,  leaving  a  considerable  cavity  in  the  right  side, 
which  was  occupied  by  about  a  pint  of  dirty  reddish-brown  fluid,  possessing  a  strong 
foeculent  odour.  On  separating  the  intestines,  a  knuckle  of  the  ileum,  in  its  upper 
thhd,  was  found  to  be  strangulated  in  the  left  inguinal  ring,  presenting  externally 
to  it,  and  forming  the  base  of  the  ulcer,  two  soft  prominent  projections.  On  the 
summits  of  these  were  two  ragged  ulcers  perforating  the  gut.  Into  the  superior  of 
these  a  probe  only  passed  a  few  lines ;  into  the  mferior  it  readily  passed  into  the 


490  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

dilated  and  upper  portion  of  the  intestine.  The  duodenum,  jejunum,  and  three  or 
four  feet  of  the  ileum,  up  to  the  point  of  strangulation,  were  greatly  distended  with 
flatus  and  fluid  foeces,  resembling  that  found  in  the  right  side  of  the  peritoneal  cavity. 
The  smaU  and  large  intestines  below  tlie  strangulation  were  eoUapsed  and  apparently 
contracted  About  eight  inches  from  the  strangulation,  in  the  upper  part  of  the  gut^ 
was  an  ulcer  the  size  of  a  halfpenny,  with  two  perforations  in  its  centre,  each  about 
the  size  of  a  goose's  quill,  through  which  fluid  foeces  had  escaped  into  the  peritoneal 
cavity.  For  about  eighteen  inches,  extending  from  the  strangulation,  the  ileum  was 
of  a  dark  mahogany,  and  in  the  centre,  as  well  as  near  the  strangulation,  of  a  claret 
colour,  evidently  gangrenous.  The  rest  of  the  intestines  and  other  abdominal  organs 
were  lieallhy  in  texture.  The  gall-bladder  was  distended  with  tenacious  bile  having 
the  appearance  of  tar. 

Commentary. — In  this  case  the  intestine  had  been  stranQ;nlated  in  the 
inguinal  ring  seven  days  previous  to  admission,  and  the  svmptoius  on 
her  coming  into  the  house  were  not  only  those  of  intestinal  obstruction, 
but  of  peritonitis  also.  Purgatives  had  been  administered  before  she 
came  in.  Mr.  Syme  recognised  an  abscess  which  was  opened  without 
causing  relief,  external  to,  and  covering  the  hernia.  In  the  evening, 
peritonitis,  with  symptoms  of  perforation,  was  more  unocjnivocallv  pro- 
nounced, and  the  case  became  hopeless.  Large  doses  of  opium  failed  to 
relieve  the  pain.  Ileus  was  established  on  the  11th,  and  an  artificial 
anus  on  the  13th  day,  withont  relief — gangrene  and  perforation  of  the 
intestine  having  caused  escape  of  foeces  into  the  peritoneum,  and  of 
course  death. 

The  two  cases  previously  given  exemplify  two  modes  in  which  the 
intestinal  canal  may  become  permanently  obstructed,  viz.,  by  morbid 
growths  compressing  it  from  without,  and  by  the  sti'angulation  of  a 
hernial  protrusion.  An  instance  of  internal  obstruction  from  a  band  of 
Ivmph  acting  as  a  ligature,  and  constricting  the  gut,  will  be  found  under 
the  head  of  Ovarian  Dropsy.  (Case  of  Jessie  Fleming.)  A  variety  of 
other  causes  may  also  occasion  permanent  obstruction,  such  as  invagina- 
tion, accumulation  of  foeces  or  foreign  bodies,  and  calculi  impacted  in  the 
tube,  intiammation,  gangrene,  paralysis,  etc.  In  most  of  these  cases  dis- 
tension of  the  upper  and  corresponding  collapse  of  the  inferior  portion  of 
the  intestine  occur,  followed  at  length  by  ulceration  or  rupture,  occasion- 
ing fatal  peritonitis.  Vomiting  is  a  common  symptom  of  permanent 
obstruction,  and  when  the  disease  is  far  advanced,  the  foeces  are  pro- 
pelled backwards,  and  rendered  by  the  mouth,  constituting  ileus,  as  in 
Case  LXXMII. 

The  pathology  of  this  anti-peristaltic  action  of  the  tube  has  been 
much  discussed,  more  especially  as  to  whether  it  be  owing  primarily 
to  spasmodic  contraction,  or  to  paralysis.  In  all  such  cases  it  has 
been  found  that  one  portion  of  the  intestine  has  been  over-distended, 
and  another  collapsed,  and  thus,  even  though  a  mechanical  obstruction 
does  not  exist,  a  portion  of  the  tube  may  be  inflamed,  and  even  gan- 
grenous, giving  rise  to  ileus,  without  the  passage  being  actually  closed.* 
In  these  cases  the  cause  of  the  obstruction  producing  ileus  is  not  easy 

*  See  Abercrombie  on  Diseases  of  the  Stomach  and  Abdominal  Viscera. — Cases 
XXX.,  xxxi.  and  xxxvi. 


DISEASES   OF   THE   INTESTINES.  491 

to  determine;  but  the  reasoning  of  Abercrombie  on  tbis  point  bas 
always  appeared  to  me  so  good,  tbat  I  sball  quote  it  in  bis  own  words. 
"If  we  suppose,  tben,  tbat  a  considerable  tract  of  tbe  canal  is  in  a 
collapsed  state,  and  tbat  a  mass  of  alimentary  matter  is  propelled  iuto 
it  by  tbe  contraction  of  tbe  parts  above,  tbe  series  of  actions  wbicb 
will '  take  place  will  probably  be  tbe  following : — When  a  portion, 
wbicb  we  sbjdl  call  Xo.  1,  is  propelling  its  contents  into  a  portion 
Xo  2,  tbe  force  exerted  must  be  such,  as  both  to  propel  these  contents, 
and  also  to  overcome  tbe  tonic  contraction  of  Xo.  2.  The  portion 
Xo.  2  tben  contracts  in  its  turn,  and  propels  the  matter  iuto  Xo.  3  ; 
this  into  Xo.  4,  and  so  on.  Xow,  for  this  process  going  on  in  a  healthy 
manner,  it  is  necessary  that  each  portion  sball  act  in  consecutive  har- 
mony with  the  other  portions ;  but  there  appear  to  be  several  ways  in 
which  we  may  suppose  this  harmony  to  be  interrupted;  (Is/)  If  the 
portion  Xo.  1  has  contracted  and  propelled  its  contents  into  Xo.  2,  and 
Xo.  2  does  not  contract  in  its  turn,  the  function  of  the  whole  will  be 
to  a  certain  extent  interrupted,  and  tbe  contents  will  lodge  in  Xo.  2 
as  in  an  inanimate  sac.  The  parts  above  continuing  to  act  downwards, 
one  of  two  results  will  now  take  place  :  either  the  parts  above  will  be 
excited  to  increased  contraction,  and  tbe  matters  will  be  forced  through 
into  Xo.  3,  independently  of  tbe  action  of  Xo.  2,  and  so  the  action  be 
continued ;  or,  new  matter  being  propelled  into  X'o.  2,  this  will  be 
more  and  more  distended,  until  an  interruption  of  a  very  formidable 
nature  takes  place  in  the  function  of  the  canal.  (2d.)  If,  in  the  series 
of  actions  now  referred  to,  Xo.  2  conti-acts  in  its  turn,  while  some 
obstacle  exists  to  tbe  free  dilatation  of  Xo.  3,  it  is  probable  tbe  motion 
may  be  so  inverted,  that  tbe  contraction  of  Xo.  2  may  dilate  Xo.  1, 
and  that  the  action  may  thus  be  communicated  backwards.  In  the 
state  of  parts  here  referred  to,  varieties  may  occur,  which  appear  to 
give  rise  to  important  differences  in  tbe  phenomena.  The  obstruction 
to  the  dilatation  of  X'o.  3  may  exist  in  various  degrees ;  in  a  smaller 
deo-ree,  it  mav  not  prevent  it  from  acting  in  barmonj'  with  other  parts, 
when  the  quantity  of  contents  is  small,  and  only  a  small  degree  of 
dilatation  is  required ;  but,  when  there  is  an  increased  distension  of 
the  parts  above,  either  from  increase  of  solid  contents,  or  from  some 
accidental  accunmlation  of  flatus,  tben  a  greater  degree  of  expansion 
mav  be  required  than  Xo.  3  is  capable  of,  and,  in  tbis  manner,  inter- 
ruption mav  take  place,  to  tbe  harmonious  action  of  tbe  canal.  It  is 
probably  in  this  manner  tbat,  in  connection  with  slight  organic  affec- 
tions of  the  canal,  we  find  tbe  patient  liable  to  attacks  of  pain  and 
other  concomitant  symptoms,  which  at  first  occur  only  at  long  and 
uncertain  intervals,  but  at  length  terminate  in  fatal  ileus." 

Tbe  treatment  of  intestinal  obstruction,  however  it  originates,  must 
always  be  a  matter  of  anxious  consideration.  At  first  it  is  more  or  less 
diflicult  to  determine  whether  there  be  only  an  obstinate  constipation, 
which  may  be  overcome  by  purgatives,  or  whether  there  be  a  mechani- 
cal obstruction,  rendering  them  useless  and  perhaps  dangerous.  Under 
these  circumstances,  I  think  one  full  purgative  at  least  should  always 
be  wiven  as  a  rule,  for  the  simple  reason,  that  not  only  may  its  action 
overcome  many  forms  of  simple  obstruction,  but  because  without  it  no 
one  can  determine  whether  or  not  there  is  an  obstruction  at  all.      As 


492  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

soon,  however,  as  it  becomes  evident  with  what  we  have  to  do,  all 
attempts  to  stimulate  the  action  of  the  canal  should  cease,  and  we 
must  have  recourse  to  anodynes  to  diminish  spasm,  lessen  iiTitability, 
and,  if  possible,  cause  relaxation.  Surgical  means  may  be  had  recourse 
to,  if  the  nature  of  the  case  admit  of  them,  and  operations  performed 
with  a  view  of  relieving  the  strangulation  or  extracting  any  impacted 
mass ;  and  the  colon  may  be  dilated  with  air  or  fluid,  by  means  of  long 
tubes.  These  important  points,  however,  are  so  purely  surgical,  that  I 
need  not  dwell  upon  them  here. 


INTESTINAL  WORMS. 

The  observations  of  recent  helminthologists,  but  more  especially  of 
Siebold,  Van  Beneden,  Dujardin,  Leuckart,  Steenstrup,  and  Blanchard, 
have  cleared  away  the  mystery  which  so  long  hung  over  the  origin  of 
tape-worms  and  other  entozoa.  It  seems  now  determined  that  tape- 
worms are  only  farther  stages  of  development  of  Cysticerci,  as  flukes 
are  only  farther  stages  in  growth  of  certain  Cercaria3.  This  important 
fact  is  a  result  of  the  researches  now  everywhere  prosecuted  with  so 
much  zeal  by  anatomists  and  physiologists  in  embrvologv,  and  fi'ora 
which  it  has  resulted  that  many  animals  hitherto  considered  altogether 
distinct  species,  bear  the  same  relation  to  each  other  as  a  caterpillar 
does  to  a  butterfly. 

Professor  Siebold  first  pointed  out  that  the  Cysticercus  fasciolaris 
found  in  the  liver  of  the  mouse,  reaches  its  ultimate  stage  of  develop- 
ment in  the  intestines  of  the  cat,  and  is  there  transformed  into  the 
Tcenia  crassicollis.  This  fact  was  confirmed  by  a  careful  series  of 
observations  made  by  Dr.  Henry  Nelson,  who,  in  his  thesis  presented 
to  this  University  in  1850,  carefully  traced  and  figured  all  the  various 
stages  which  the  tape-worm  of  the  cat  passes  through.  Each  joint  of 
this  worm  is  estimated  to  contain  125,000  ova,  which  gives  for  the 
entire  animal  about  12,500,000.  These  minute  bodies  pass  off"  by  the 
fcEces  in  incalculable  numbers,  and  enter  the  body  of  the  mouse  mixed 
with  its  food  or  drink,  or  by  licking  its  furry  coat,  to  which  they 
adhere.  From  the  aliinentary  canal  of  the  mouse  they  may  enter  the 
liver  of  that  animal  in  three  ways:  1st,  They  may  ascend  the  bile 
ducts.  2dly,  They  may  pass  through  the  coats  of  the  intestine,  and 
penetrate  the  adjoining  portion  of  the  liver.  3dly,  They  may  bore 
their  way  into  one  of  the  mesenteric  veins,  and  be  carried  by  tlie  blood 
along  the  vena  porta  to  the  liver.  Dr.  Nelson  considers  the  last  to 
be  the  most  correct  view,  for,  as  he  shows,  the  ova  are  furnished  with 
temporary  teeth,  which  enable  them  to  pierce  the  tissues.  That  they 
do  not  perforate  the  intestine,  and  &o  get  into  the  liver,  is  shown  by 
the  fact  that  they  are  most  developed  on  the  surface  of  that  organ,  and 
least  so  in  its  interior.  Neither  are  they  found  especially  in  the  biliary 
ducts,  like  the  Dintomafa,  Hence  the  blood-vessels  seem  to  be  the 
channel  of  their  introduction — an  idea  still  further  supported  by  facts, 
the  number  of  which  is  rapidly  augmenting,  which  demonstrate  the 
presence  of  entozoa   in   various   stages  of  development   in  the  blood 


INTESTINAL  WORMS.  493 

itself.  Arrived  at  the  liver,  these  ova  are  transformed  into  Cysticerci 
fasciolares,  and  would  never  proceed  further  in  development  in  the 
mouse ;  but  being  eaten  by  the  cat,  they  become  tape-worms,  and  are 
developed  into  Tcenice  crassicolles. 

This  series  of  observations  renders  it  probable,  that  all  the  various 
kinds  of  Taenia  are  only  different  Cysticerci  in  advanced  stages  of 
development.  Dr.  Xelson  points  out  that  "  the  head  of  the  Ci/sticercus 
cellulosus  resembles  in  every  respect  that  of  the  Tcenia  solium  of  man. 
The  two  figures  given  by  Bremser  are  identical,  if  we  allow  for  stretch- 
ing of  the  neck  in  the  latter.  Both  have  a  double  circle  of  hooks,  and 
although  the  Tcenia  solium  is  sometimes  found  without  any  teeth, 
Bremser  has  fully  proved  that  this  is  the  result  of  age,  and  not  the 
original  condition.  He  also  observed  that  as  the  worm  increased  in 
age,  one  row  of  the  double  corona  first  fell  otf,  and  was  after  a  time  fol- 
lowed by  the  other,  leaving  the  worm  thus  unarmed.  The  size  of  the 
head  in  both  are  similar,  as  also  are  the  attenuated  neck,  and  the  gradu- 
ally increasing  body."  Besides,  man  feeds  on  animals  in  which  these 
Cysticerci  ai'e  common,  especially  on  the  pig  and  sheep;  and  it  has 
been  observed  that,  in  countries  where  meat  is  often  eaten  raw,  as  in 
Abyssinia,  tape  worms  are  very  common.  The  reason  of  the  rare  occur- 
rence of  Ta?nia  in  civilized  countries,  is  probably  owing  to  the  cookino- 
of  food,  which  destroys  the  vitality  of  the  Cysticerci.  Verv  thorouo-h 
curing  or  salting  meat  also  appears  to  produce  the  same  efiect.  How- 
ever, it  may  easily  be  conceived,  that  owing  to  meat  being  verv  under- 
done, or  to  the  tenacity  of  Hfe  in  certain  of  these  creatures  (and  manv  of 
theni  resist  a  high  temperature  without  injury),  they  mav  occasionally 
escape  the  action  of  the  teeth,  anrive  living  in  the  human  stomach,  and 
be  converted  into  young  Tsenise, 

These  ideas  with  regard  to  the  origin  of  tape-worms  have  been  con- 
verted into  certainties  by  the  experiments  of  Dr.  Kuchenmeister,  first 
recorded  in  the  Prague  Vierteljahrschrift  (Band  i.  185'2,  p,  126).  He 
fed  dogs  and  cats  upon  parts  of  animals  which  contained  difterent  kinds 
of  Cysticerci,  and  subsequently  found  the  tape-worms  into  which  these 
had  been  transformed  in  various  stages  of  development,  accordincr  as  the 
life  of  the  animal  who  had  eaten  the  Cysticerci  had  been  more  or  less 
prolonged  afterwards.  Every  precaution  seems  to  have  been  used  in 
these  experiments,  one  of  which  may  be  cited : — An  old  dog,  durino-  a 
period  of  from  six  to  eight  weeks,  was  fi-equently  purged  witlT  castor  oil, 
so  as  to  prevent  the  possibility  of  tape-worms  being  present.  On  the 
18th  of  March,  1851,  he  ate  food  containing  ten  Cysticerci ;  on  the  25th 
he  ate  as  many  more ;  and  on  the  1st  of  April,  several  others  which  were 
not  numbered.  On  the  10th  of  April  the  dog  was  killed,  and  thii-tv- 
five  Taeniae  were  found  in  the  intestines,  of  which  five  were  from  124  to 
390  millimetres  (from  about  5  to  15  inches)  in  length,  and  possessed 
from  ]  30  to  160  joints.  There  were  six  others,  from  25  to  96  millimetres 
(1  to  5  inches)  in  length,  having  from  40  to  60  joints.  There  were  21 
others,  which  measured  from  8  to  16  millimetres  {\  to  \  an  inch)  in 
length,  in  which  the  joints  were  so  indistinct  that  thev  could  not  be 
counted.  Lastly  there  were  three,  measuring  from  4  to  5  millimetres 
(J-th  of  an  inch)  in  length,  in  which  the  joints  could  scarcely  be  dis- 
tinguished.    Considering  the  power  of  contraction  and  elongation  pos- 


4:94:  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

sessed  by  these  worms,  their  length  was  not  so  decided  a  character  of 
their  stage  of  development,  as. the  size  of  the  head  and  hooks,  which 
corresponded  to  the  three  periods  in  which  the  Cysticerci  had  been 
swallowed.  Similar  results  have  since  been  obtained  in  cats;  and  even 
in  a  man,  a  condemned  criminal,  to  whom  Ki;chenmeister  gave  Cysticerci 
in  broth,  and  found  tape-worms  in  his  intestinal  canal  after  death. 

On  feeding  dogs  upon  the  liver  of  the  mouse,  containing  the  C. 
fasdolaris,  Dr.  Kuchenmeister  never  found  Tsenise  in  the  intestines. 
But  when  he  fed  cats  on  the  same  liver,  the  intestines  contained  the 
Tcenia  crassicollis.  This  observation  indicates  that  not  only  are  certain 
Cysticerci  transformed  into  certain  Tanife,  but  that  tlie  former  can  only 
undergo  this  transformation  in  certain  habitats,  or  in  peculiar  animals. 
Although  the  present  amount  of  our  knowledge  does  not  enable  us  to 
state  from  what  kinds  of  Cysticerci  many  species  of  Taenia  are  formed,  it 
seems  probable,  from  the  observations  of  Siebold,  Nelson,  and  Kuchen- 
meister, that  the  Cysticercus  fasciolaris  of  the  mouse  is  transformed  into 
the  Taenia  crassicollis  of  the  cat;  the  C.  plslformis  of  hares  and  rabbits 
into  the  T.  crassiceps  of  the  fox ;  the  C.  tenuicollls  of  ruminantia  and 
squirrels  into  the  T.  serrata,  so  common  in  the  dog ;  and  the  C.  cellu- 
losus  of  the  pig,  sheep,  and  rabbit,  into  the  Tcenia  solium  of  man.  It  is 
also  tolerably  certain,  from  the  observations  of  Eschricht,  that  the 
Bothriocephalus  latus  found  in  man  in  certain  countries,  especially  in 
Russia,  is  the  further  development  of  a  species  of  Lhjula,  which  exists  in 
large  numbers  in  the  flesh  of  the  dorse,  and  other  fish  of  the  northern 
seas. 

Numerous  instances  have  occurred,  especially  in  India,  where  men 
encamped  on  the  borders  of  a  lake  have  subsequently  been  attacked  by 
tape-worm,  evidently  in  consequence  of  the  water  they  consumed  con- 
taining the  ova  of  the  worm.  The  parasite  also  has  been  known  to 
infect  Hindoos  who  have  eaten  no  flesh.  There  can  be  little  doubt, 
therefore,  that  the  numerous  ova  of  tape-worms  voided  by  animals  may 
enter  the  intestines  of  man  with  the  food  or  drink,  and  there  be  trans- 
formed into  Taenia?.  This  direct  mode  of  entry  must  not  be  overlooked 
while  investigating  the  undoubted  origin  of  the  worm  fi'om  its  cystic 
stage  of  transformation  in  the  tissues  of  other  animals.  Dr.  Fleming 
considers  that  the  frequency  of  measly  pork  in  Ireland  is  due  to  the  pig 
being  reared  in  the  peasant's  cabin,  where  it  has  commonly  a  dog  for  its 
companion,  which  animal  is  almost  always  infected  with  tape-worm,  and 
must  void  a  multitude  of  minute  ova  that  find  ready  access  to  the  ali- 
ment of  the  other.  "  Experiment  shows,"  he  says,  "  that  the  '  measle' 
is  generated  in  the  muscle  of  the  pig  by  feeding  it  with  ripe  joints  of 
the  dog's  tape-worm  (the  Tcenia  serrata,  now  considered  to  be  the 
same  as  the  Tcenia  solium  or  human  tape-worm),  and  that  the  same 
tape-worm  is  developed  in  the  intestines  of  a  dog  fed  with  fresh  measly 
pork.  The  measle  is  not  generated  in  the  dog  by  feeding  it  with  the 
tape-worm  eggs."'"  Why  in  some  animals  these  ova  are  fully  developed 
into  Taeniaj  in  the  intestines,  whilst  in  others  they  enter  the  blood  and 
are  transformed  only  into  Cystic  worms  in  the  liver,  brain,  or  other 
organs,  is  probably  owing  to  peculiarities  of  structure  which  have  not 
yet  been  investigated. 

*  Dublin  Quarterly  Journal  of  Med.  Science.     Feb.  1857. 


IXTESTIXAL   WORMS.  495 

The  importance  of  the  head  of  tape-worms,  so  long  recognised  by 
practical  physicians  as  the  only  certain  proof  of  the  complete  expulsion 
of  the  -worm,  has  also  received  an  explanation  from  the  researches  of 
helminthologists  into  the  anatomy  and  development  of  these  animals. 
Xotwithstanding  the  doubts  expressed  by  Van  Benedin  as  to  the  lateral 
canals  being  connected  with  the  digestive  system,  and  his  notion  of  their 
beincr  peculiar  secreting  organs,  Dr.  Xelson  in  his  Thesis  has  distinctly 
traced  them  into  the  suckers  of  the  Tcenia  crassicolUs.  From  each  of 
the  four  suckers  canals  descend,  which  afterwards  unite,  two  and  two,  to 
form  the  lateral  canals.  He  also  carefully  describes  the  manner  of  feed- 
ino-  and  propulsion  of  the  contents  of  these  canals  from  the  cephalic  to 
the  caudal  segment.  Hence  the  head  is  important  as  the  means  by 
which  the  animal  is  nourished. 

But  the  head  is  further  important,  as  pointed  out  by  Van  Benedin,  as 
the  part  from  which  all  the  joints  are  thrown  oft'  by  gemmiferous  repro- 
duction— those  formed  first  being  pushed  downwards,  and  afterwards 
undergoing  further  development.  Hence  why  the  joints  are  narrow  near 
the  head,  and  become  larger  and  longer  near  the  tail.  These  caudal 
joints  after  a  time  separate,  and  then,  according  to  Van  Benedin,  may 
still  go  on  developing,  and  become,  he  thinks,  a  species  of  fluke  or 
distoma.  In  fact,  he  considers  a  tape-worm  as  a  compound  fluke-worm, 
the  whole  consisting  of  three  stages  or  periods  : — 1,  The  cystic  head 
[Scolex)  ;  2,  The  compound  tape-worm  [Strobila)  ;  3,  The  separated 
joint  [Pror/lottis).  This  latter  view,  however,  is  opposed  by  the  observa- 
tions of  Steenstrup  as  to  the  development  of  the  fluke,  as  well  as  by  what 
we  know  of  the  arrangement  of  the  nervous  and  digestive  systems  of  this 
entozoon. 

The  intestinal  worms  hitherto  discovered  in  man  are — the  Ascarig 
lumbricoides ;  Tcenia  solium;  Bothriocephalus  latus ;  Tricocephalus 
dispar  ;  and  Ascaris  vermicularis.  None  of  these  are  very  common  in 
Edinburgh,  a  circumstance  which  I  attribute  to  the  diet  of  the  people, 
as  well  as  to  the  excellent  quality  of  the  water  distributed  over  the 
town.  In  unhealthy  children,  indeed,  Ascarides  are  occasionally 
observed,  but  such  children  seldom  enter  the  Infirmary.  Lumbricoid 
worms  in  man  are  very  rarely  observed  here,  whereas  in  certain  districts 
on  the  Continent,  and  especially  in  the  Rhenish  provinces,  the  great 
majority  of  bodies  I  have  seen  examined  contained  them  in  abundance. 
Tape-worm  also  is  very  rare,  though  sometimes  met  with,  of  which  the 
following  cases  are  examples  : — 


Case  LXXIX.* — Tape-v:orm  treated  by  the  ethereal  Extract  of  the  Male  Shield  ^ 

Fern. 

History. — James  Seth,  set.  35,  a  weaver — admitted  April  7th,  1852.  When  a 
boy  he  used  to  pass  the  lumbricoid  worms ;  during  the  past  six  months  he  has  also 
observed  ascarides.  It  is  now  three  years  since  he  first  noticed  fi-agments  of  the 
tape-worm  in  his  stools.  These  fi-agments  were  tlien  about  a  foot  in  lengtli,  and 
were  noticed  at  intervals  of  months.  About  twelve  months  ago  the  fragments 
occurred  almost  every  day  for  six  weeks,  varjing  from  single  joints  to  a  piece  six 

*  Reported  by  Mr.  William  Broadbent,  Clinical  Clerk. 


496  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

feet  in  length.  Xo  long  piece  has  been  passed  for  three  months.  No  information 
can  be  obtained  as  to  the  kind  of  food  on  which  he  has  lived ;  but  his  appetite  has 
remained  natural.  Before  admission  he  was  treated  with  turpentine  by  the  mouth, 
and  also  by  injection. 

Progress  of  the  Case. — Aiml  8th. — To  have  25  grains  of  the  ethereal  extract 
of  the  male  shield  fern ;  and  in  a  few  hours,  a  powder  containing  three  grains  of 
calomel,  and  one  drachm  of  compound  jalap  powder.  April  9th. — Several  fragments 
of  Tajnia,  in  single  or  double  joints,  or  in  longer  pieces,  were  passed,  being  70  inches 
in  all.  They  varied  in  breadth  from  oue-eightli  to  one-fourth  of  an  inch. — A2}ril  lid. 
— The  dose  was  repeated  on  the  10th,  but  only  two  or  three  single  joints  were  found. 
No  further  trace  of  the  worm  has  been  obtained  by  administration  of  castor  oil,  and 
the  patient  was  discharged  cured. 

"Was  re-admitted  July  \si. — States  that  two  months  after  he  left  the  hospital  he 
again  detected  jomts  of  the  entozoon  in  his  stools.  lie  was  at  once  ordered  twenty- 
four  grains  of  the  etliereal  extract  of  the  male  shield  fern,  and  a  subsequent  dose 
of  castor  oil.  Numerous  fragments,  in  all  8  feet  in  length,  were  discharged  in  the 
next  stool.  July  9ih. — The  remedy  was  repeated  on  the  5ih  without  further  effect. 
Castor  oil  has  also  been  administered,  but  no  fragments  appear.  Patient  now  states 
that  he  has  been  in  the  habit  of  drinking  marsh  water  of  impure  quality,  and  of 
eating  salt  pork  meat.     July  I'Sth  — Dismissed  cured. 


Case  LXXX.* — Tape-worm  expelled  hy  the  JEthereal  Extract  of  the  Male  Shield  Fern. 

History. — Catherine  Watt,  set.  25,  married,  with  children — admitted  November 
20th,  1854.  She  had  always  enjoj-ed  good  health,  until  three  years  ago,  when  joints 
of  tape-worm  passed  from  her  involuntarily  when  out  working,  and  they  have  con- 
tinued to  pass  from  her  involuntarily,  and  sometimes  in  large  quantities  by  stool 
ever  since.  On  one  occasion  she  passed  blood  at  stool  with  portions  of  tape-worm. 
Has  taken  various  kinds  of  medicine,  but,  with  the  exception  of  turpentine,  does  not 
know  what  they  were.     They  have  all  been  ineflectual. 

Syjiptoms  ox  Adjiission. — On  admission  she  complained  of  tenderness  in  the 
left  ihac  region,  and  of  tenesmus  when  at  stool ;  but,  with  the  further  exception  of 
the  frequent  passage  of  joints  of  tape-worm,  the  functions  of  the  body  were  per- 
formed with  regularity.  She  was  ordered  3ij  of  tlie  a^thereal  extract  of  the  male 
shield  fern,  to  be  followed  in  the  morning  by  ^j  of  castor  oO.  This  caused  the 
evacuation  of  seven  joints  of  the  worm,  all  of  which  were  longer  than  they  were 
broad.  Another  3j  dose  of  the  extract  was  ordered  at  niglit,  also  to  be  followed 
by  §  j  of  castor  oil  in  the  morning. 

Progress  of  the  Case. — November  22d. — Only  tliree  joints  of  the  worm  passed. 
To  have  this  evening  3  ss  of  the  extract.  Nov.  23d— This  morning,  after  taking 
the  oz.  dose  of  castor  oil,  she  passed  many  separate  joints,  and  several  long  portions 
of  taenia.  The  whole  together,  when  measured,  was  calculated  to  be  about  fifteen 
yards  long.  One  portion  was  evidently  formed  of  the  joints  of  the  worm  near  the 
head,  as  they  were  l^roader  than  they  were  long,  and  not  above  the  tenth  of  an  inch 
in  length.  Some  joints  were  square,  and  others  longer  than  they  were  broad, 
measuring  from  half  an  inch  to  three  quarters  of  an  inch  in  length.  No  head  could 
be  discovered,  though  carefully  searched  after.  She  remained  in  the  house  till  the 
6th  of  December ;  but  although  she  took  3  ss  of  the  extract  three  times,  and  one 
dose  of  3ij,  no  more  joints  of  the  worm  came  away.  This  woman  was  freed  from 
the  worm  for  many  months,  but  it  subsequently  returned. 

*  Reported  by  Mr.  Almeric  "W.  Seymour,  Clinical  Clerk. 


INTESTINAL   WORMS."  497 


Case  LXXXI.* — Tape-worm  eicpelled  by  the  same  remedy. 

History. — William  Perry,  pet.  6,  son  of  a  soldier — admitted  November  19th, 
1855.  Has  been  troubled  with  the  tape-worm  since  he  was  two  years  old.  Has 
passed  separate  joints  often  without  medicine ;  doses  of  rhubarb  and  jalap  have 
brought  away  more ;  the  child  has  also  taken  turpentine.  A  year  and  a  half  ago 
he  obtained  a  prescription  at  this  Infirmary,  for  a  medicine  which  expelled  a  very 
large  portion  of  the  tape-worm.  In  six  months  it  was  necessary  to  repeat  the 
same  medicine,  again  with  success.  But  the  symptoms  have  again  returned ;  the 
child  is  always  hungry  and  wants  drink  ;  complains  of  pain  in  his  bell}^,  and  passes 
joints  of  the  entozoon  per  rectum.  His  food  latterly  has  been  plain,  consisting  of 
milk,  bread,  tea,  potatoes,  and  some  meat.  The  meat  is  boiled  for  broth,  and  is 
shared  with  him  by  father  and  mother,  neither  of  them  being  affected.  He  is  fond 
of  sugar,  butter,  and  salt. 

Progress  OP  THE  Case. — November  list. —  Ordered  30  grains  of  the  cuthereal  exti-act 
of  the  male  shield  fern,  with  a  subseqv£nt  dose  of  castor  oil.  Nov.  2^d. — As  the  remedy 
was  ineffectual,  it  was  increased  yesterday  evening  to  one  drachm.  This  morning, 
an  unbroken  mass  consisting  of  six  yards  and  six  inches  of  the  tape-worm  joints, 
was  evacuated ;  the  smallest  joints  were  one-fourth  to  one-sixth  of  an  inch  in  breadth 
and  length  ;  the  head  was  not  found.  Dec.  2oth. — After  two  other  administrations 
of  the  extract,  and  more  frequent  administrations  of  castor  oil,  no  further  fragments 
of  the  t;enia  have  been  procured ;  was  discharged. 

Commentarij. — Of  all  the  vermifuge  remedies  proposed  for  the  expul- 
sion of  tape-worm,  I  have  found  tlje  jethereal  e.xtract  of  the  male  shield 
fern  the  most  effectual — a  preparation  first  proposed  by  Peschier  of 
Geneva,  and  since  strongly  recommended  by  Dr.  Christison.  That  it 
readily  dislodges  large  masses  of  the  parasite,  has  been  witnessed  by  all 
who  have  tried  it,  although  it  has  not  succeeded  in  every  instance  in 
permanently  destroying  or  removing  the  animal.  This,  however,  appears 
to  me  in  great  part,  if  not  wholly,  accounted  for  by  the  circumstance 
that  patients,  on  being  dismissed,  return  to  the  kind  of  food  from  which 
they  originally  received  the  ova  of  these  worms.  This  is  very  likely  to 
be  the  case  in  certain  English  counties,  wiiere  bacon  and  other  prepara- 
tions of  pork  are  common  articles  of  diet  among  the  people.  Dr. 
Paterson  of  Tiverton  has  recorded  some  very  obstinate  cases,  wdiich 
resisted  the  action  of  the  male  shield  fern,  of  the  kousso,  and  of  turpen- 
tine.f  Now,  in  Devon,  pork  is  a  very  common  article  of  diet,  whilst 
in  Scotland  certainly  it  is  not  much  employed  as  food.  I  carefully 
interrogated  the  woman,  Catherine  Watt,  as  to  whether  she  had  eaten 
pork,  and  she  admitted,  that  about  the  time  the  disease  commenced,  her 
husband  being  out  of  work,  her  diet  had  been  very  poor,  and  had  con- 
sisted in  some  measure  of  salt  pork,  and  occasionally  of  rabbits.  Whether 
the  Ci/sticercus  cellulosiis,  commonly  found  in  the  Hesh  of  pigs,  could  have 
retained  its  vitality  in  the  salt  pork  eaten  by  this  woman,  cannot,  of 
course,  be  stated  with  certainty.  But  it  is  worthy  of  remark,  that  the 
flesh  of  pork  is  frequently  sold  cheap  to  the  lower  orders,  after  it  has 
been  laid  in  brine  for  a  very  short  period,  or  been  imperfectly  cured,  so 

*  Reported  by  Mr.  John  Glen,  Clinical  Clerk.  ^ 
f  Monthly  Journal  of  Medical  Science.     July,  1854 
32 


4Q8  DISEASES   OF  THE   DIGESTIVE   SYSTEM, 

that  tlie  tenacious  vitality  of  these  Cysticerci,  or  of  the  ova  of  Taeniae, 
is  by  no  means  necessarily  destroyed.  Then,  rabbits  are  known  to  be 
very  commonly  infested  with  Cysticerci ;  so  that  her  indulgence  in  either 
kind  of  animal  food  may  have  been  the  means  of  introducing  Tajnise 
into  her  economy. 

The  general  considerations  previously  given  as  to  the  origin  and  mode 
of  development  of  tape-worms  must  render  it  evident  that,  whilst  by 
means  of  vermifuge  remedies  the  practitioner  endeavours  to  expel  such  as 
are  already  formed,  his  chief  reliance,  in  preventing  their  return,  must  be 
placed  on  careful  attention  to  the  food  and  drink  consumed  by  his  patient. 


Case  LXXXII.* — Tajye-Wonyi  expelled  by  Kamala. 

History. — Mary  Park,  ret.  9,  a  thin  cachectic-looking  girl,  native  of  Edinburgh, 
where  she  has  for  the  most  part  resided — admitted  1 1th  January  1859.  Her  mother 
states  that  for  four  years  she  has  never  been  free  from  v,  orms,  for  which  she  has 
taken  turpentine,  castor-oil,  and  other  remedie.s,  without  benefit. 

Progress  of  the  Case. — On  the  12th  of  January  a  table-spoonful  of  castor-oil 
brought  away  a  few  long  joints  of  a  tape-worm.  On  the  afternoon  of  the  16th  of 
January  two  drachms  of  kamala  in  powder  were  given.  On  the  same  evening  she 
had  three  motions,  followed  early  the  next  morning  by  a  fourth.  In  the  three  first 
stools  were  several  isolated  joints  of  tape-worm,  but  in  the  fourth  there  was  a  mass, 
consisting  of  the  body  of  the  worm,  several  yards  long.  A  careful  search  was  made 
for  the  head,  but  without  success.  The  smallest  joints  were  the  tenth  of  an  inch 
broad.  Jan.  23d. — One  drachm  of  kamala  in  powder  was  administered,  followed 
by  three  copious  motions,  in  which  no  portions  of  worm  could  be  found.  No  more 
of  the  worm  having  passed,  she  was  dismissed  January  31st. 

Commeniary. — "Whetlier  a  permanent  cui'e  was  accomplished  in 
this  case  it  is  impossible  to  say,  as  the  head  and  neck  of  the  worm, 
notwithstanding  the  most  careful  search,  were  not  to  be  found.  Kamala 
has  been  recommended  to  us  by  medical  men  in  India  as  a  cheap  and 
powerful  anthelmintic,  and  has  recently  been  pretty  extensively  tried 
in  this  country.  Dr.  M'Kinnon,  of  the  Horse  Artillery,  published  a 
brief  account  of  it  in  the  Indian  Annals  of  Medical  Science  for  October 
1853 ;  and  it  is  referred  to  by  Dr.  Royle  in  his  Materia  Medica  as  an 
active  vermifuge.  It  is  a  dark,  brick-red  coloured  powder,  brushed 
off  from  the  capsules  of  the  Rottlera  tinctoria,  a  species  of  euphorbiacege 
found  in  the  hilly  portions  of  India.  Under  the  microscope  it  exhibits 
a  mass  of  blood-red  semi-transparent  granules,  more  or  less  shrivelled, 
mingled  with  stellate  hairs,  to  the  irritating  properties  of  which  some 
have  ascribed  the  vermicidal  properties  of  the  drug.  The  dose  is  from 
3  ij  to  3  iij  for  an  adult.  Dr.  T.  Anderson  says  an  alcoholic  tincture 
in  3  ss  doses  is  also  very  effectual  [Indian  Annals,  October  1855). 
Unlike  the  root  of  the  male  shield  fern,  it  is  in  itself  a  violent  purga- 
tive. But  whether  it  will  ultimately  be  ascertained  to  destroy  tape- 
worm more  effectually  than  that  drug,  further  observations  alone  can 
determine.  Dr.  Christison  has  informed  me  that  not  long  ago  (1859) 
an  Indian  officer,  who  had  taken  a  dose  of  the  Kamala  for  several  con- 

*  Reported  by  Mr.  H.  Graham  Dignum,  Climcal  Clerk. 


PERITONITIS.  499 

secutive  montlis,  with  the  effect  only  of  expelling  considerable  quan- 
tities of  the  worm,  was  permanently  cured  by  one  dose  of  the  Male 
Shield-Fern  Extract. 


^  PERITONITIS. 

Case  LXXXIII.*— ^cw<e  Peritoniils  from   bursting  of   Graafian   Vesicles  into  the 
Peritoneum — Pleurisy— Liter-lobular  Pneumonia. 

History.— Margaret  M'Guire,  ajt.  21,  a  milliaer,  uative  of  Edinburgh— admitted 
September  27tli,  1855.  Had  enjoyed  good  health  until  the  21st  of  the  mouth,  when, 
being  sent  out  on  a  message,  while  walking  she  suddenly  experienced  a  sensation 
as  of  a  stone  being  dropped  into  the  pelvis  (so  the  patient  describes  her  feehug), 
immediately  followed  by  intense  pain.  She  went  immediately  to  bed,  but  was 
prevented  from  sleeping  by  the  intensity  of  tlie  pain,  which  increased  in  severity. 
At  first  felt  only  in  the  lower  part  of  the  abdomen,  it  gradually  spread  upwards 
towards  the  upper  part  of  the  cavity,  but  has  again,  within  the  last  day  or  two, 
become  concentrated  in  the  lower  and  right  part  of  the  hypogastric  region. 

Symptoms  ox  Admission. — On  admission  her  appetite  is  entirely  lost.  The  tongue 
cannot  be  seen,  owing  to  an  old  anchylosis  of  the  lower  jaw.  Lips  dry  and  cracked, 
with  sores  on  them  in  places.  Vomiting,  which  greatly  aggravates  her  pain,  has 
followed  every  attempt  to  take  food  since  the  beginning  of  the  attack.  Abdomen 
somewhat  swollen.  The  hypogastric  region  is  duU  on  percussion.  Diarrhoea  has 
continued  ever  since  she  took  a  dose  of  castor  oil  four  days  ago.  Pressure  causes 
intense  pain  on  every  part  of  the  abdomen.  The  breathing  is  hurried  and  irregular 
entirely  thoracic  in  character.  Respiration  24  per  minute.  No  cough.  No  dulness, 
on  percussing  the  chest,  as  far  as  can  be  determined;  though  examination  is 
difQcult,  owing  to  the  extreme  pain  which  any  movement  causes  the  patient.  Pulse 
124,  full  and  thrilling.  Menstruation  had  been  suspended  for  two  months  previously, 
but'  has  come  on  profusely  within  the  last  two  days.  Has  frequent  desire  to  pass 
water,  which  is  voided  in  small  quantity,  attended  with  great  heat  and  uneasiness. 
Face  flushed;  expression  anxious;  severe  headache.  Applicentur  Mrudines  xv. 
abdomini.  To  be  followed  by  hot  fomentations.  5  Pulv.  Opii,  gr.  vi.:  Coiiserv, 
Rosar.  q.s.,  utfiantpil.  vj.;  Capiat  unam  tertid  quaque  hord. 

Progress  of  the  Case.— Ocif.  Isi.- The  patient  has  regularly  taken  the  pills  of 
opium:  is  in  a  very  weak  state;  breathing  laboured;  pulse  154.  Both  purging 
and  vomiting  have  in  a  great  measure  ceased.  Conjunctivas  slightly  tinged  yellow. 
To  take  strong  beef-tea,  and  Sherry  %  iij.  Oct.  2d— Patient  appears  to  be  sinking; 
pulse  160,  quick  and  flutteriug;  respiration  laborious  and  painful;  skin  cold  and 
moist;  abdominal  tenderness  great ;  swelling  in  abdomen  rather  increased ;  bowels 
open  this  morning;  stool  free  and  foeculent.  Urine  acid;  sp.  gr.  1020 ;  deep  orange 
coloured,  contains  a  small  amount  of  albumen,  is  tinged  green  by  nitric  acid. 
Crystals  of  triple  phosphate  seen  under  microscope.  Oct.  3d. — Patient  continued  to 
sink  during  the  night,  and  died  tliis  morning. 

Sectlo  Cadaveris.— Forty-eight  hours  after  death. 

The  tissues  were  well  nourished;  more  than  one  inch  of  fat  in  abdominal 
parietes. 

*  Reported  by  Mr.  Alexander  Simpson,  Clinical  Clerk. 


500  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

Thorax. — Heart  and  pericardium  healthy.  The  entire  svirface  of  each  pleura 
was  covered  by  an  exudation  of  recent  lymph.  This  lymph  was  in  some  places  thin, 
in  others  nearly  a  line  in  thickness;  it  was  soft,  and  had  an  unhealthj-  appearance, 
being  of  a  dirty  yellowish-green  colour.  There  was  no  fluid  effusion  in  either  pleura. 
Left  lung,  when  cut  into,  presented  notliing  remarkable.  The  lower  third  of  the 
right  lung  presented  a  singular  marbled  appearance,  in  consequence  of  each  pul- 
monary lobule  being  surrounded  b}-  a  la3'er  of  coagulated  exudation,  generally  about 
one-eighth  of  an  incli  in  tliickness.  Careful  examination  demonstrated  the  fact  that 
the  interlobular  vessels  had  poured  forth  an  exudation,  which  had  coagulated  out- 
side the  lobules,  which  were  oedematous,  but  not  hepatized. 

Abdomem. — The  whole  surface  of  the  peritoneum  was  coated  with  lympli,  but 
there  was  no  collection  of  serum.  The  lymph  in  some  places  was  in  flakes,  in 
other  situations  it  was  of  the  consistence  of  thick  gruel,  closely  resembling  pus.  The 
coils  of  the  intestines  were  glued  together  by  lymph ;  but  the  exudation  was  most 
abundant  near  the  pelvis.  Tlie  whole  of  the  intestinal  canal  was  carefully  removed 
and  examined ;  there  was  no  appearance  of  ulceration  or  of  perforation.  A2:)pendix 
vermiformis  normal.  The  liver  was  of  a  brick-red  colour,  and  was  decidedly  softer 
than  natural.  The  kidneys  likewise  were  somewhat  softened,  but  otherwise  appeared 
healthy.  The  spleen  was  of  pulpy  consistence,  and  broke  down  under  tlie  slightest 
pressure.  The  uterus  was  healthy.  The  right  ovary  was  about  the  size  of  a  walnut ; 
on  being  cut  into,  its  stroma  was  found  somewhat  softened;  it  contained  an  unusual 
number  of  graafian  vesicles.  Externally  there  was  adherent  to  the  serous  covering 
a  layer  of  Arm  lymph,  so  adherent  that  it  could  only  be  removed  with  difficulty.  It 
apparently  originated  from  the  rupture  of  one  or  more  graafian  vesicles,  several  of 
which  were  on  the  surface,  large,  and  filled  with  sanguineous  serum.  The  left  ovary 
was  the  size  of  a  small  orange,  and  contained  a  cyst  about  the  size  of  a  walnut,  filled 
with  blood.  Such  of  its  substance  as  remained  was  of  exactly  the  same  consistence 
as  that  on  the  right  side.  The  peritoneum  covering  it,  however,  was  healthy.  The 
veins  in  the  broad  ligaments  were  examined,  but  i^resented  nothing  unusual. 

Commentary. — Tn  the  case  of  tin's  young  girl,  the  inenstniation,  after 
being  suspended  for  two  periods,  comes  back  profusely  ;  and  when  walk- 
ing, she  experiences  a  sudden  pain  deep  in  the  pelvis.  This  is  followed 
by  excessive  agony  and  all  the  symptoms  of  acute  peritonitis.  She  is 
admitted  into  hospital  on  the  sixth  day.  Leeches  and  fomentations  are 
applied  locally,  but  without  any  avail.  A  grain  of  opium  is  given  every 
third  hour,  but  without  checking  the  disease.  She  dies  on  the  eleventh 
day.  On  dissection,  both  ovaries  are  found  enlarged  and  cystic ;  the 
I'ight  one  is  firmly  encrusted  with  recent  lymph,  and  several  cysts  imme- 
diately below  the  layer  of  exudation  are  enlarged,  prominent,  and  filled 
with  sanguineous  serum.  The  inference  obviously  is,  that  one  or  more 
of  those  graafian  vesicles  had  burst  into  the  peritoneum,  instead  of  into 
the  fallopian  tubes,  and  so  excited  the  peritonitis.  The  cause  of  the  dis- 
ease spreading  to  the  right  pleura  and  interlobular  spaces  could  not  be 
discovered. 

In  such  a  case  whei'e  the  peritonitis  was  clear  and  evident  from  the  first, 
the  treatment  by  quietude,  warm  fomentations  and  leeches  locally,  and 
opium  internally,  was  indicated  and  put  in  practice.  Purging  rarely 
occurs,  though  it  did  in  this  instance ;  generally  speaking,  there  is  great 
constipation  in  peritonitis.  Under  such  circumstances  active  purgatives 
should  not  be  administered  for  two  or  three  days  after  the  onset  of  the 
inflammation,  and  then  onlv  the  mildest  remedies  of  that  class ;  or  ene- 


PERITONITIS,  501 

inata  may  be  given.  Percussion,  by  indicating  wbether  tbe  coecum  or 
rectum  are  the  parts  distended  with  toeces,  will  occasionally  enable  us  to 
decide  whether  an  aperient  or  an  injection  will  be  most  appropriate. 
Other  cases  occur  where,  from  acute  symptoms  being  absent  and  local 
tenderness  obscure,  active  purgation  is  often  practised,  to  the  detriment 
of  the  patient.  This  is  very  apt  to  occur  when  acute  peritonitis  is  com- 
bined with  jaundice  and  liver  disease.  The  treatment  of  such  cases  is 
most  ditiicult,  as  the  means  requisite  for  overcoming  obstruction  in  the 
gall  ducts  are  those  which  we  should  avoid  in  peritonitis.  In  cases  aris- 
mo-from  perforation  of  the  stomach  and  intestines,  the  utmost  caution  is 
required  (which  cannot  be  too  often  enforced)  before  stimuli  and  purga- 
tives are  given.     (See  Cases  LYIII.  and  LIX.) 

Although,  in  the  vast  majority  of  cases,  peritonitis  arises  from  some 
lesion  of  the  abdominal  organs,  which,  as  in  the  present  case,  affects  the 
serous  membrane  secondarily,  it  sometimes  happens  that  no  lesion  to 
account  for  the  inflammation  can  be  discovered  after  death;  although  the 
symptoms  of  perforation  may  have  existed  during  life.  In  such  cases  the 
inspection  should  never  be  concluded  without  a  c.areful  examination  of 
the  appendix  vermiformis,  where  I  have  seen  minute  perforations  very 
apt  to  escape  notice.  This  part,  besides  being  exposed  to  all  the  ordi- 
nary diseases  of  texture,  is  especially  liable  to  have  impacted  in  it  grains 
of  wheat,  barley,  or  other  kind  of  seed,  cherry-stones,  pins,  and  a  variety 
of  foreio-n  bodies,  which  pass  readily  through  the  other  portions  of  the 
intestines,  but  which,  in  the  appendix,  may  give  rise  to  ulceration,  perfo- 
ration, and  fatal  peritonitis. 

Although  our  lirst  efforts  in  cases  of  peritonitis  should  be  directed  to 
relieve  pain,  maintain  quietude,  and  diminish  peristaltic  action  by  means 
of  opium,  we  must  not  lose  sight  of  the  necessity  of  favouring  such  trans 
formations  in  the  exudation  as  will  cause  absorption  or  chronic  adhesions. 
All  exhaustive  remedies,  therefore,  are  to  be  avoided ;  and  as  soon  as  the 
circumstances  of  the  case  admit  of  it,  nourishment  and,  if  necessary, 
stimuli  should  be  administered. 


Case  LXXXIV.* — Tubercular  Peritonitis  with  great  Deposit  in  Parietal  Layer — Tu- 
bercle  and  Ilepatisation  of  Lungs — Pleuritic — Adherent  Pericardium — Commenc- 
ing Fatty  Degeneratiim  of  Heart — Biliary  Congestion  and  Fatty  Degeneration  of 
Liver — Slight  Leucocythemia. 

History. — Elizabeth  Barker,  £et.  17 — admitted  October  6th,  1854;  single;  em- 
plo3^ed  in  a  factory ;  has  been  ill  for  about  eight  months.  In  the  month  of  February 
last  she  was  attacked  with  a  "  fever,"  which  she  attributes  to  working  in  a  cold  and 
damp  room.  This  confined  her  to  her  bed,  and  she  was  under  medical  treatment  for 
two  months,  at  the  end  of  which  time  she  was  much  Ijetter.  A  fortnight  afterwards 
she  was  attacked  with  pain  in  the  lumbar  region  and  left  .side,  and  with  a  dry  cough, 
and  she  did  not  pass  so  much  water  as  usual.  Her  abdomen  and  legs  also  became 
swollen.  She  took  medicines,  which  partially  removed  the  swelling.  She  came  to 
Edinburgh  three  weeks  ago,  and  since  tlieu  the  swelling  in  the  abdomen  and  legs 
has  been  gradually  increasing. 

SYiiPTOMS  ON  Admission. — On  admission,  urine  scanty  and  high-coloured;  sp.  gr. 

*  Reported  by  ilr.  Almeric  "W.  Seymour,  Clinical  Clerk. 


502  DISEASES   OF  THE   DIGESTIVE   SYSTEM, 

1030;  does  not  contain  albumen.  She  has  never  menstruated.  Complains  of  pain 
over  the  lumbar  vertebne,  increased  by  pressure.  Tongue  moist  and  furred,  appetite 
impaired.  Has  a  sour  taste  in  mouth,  and  is  troubled  with  flatulence.  Bowels 
costive.  Cardiac  sounds  normal.  Pulse  128,  small  and  thready.  A  friction  sound 
is  audible  over  the  inferior  part  of  botli  lungs,  anteriorly,  posteriorly,  and  laterally) 
with  dulness  on  percussion,  and  diminution  of  vocal  thrill.  In  the  upper  part  of 
right  lung,  anteriorly  and  posteriori}^,  the  respiratory  murmur  is  audible,  with  slight 
increase  of  vocal  resonance.  Over  upper  part  of  left  lung  anteriorly,  the  natural 
respiratory  murmur  is  audible,  but  posteriorly  there  is  a  marked  increase  of  vocal 
resonance,  with  tubular  breathing.  Posteriorly  oegophony  at  the  angle  of  right 
scapula.  Skin  moist,  of  natural  temperature.  ]J  Hydrarg.  Protoiod.  gr.  vj. ;  Exi. 
Hyoscyami  3  ss. ;  Conserv.  JRosar.  q.s.  ut  fiant  pil.  xij.  Sumat  unam  lis  die.  ]J  Sp. 
jEth.  Nitrici  |iss;  Tr.  Scillce;  Tr.  Digitcdis  slSl  3  ij.  M.  Sumat  3j  ex  aqua  indies. 
PRoaRESS  OF  THE  Case. —  October  llth — Dyspnoea  continues.  Pain  in  abdo- 
men increased.  Has  been  suffering  from  purging  for  the  last  24  hours.  To  take 
chalk  'inixture  with  Sol.  Mur.  Morphia.  Oct.  \Mh. — Six  leeches  were  ordered  to 
the  sternum  yesterday.  To-day  the  friction  sound  has  disappeared.  To  have  5  ij 
of p)ort-ivine.  Nov.  \st. — The  distended  abdomen  measures  32J  inches.  Fluctua- 
tion distinctly  felt.  Vertical  hepatic  dulness  2f  inches.  DuU  pain  in  hepatic  and 
riglit  lumbar  region,  but  no  tenderness,  as  it  can  be  handled  and  pressed  freely 
without  causing  inconvenience.  Feet  cedematous.  Sweats  considerably.  IJ  Potass. 
Acetat.  3  ij ;  Sp.  ^th.  Mtrici  §ss;  Mist.  Scillce  ^  viss  M.  Sumat  §  ss  fer  indies. 
Omittantur  alia.  Nov.  12ih. — Quantity  of  urine  much  increased.  Abdomen 
measures  31  inches.  Nov.  22d. — Abdomen  measures  30^  inches.  Nov.  25th. — 
Fluid  in  abdomen  much  diminished.  Swelling  and  tension  of  its  walls  greatly 
decreased.  Circular  measurement  29  inches.  On  palpation  a  distinct  hardness 
may  be  felt  in  the  right  hypochondriac  region,  extending  into  tlie  epigastrium. 
Tongue  dry  and  brown.  Has  been  suffering  from  diarrhoea  for  some  days  past. 
The  stools  have  of  late  been  clay-coloured,  and  slight  jaundiced  tint  of  skin  has  made 
its  appearance.  Urine  contains  bOe,  and  is  slightly  coagulable  by  heat  and  nitric 
acid.  Bhod  presents  a  slight  increase  in  number  of  white  corpuscles.  To  have  a 
starch  enema  ivith  Tinct.  Opii.  Nov.  26t.h. — Much  worse.  Skin  cold.  Face  sunken 
and  pale.  She  lies  on  left  side  ;  any  other  position  causes  great  dyspnoea.  Respi- 
ration 36  to  40  per  minute.  Coarse  crepitation  may  be  heard  over  the  whole  right 
side.  Pulse  120,  very  weak.  Diarrhoea  continues,  but  stools  this  morning  were 
foeculent.  Urine  dark  brick  red;  sp.  gr.  1012,  with  some  traces  of  bile.  Not  a  trace 
of  chlorides  present.  To  have  the  enema  repeated  immedicdtly,  and  3  oz.  of  brandy. 
Nov.  21  ih. — She  gradually  sank,  and  died  to-day  at  10  p.ii. 

Secfio  Cadaveris. —  Tiventy-seven  hours  after  death. 

External  Appearances. — Body  emaciated.     Abdomen  somewhat  distended. 

Thorax  — The  pericardium  was  universall}'  adherent.  The  adiiesions  were  firm, 
and  were  broken  down  with  difiSculty.  The  valves  of  the  heart  were  healthy,  but 
the  muscular  substance  was  of  a  brownish-red  colour,  and  rather  softer  than  natural. 
The  size  of  the  heart  was  normal.  There  were  firm  old  adhesions  over  the  upper 
lobe  of  the  right  lung.  Over  the  lower  lobe  there  was  a  thin  layer  of  recent  lymph. 
Between  the  diapliragm  and  the  base  of  the  lung  was  a  pouch  containing  about  six 
ounces  of  turbid  fluid,  in  which  floated  some  flakes  of  lymph.  The  whole  lung  felt 
firm  and  dense.  When  cut  into,  it  presented  a  somewhat  granular  surfoce  of  a  red 
colour,  was  scarcely  crepitant,  broke  down  readily,  and  some  portions  of  it  sank  in 
water.     Scattered  through  it  were  a  number  of  yellow  masses,  from  the  size  of  a 


PERITONITIS.  503 

millet  seed  to  that  of  a  small  pea.  Tliey  were  of  cheesy  consistence,  and  were 
pretty  readily  broken  down.  They  were  scattered  equally  through  the  pulmonary 
substance,  aud  were  not  more  abundant  at  the  apex  than  elsewhere.  None  were 
softened.  The  kft  lung  was  universally  adherent,  but  there  was  no  recent  lymph. 
The  lung  felt  firm,  and  when  cut  into  presented  altogether  the  same  appearance  as 
the  right  lung.  The  same  yellowish  masses  were  scattered  through  it.  The  bron- 
chial glands  were  enlarged,  and  when  cut  into  were  found  to  contain  yellow,  cheesy, 
tubercular  matter. 

Abdomen. — The  cavity  of  the  abdomen  contained  about  a  gallon  of  j'ellowish 
tolerably  clear  fluid.  The  parietal  peritoneum  was  very  much  thickened  by  a 
deposit,  varying  from  about  one  line  to  half  an  inch  in  thickness.  It  was  of  a  yellow- 
ish colour,  but,  on  looking  closely  into  it,  numerous  opaque  points,  of  the  size  of 
pins'  heads  or  so,  were  seen  separated  from  one  another  by  a  clear  substance.  On 
cutting  into  the  deposit  this  appearance  was  still  more  distinct.  Numerous  blood- 
vessels were  seen  on  its  surface,  and  in  its  substance ;  Jhid  on  the  former  were 
numerous  particles  of  extravasated  blood  of  a  bright  red  colour.  The  deposit  was 
of  firm  consistence.  Tlie  coils  of  the  intestines  were  firmly  adherent  by  tolerably 
firm  lymph.  Their  coats  were  softened,  so  that,  in  endeavouring  to  separate  tlie 
adhesions,  they  tore  readil3\  On  looking  closely  at  the  surface  of  the  intestines, 
numerous  small,  semi-transparent,  j'ellowish-white  deposits  were  seen  on  the  serous 
surface,  and  there  presented  all  the  usual  characters  of  tubercle.  The  mucous  coat 
of  the  intestines  was  healthy.  The  capsule  of  the  liver  was  thickened,  and  the 
upper  and  anterior  part  of  it  was  adherent  to  the  diaphragm.  The  liver  was 
externally  of  a  yellow  orange  colour.  On  cutting  into  it,  numerous  opaque  j-ellow- 
ish -white  masses  varying  from  the  size  of  a  pin's  point  to  that  of  a  millet  seed, 
were  seen  surrounded  by  deep  orange-coloured  matter.  The  surface  of  the  section 
was  quite  smooth  ;  the  tissue  of  the  liver  was  rather  softer  than  natural ;  and  there 
did  not  appear  to  be  any  increase  in  the  amount  of  fibrous  tissue.  The  liver  was 
small  and  weighed  2  lb.  7  oz. ;  sp.  gr.  1051.  The  gall  bladder  was  small,  its  coats 
were  thickened,  and  it  was  bound  down  to  the  fiver  by  fibrous  tissue.  It  contained 
about  two  drachms  of  orange-coloured  bile.  The  spleen  was  natural.  Mesenteric 
and  lumbar  glands  enlarged,  of  white  appearance,  of  a  smooth  surface  on  section, 
yielding  a  copious  opaque  juice  on  pressure.  The  kidneys  presented  nothing 
unusual. 

Microscopic  Examination'. — The  muscular  fibres  of  the  heart  had  lost,  to  a 
certain  degree,  their  striated  appearance,  which  was  replaced  in  some  by  granular 
fatty  matter.  The  masses  of  deposit  in  the  lungs  presented  all  the  usual  characters 
of  tubercle.  On  examining  the  thickened  peritoneum,  large  groups  of  tubercle 
corpuscles  and  granular  matter  were  seen  to  be  surrounded  and  isolated  by  fibrous 
tissue.  The  pale,  opaque-looking  points  in  the  liver  consisted  of  accumulations  of 
fat,  partly  free,  partly  in  hepatic  cells.  The  surrounding  parts  were  loaded  with 
yellow  biliary  matter.  There  was  no  increased  quantity  of  fibrous  tissue.  The 
tubes  and  cells  of  the  kidneys  appeared  quite  natural. 

Commentary. — This  is  a  cliaracteristic  case  of  so-called  tubercular 
peritonitis,  associated  with  pulmonary  tubercle  and  various  other 
lesions.  In  a  practical  point  of  view  it  is  to  be  remarked,  that  the 
symptoms  were  wholly  different  from  those  in  the  previous  case. 
There  was  no  abdominal  tenderness,  no  inflammatory  fever — and,  not- 
withstanding tlie  large  amount  of  lympli  exuded,  some  of  it  recent, 
all  the  symptoms  were  those  of  ascites  dependent  on  atrophy  of  the 
liver.      In  some    cases    of  this    disorder,  the   j^eculiar  doughy  feeling. 


504  DISEASES   OF   THE    DIGESTIVE   SYSTEM. 

communicated  to  the  hand,  and  the  roughened  friction  perceptible  on 
moving  the  two  peritoneal  surfaces  over  the  other,  gave  an  indication 
of  the  nature  of  the  disease — the  latter  symptom  was  absent  in  the 
present  case  in  consequence  of  the  accumulation  of  fluid.  Occasion- 
ally the  amount  of  tubercular  exudation  is  very  great;  I  have  seen  it 
matting  together  all  the  intestines  and  abdominal  viscera  in  a  layer 
varying  from  a  half  to  an  entire  inch  in  thickness.  In  such  cases  also 
it  frequently  happens  that  whilst  the  abdomen  is  loaded  with  tubercle, 
the  lungs  are  comparatively  free  fi'om  it. 

The  mesenteric  and  lumbar  glands  in  these  cases  are  very  apt  to 
become  hypertrophied,  and  the  blood  to  contain  an  unusual  number  of 
colourless  corpuscles.  In  a  man,  James  M'Arthur,  who  died  in  Paton's 
Ward  during  the  summer  1857,  these  glands  were  enlarged.  There 
was  also  an  enormous  collection  of  tubercular  exudation  in  the  abdomen, 
which  on  examination  was  found  to  foi'm  a  layer  from  one-half  to  an 
inch  in  thickness,  glueing  the  intestines  and  abdominal  viscera  together. 
On  examining  a  drop  of  his  blood  under  the  microscope  in  the  usual 
way,  during  life,  from  twenty-five  to  forty  colourless  corpuscles  could 
always  be  counted  in  the  field  of  the  instrument.     (See  Leucocythemia.) 


Case  LXXXY.* — Cancer  of  various  Abdominal  Organs  and  of  the  Lungs,  producing 
Symptoms  of  Peritonitis. 

History. — Christina  Galbraith,  ait.  52,  a  fish-cleaner,  at  Newcastle,  single — 
admitted  November  29,  1854.  The  patient  states  that,  until  nine  months  ago,  she 
enjoyed  good  health,  since  which  time  her  strength  has  been  diminishing.  She  has 
been  decidedly  ill  for  the  last  three  months.  Her  first  symiJtoms  were  pain  in  the 
epigastrium,  a  feeling  of  cold,  great  thirst,  anorexia,  sickness,  and  severe  night- 
sweats.  The  pain  in  the  epigastrium  has  gradually  increased  up  to  the  present  time. 
About  ten  weeks  before  admission,  she  noticed  that  her  abdomen  began  to  swell,  and 
the  swelling  has  since  gradually  increased.  Her  feet  have,  for  the  last  five  years, 
evinced  a  tendency  to  oedema  towards  evening,  in  consequence,  as  she  thinks,  of  her 
work  requiring  her  to  be  much  in  the  erect  position,  and  lately  they  have  become 
more  swollen.  Four  weeks  ago  she  had  an  attack  of  jaundice  accompanied  by  severe 
pain  in  the  lumbar  and  right  h3^pochondriac  regions.  The  colour  of  the  stools  is  not 
known,  but  she  thinks  her  bowels  were  regular  at  the  time,  although  she  is  habitu- 
ally subject  to  constipation.  A  week  after  its  appearance,  her  bowels  became  very 
loose ;  the  stools  were  foeculent  and  abundant.  On  one  occasion  she  passed  a  con- 
siderable quantity  of  blood,  accompanied  by  what  she  describes  as  "  great  lumps  and 
strings,"  but  of  the  colour  of  which  she  has  no  idea.  At  this  time  slie  had  no  vomit- 
ing, but  felt  great  pain  over  the  whole  of  the  abdomen,  which  became  very  swollen 
and  tense.  She  improved  under  medical  treatment:  the  bowel  complaint  disap- 
peared, and  the  i^ain  in  the  abdomen  abated.  But  she  does  not  know  how  long  the 
attack  lasted.  During  its  continuance  she  also  suff"ered  from  vomiting;  the  matters 
ejected  were  sometimes  of  a  green,  at  others  of  a  coffee-ground  colour.  The  bowel 
complaint  and  the  pain  returned  with  great  severity  on  her  voj-age  from  Newcastle 
to  Edinburgh.  She  also  vomited  considerably,  and  was  brought  to  the  Infirmary  in 
a  state  of  great  exhaustion,  on  the  evening  of  the  29th  of  November. 

Symptoms  on  Admission. — On  admission,  she  complained  of  great  pain  over  the 

*  Reported  by  Mr.  0.  Beaujeard,  Clinical  Clerk. 


PEKITOXITIS.  505 

epigastrium  and  right  bypocliondrium,  and  generally  all  over  the  abdomen ;  face 
very  anxious ;  pulse  small  and  quick.  Ordered  Wine  and  Brandy,  Tannin  and 
Opium  Fills,  and  four  leeches  to  right  hypochondrium.  Next  day  was  carefully 
examined.  Face  and  conjunctivae  have  a  yellowish  tinge;  countenance  anxious, 
but  speech  is  clear  and  comprehension  quick.  She  complains  both  of  a  continuous 
and  a  shooting  pain,  worse  over  the  epigastrium  and  over  the  left  side  of  the  abdo- 
men, in  the  course  of  the  descending  colon.  The  pain  felt  last  night  in  the  right 
hypochondrium  has  been  diminished  by  the  leeches,  which  bled  well.  She  lies  with 
greatest  ease  on  the  right  side,  and  feels  great  pain  when  she  assumes  the  supine 
position.  The  abdomen  is  exceedingly  tender  on  pressure ;  it  is  swollen,  tense,  and 
tympanitic,  permitting  nothing  deei>seated  to  be  felt.  Pungent  heat,  and  drj-ness 
of  skin  over  its  surface.  Tongue  white,  with  prominent  papillje,  pale,  smooth,  and 
glossy  at  tip  and  edges.  Complains  of  constant  bad  taste  in  mouth ;  has  a  burning 
pain  at  epigastrium,  and  most  intense  thirst,  but  cannot  take  cold  water,  as  it  causes 
immediate  vomiting,  though  she  does  not  otherwise  feel  sick.  Appetite  entirely 
gone;  bowels  have  not  been  moved  since  her  admission.  Urine  diminished  in 
quantity,  high-coloured,  with  a  deposit  of  lithates;  the  chlorides  are  present;  sp,  gr. 
1014;  she  has  a  sense  of  heat  in  passing  it,  Catamenia  last  appeared  about  a  month 
ago.  Pulse  108,  small  and  weak.  Apex  of  heart  beats  between  fifth  and  sixth 
ribs ;  transverse  dulness  normal.  Sounds  normal.  Breathing  mostly  thoracic ;  respi- 
rations, 32  per  minute ;  cannot  take  a  full  breath  without  pain  ;  has  a  short  hacking 
cough.  Chest  expands  equally,  but  imperfectly.  Percussion  good,  both  anteriorly 
and  posteriorly ;  respiratory  murmurs  natural.  Has  headache,  tinnitus  aurium,  and 
niuscse  volitantes.  Feels  sick  and  giddy  on  sitting  up.  There  is  oedema  of  the  feet, 
ankles,  and  legs  To  have  wine  4  oz^  and  in  the  evening  a  Turpentine  and  Asafoetida 
enema. 

Progress  of  the  Case. — December  Isi. — The  enema  was  followed  by  two  fcecu- 
lent  and  hard  stools.  Pain  in  the  abdomen  considerable — most  felt  below  the 
margin  of  the  right  false  ribs.  Complete  anorexia.  Great  thirst ;  pulse  104,  small 
and  hard-  Dec.  2d. — State  much  the  same;  bowels  not  again  opened.  Pain  in 
the  abdomen  being  increased,  she  was  ordered  six  tnore  leeches  to  the  right  hypo- 
chondrium, and  the  following  diuretic  mixture — 5  Potassce  Acetatis  3ij;  <Sip.  ^th. 
Nitrici  §  ss;  Mist.  Scillce,  |  vss.  M.  ^^s.  to  be  taken  three  times  a  day.  Dec.  5th. — 
Breathing  natural ;  abdomen  not  so  tense  and  hot ;  pain  greatly  diminished ;  appetite 
not  improved ;  stools  dark  but  healthy ;  pulse  96,  small  and  weak.  Dense  deposits 
of  lithates  in  urine.  Dec.  lOih. — Pulse  92,  very  small  and  weak.  No  thirst;  appe- 
tite not  improved,  abdomen  less  tense — fluctuation  may  be  distinctly  felt.  Pain 
less — most  severe  on  left  side,  Dec.  I8th. — Pas.ses  very  little  urine;  it  is  high 
coloured,  and  deposits  lithates  abundanth'.  Abdomen  less  tense — measures  33 
inches  in  circumference.  It  is  tympanitic,  and  fluctuation  may  be  felt.  Feet 
cedematous;  bowels  regular;  no  appetite,  great  thirst;  slight  catching  of  the  breath. 
3  Pulv.  Digitalis,  gr,  iij,  Pulv.  Scilke,  gr.  vj,  E.ct.  Taraxaci,  q.  s.  ut  fiant  pil.  vj, 
Sumat  unam  bis  indies.  Omittaniiir  alia.  Dec.  19th. — Urine  much  increased  in 
quantity;  is  very  high  coloured;  deposits  lithates.  Dec.  20th. — Great  pain  com- 
plained of  in  lumbar  region.  Yellowish  tinge  of  complexion  increasing.  To  apply 
to  the  abdomen  the  Spongio-Piline  soaked  in  Inf.  Dic/ifalis  of  four  times  the  usual 
strength.  Dec.  2lst. — The  Spongio-Piline  has  relieved  the  pain  in  the  abdomen. 
Breathes  easier.  Thinks  her  urine  diminished  in  quantity.  It  is  of  a  deep  copper 
colour.  Has  vomited  her  breakfast  for  the  last  two  days,  but  is  not  sick  otherwise. 
Bowels  regular,  appetite  not  improved;  i>ulse  108,  weak,  Dec.  23d, — Yomiting 
more  frequent :  is  much  troubled  with  flatulence ;  tongue  pale,  smooth,  and  glossy ; 
bowels  regular,     Dec.  2oth. — Tr.  lodinii  to  be  painted  over  the  abdomen.     Dec.  21ih. — 


606  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

The  iodine  caused  lier  great  pain,  wliicli  was,  however,  relieved  by  warm  fomenta- 
tions. The  swelling  of  the  abdomen  and  tympanitis,  the  cough,  and  the  expectora- 
tion, have  increased ;  breatliing  slightly  laborious.  5  »^.  ^tli.  Sulpli.  3  iij ;  ^ol. 
Mur.  3fo7-ph.  3j ;  Mist.  Scilke  1  iiss.  To  be  taken  in  half  ounce  doses  token  the  cough 
is  troublesome.  Dec.  30th. — Abdomen  measures  34  inches  in  circumference.  Bowels 
regular;  percussion  normal  over  chest;  mucous  and  sibilant  rales  heard  on  auscul- 
tation. Coughs  much ;  expectoration  abundant,  purulent,  and  tenacious ;  pulse 
small  and  weak;  legs  and  feet  very  oedematons;  urine  as  before.  Jan.  2d. — 
Jaundiced  tint  of  slvin  is  growing  deeper;  distension  of  abdomen  from  tympanitis 
increased;  pulse  rapid  and  thready;  vomits  all  her  food  immediately  after  taking  it, 
together  with  a  quantity  of  black  matter ;  thirst  great ;  stools  pale-coloured  but 
consistent.  To  omit  the  Squill  and  Digitalis  Pill,  and  to  take  Potass.  Bitart.  3j  ier 
indies.  Jan.  4dh  — Jaundice  increases ;  urine  very  small  in  quantity,  and  contains 
bile.  Swelling  of  abdomen  augmented ;  great  protrusion  of  lower  ribs,  but  breath- 
ing is  not  much  affected.  Yomiting  continues.  There  is  oedema  of  feet,  legs,  and 
hands;  she  is  getting  decidedly  weaker.  Pulse  96,  steady  and  weak.  Jan.  5th. — 
Died  this  morning  at  2  a.m. 

Sectio  Cadaveris. — Fiftij-eight  hours  after  death. 

The  body  emaciated ;  tlie  surface  of  a  moderately  yellow  tinge ;  abdomen  much 
distended  and  fluctuating. 

Thorax.  — Tlie  pericardium  and  heart  were  healthy ;  there  were  a  few  slight  old 
adhesions  on  the  left  side  of  the  chest;  the  left  lung,  when  removed,  had  an  irregular 
feeling  from  the  presence  of  a  number  of  masses,  some  immediately  under  the  pleura, 
others  embedded  in  the  pulmonary  tissue ;  the  masses  visible  externally  had  a 
circumference  equal  to  about  that  of  a  fourpenny  piece ;  their  margnis  were  slightly 
prominent,  while  they  were  depressed  or  flattened  in  the  centre ;  they  appeared  of 
a  greyish- white  colour,  and  felt  firm  and  hard;  on  cutting  into  the  lung,  pretty 
numerous  masses  similar  in  size  could  be  seen  scattered  through  it;  they  were 
generally  of  a  white  or  greyish- white  colour,  while  some  were  3^ellowish,  as  if  stained 
by  biliary  matter;  most  of  these  masses  felt  tolerably  firm,  but  j'ielded  on  pressure 
a  small  quantity  of  a  glairy  juice ;  others,  however  (which  were  more  opaque-looking 
than  the  rest),  crumbled  down  easily  under  the  fingers.  The  right  lung  was  very 
densely  adherent  throughout  externally ;  it  presented  masses  similar  to  those  found 
in  the  left  lung,  and  others  could  be  felt  in  its  substance ;  it  was  not  cut  into,  but 
was  sent  entire  to  the  university  museum ;  the  pulmonary  tissue  intervening  between 
the  masses  was  quite  healthy.  A  few  of  tlie  bronchial  glands  at  the  root  of  each 
lung  were  a  little  enlarged,  and  when  bisected  were  found  to  contain  a  substance 
like  that  met  with  in  the  tumours  of  the  lungs.  The  bronchi  were  unaffected. 
One  gland  in  the  anterior  mediastinum  immediately  under  the  upper  part  of  the 
sternum  was  of  the  size  of  a  walnut,  and  on  being  divided,  was  found  converted 
into  a  mass  of  almost  cheesy  consistence,  of  a  yellow  colour,  mottled  by  the  pre- 
sence of  a  good  deal  of  black  pigmentary  matter. 

Abdomen. — The  cavity  of  the  abdomen  contained  about  a  gallon  and  a  half  of  a 
clear  yellowish  fluid.  Peritoneal  membrane  everywhere  healthy.  The  liver,  which 
was  much  enlarged,  presented  a  very  irregular  appearance,  in  consequence  of  the 
projection  from  its  surface  of  numerous  masses  of  a  whitish-yellow  colour,  varying 
from  the  size  of  a  pea  to  that  of  the  fist ;  some  were  rounded,  others  of  a  very  irre- 
gular form  Only  a  very  few  of  these  masses  presented  any  central  depression. 
When  cut  into,  tlie  substance  of  the  liver  was  found,  to  a  great  extent,  occupied 
by  a  similar  matter;  at  some  places  it  occurred  in  small  isolated  masses,  but  in 
general  it  was  found  infiltrated  in  large  patches.    It  was  of  a  yellowish  colour;  some 


PEEITOXITIS.  507 

parts  of  it,  however,  were  opaque,  while  intervening  portions  were  clear  and  semi- 
transparent;  other  parts,  again,  were  intermediate  between  these  conditions;  the 
matter  was  generally  tolerably  firm,  but  the  more  opaque  parts  had  a  tendency  to 
crumble  down.  The  liepatic  tissue  itself  was  of  a  yellowish  colour,  and  moderately 
firm.  The  weight  of  the  entire  liver  was  7  lbs. ;  behind  the  liver  a  mass  of 
enlarged  glands  surrounded  and  compressed  the  vena  cava,  the  gall-bladder,  and 
common  duct ;  the  vena  cava  was  somewhat  diminished  in  size ;  the  gallbladder 
was  much  contracted,  being  little  larger  than  an  almond,  and  contained  scarcely 
any  bile ;  on  passing  a  probe  from  the  gall-bladder  along  the  cystic  duct,  the  latter 
was  found  quite  occluded,  a  little  before  its  point  of  junction  with  the  common  duct; 
a  probe  was  passed  from  the  duodenum  along  the  common  duct,  but  both  it  and 
the  hepatic  duct  were  compressed  and  contracted ;  the  enlarged  glands,  when  cut 
into,  were  found  converted  into  firm  yellowish  masses,  quite  similar  to  those  met 
with  elsewhere.  The  pancreas  was  healthy;  the  stomach  felt  indurated  towards 
its  pyloric  end,  and  on  being  cut  into,  a  large  ulcer  was  found  near  the  pyloric 
orifice ;  it  was  of  an  oval  form,  about  3^  by  2^  inches,  its  longest  diameter  being 
from  above  downwards;  its  right  margin  was  about  an  inch  from  the  pylorus. 
The  ulcer  had  a  hard  thickened  base,  and  a  very  irregular  surface  from  the  presence 
of  numerous  fungating  excrescences  of  a  greyish-white  colour.  The  margins 
of  the  ulcer  were  elevated  above  the  surrounding  mucous  membrane,  but  were 
irregular  looking,  as  if  they  had  been  gnawed  bj'  some  animal.  There  was  no 
perforation.  The  rest  of  the  stomach  and  the  duodenum  were  healthy.  Some  of 
the  gastric  lymjyhatic  glands,  particularly  some  of  those  connected  with  the  lesser 
curvature,  were  enlarged  and  cancerous.  The  spleen  was  natural.  Tlie  kidneys, 
when  cut  into,  were  of  a  yellowish  colour ;  their  surface  was  a  little  irregular,  appa- 
rently resulting  from  old  cysts;  a  few  cysts  were  seen  in  the  surface,  and  also  in 
the  cortical  portion ;  several  of  the  lumbar  glands,  lower  down  than  the  mass  found 
behind  the  liver,  were  enlarged  and  similarly  aSected.  The  uterus  and  ovaries  were 
healthy. 

Microscopic  Ex.oiixatiox. — On  examining  a  little  of  the  juice  squeezed  out  of 
any  of  the  masses  above  described,  tolerably  large  nucleated  cells  were  found. 
Many  of  them  presented  the  usual  appearance  of  cancer  cells^  others,  however,  were 
small,  and  many  nuclei  were  seen  free.  In  the  opaque  portions,  the  cells  were  less 
distinct,  and  there  was  a  large  quantity  of  fattj'  matter.  The  cells  of  the  liver  con- 
tained a  good  deal  of  bOiary  matter,  but  they  were  otherwise  quite  healthy.  The 
kidneys,  when  examined  microscopically,  also  appeared  healthy. 

Commentary. — This  subject  of  cancer  of  the  lungs,  liver,  stomach,  and 
other  org-ans,  when  she  entered  the  clinical  ward,  presented  all  the 
symptoms  of  acute  peritonitis,  including  great  tenderness,  with  disten- 
sion of  the  abdomen,  fever,  and  increase  of  urates  in  the  urine.  There 
was,  however,  no  evidence,  on  palpation,  of  the  nodular  swellino-s  found 
after  death  ;  these  were  masked  by  the  accumulation  of  fluid  and  tym- 
panitis. Neither  did  physical  signs  indicate  the  cancerous  deposition  in 
the  lung,  it  being  so  diffused  as  not  to  occasion  any  marked  abnormal 
respiratory  symptoms ;  such  as  did  exist  were  explicable  bv  the  abdo- 
minal disease. 

The  facts  presented  in  these  three  cases  indicate  the  uncertainty  of 
our  diagnosis  in  abdominal  diseases.  In  the  first,  jt  is  true,  the  symp- 
toms corresponded  with  the  acute  peritonitis  of  authors;  but  in  the 
second  there  were  no  such  symptoms,  though  there  was  abundance  of 


508  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

exudation ',  while  tlie  third  case  presented  all  of  them  in  a  marked  and 
chai'acteristic  degree,  in  connection  with  cancer  of  the  abdominal  organs, 
and  effusion  of  serum.  I  never  saw  a  case  which  better  satisfied  me  of 
the  insufficiency  of  mere  symptoms,  for  the  purpose  of  arriving  at  an 
exact  knowledge  of  a  patient's  real  disease.  The  history  of  this  case,  it 
is  true,  indicated  the  existence  of  some  chronic  disease,  but  all  the 
positive  symptoms,  after  her  admission,  including  extreme  tenderness  of 
the  abdomen,  its  distension,  tympanitis,  constipation,  high  fever,  vomit- 
ing, etc.,  pointed  out  that  the  chronic  disease  of  the  stomach  and  other 
organs  had  terminated  in  acute  peritonitis.  Yet,  on  examination,  peri- 
tonitis there  was  none,  but  only  serous  effusion,  or  ascites  evidently 
resulting  from  the  organic  disease  of  the  liver  obstructing  the  abdominal 
circulation.  When  contrasted  with  the  last  case,  in  which  the  perito- 
neal membrane  was  covered  with  lymph,  the  present  one,  wdiere  it  was 
healthy,  exhibits  a  remarkable  discordance  with  systematic  descriptions 
of  disease.  The  true  exudation  had  not  one  of  the  so-called  symptoms 
of  that  lesion,  whereas,  in  the  last  case,  there  was  every  symptom,  with 
a  perfectly  sound  peritoneum.  I  have  recorded  therefore  this  case  at 
great  length,  because  the  acute  symptoms  will  speak  for  themselves,  and 
because,  when  compared  with  some  remarkable  cases  afterwards  to  be 
given  of  pleuritis  without  the  usual  symptoms,  it  serves,  in  my  opinion, 
to  convince  us  that  many  of  our  existing  notions  as  to  the  pathology  of 
acute  diseases  require  to  be  modified.  For  other  examples  of  perito- 
nitis, see  Cases  LVIII.  and  LXXVIII. 


Case  LXXXA'I.* — Cancero^is  PeriionitU — Ascites  and  Hydrofhorax — Paracentesis 
Abdominis — Arrested  Pldhisis  Pulmonalis. 

History. — Margaret  Purdou,  xt.  G3,  a  widow,  has  had  two  children — admitted 
December  15th,  1856.  Three  years  ago  she  had  profuse  hematemesis,  accompanied 
by  loss  of  blood  j^er  anum,  which  caused  faiiitness.  lu  a  few  days,  however,  she 
quite  recovered,  and  remained  perfectly  well  until  three  months  ago,  when  she  first 
observed  that  the  lower  part  of  the  abdomen  was  swollen,  but  not  painful.  About 
a  fortnight  afterwards  she  experienced  severe  pain  iu  the  left  lumbar  region, 
together  with  a  sensation  as  of  cold  water  trickling  down  her  left  thigh  as  far  as  the 
knee.  Two  months  after  the  first  sjaiiptoms  had  shown  themselves,  the  abdomen 
had  become  gradually  much  distended,  and  she  experienced  a  "dead  pain"  in 
the  epigastric  region,  which,  she  saj^s,  was  constant,  but  not  aggravated  by  pres- 
sure, and  caused  great  shortness  of  breath.  Simultaneously  with  this  epigastric  pain 
a  scantiness  and  turbidity  of  the  urine  appeared,  and  a  day  or  two  subsequently 
both  feet  and  legs  became  very  much  swollen,  the  right  one  especially  so.  During 
the  last  fortnight  she  has  taken  several  doses  of  rhubarb  and  magnesia,  the  purga- 
tive action  of  which  has  been  followed  by  considerable  alleviation  of  her  symptoms, 
and  diminution  in  the  size  of  the  abdomen,  and  of  the  dropsical  swelling  of  the 
inferior  extremities. 

Symptoms  on  Admission. — The  abdomen  is  so  distended  as  to  measure  at  the 
epigastrium  29J,  and  at  the  umbilicus  35  inches  round.  It  fluctuates  on  palpation, 
but  there  is  no  pain  on  pressure.  In  every  position  the  lower  portion  of  the  abdo- 
men is  dull,  and  the  upper  tympanitic  on  percussion.      Xo  tumour  can  be  detected, 

*  Reported  by  Mr.  Alexr.  M'Leod  Pemberton,  Clinical  Clerk. 


PERITONITIS. 


509 


nor  can  the  amount  of  the  hepatic  dulness  be  accurately  determined.  The  tongue 
is  covered  with  a  -white  fur  on  the  right  side,  and  is  perfectly  clean  on  the  left.  She 
has  a  good  appetite,  but  cannot  eat  much  on  account  of  the  uneasiness  it  occasions 
in  the  epigastrium — a  symptom  from  which  she  is  now  seldom  free.  The  bowels  are 
opened  naturally  every  other  day.  Xo  flatulence.  There  is  considerable  dyspnoea ; 
a  slight  cough,  but  no  sputum.  Percussion  is  resonant  over  the  whole  chest.  At 
the  apex  of  the  left  lung  expiration  is  prolonged  and  hard,  and  the  vocal  resonance 
increased.  Pulse  85,  of  good  strength.  Heart's  size  and  sounds  normal  The  face 
is  much  emaciated  and  pale.  Both  feet  and  legs  somewhat  cedematous,  the  right 
one  most  so.  Does  not  sleep  well  on  account  of  the  dyspnoea.  Urine  sp.  gr.  1012 ; 
contams  phosphates  in  solution,  but  no  albumen. 

Progress  of  the  Case. — January  bth. — Since  coming  into  the  house  she  has 
had  an  occasional  dose  of  castor  oil,  and  her  symptoms  have  on  the  whole  been  much 
alleviated.  There  is,  however,  great  orthopnoea  at  night,  and  she  says  it  is  easier 
to  lie  on  the  left  side.  A  careM  examination  to-day  has  determined  that  there  is 
great  dulness  on  percussion  over  the  lower  half  of  right  lung,  and  that  the  respira- 
tory murmurs  there  are  inaudible.  The  abdomen  now  measures  at  the  epigastrium 
31+,  and  at  the  umbilicus  37  inches.  Pulse  92,  feeble.  Passes  urme,  loaded  with 
phosphates,  freely.  To  have  eocira  radrknis,  and  fmir  ounces  of  wine  daily.  Ja- 
nuary I2ih. — In  consequence  of  the  great  dyspnoea,  which  is  daily  increasing,  para- 
centesis of  the  abdomen  was  performed,  and  190  ounces  of  a  pale,  greenish  yellow- 
fluid  were  drawn  off.  This  fluid  was  of  the  sp.  gr.  1012,  and  formed  a  sohd,  gela- 
tinous m;;ss  on  the  addition  of  heat.  On  standing  it  became  slightly  turbid,  but 
exhibited  nothing  but  a  few  scattered  blood  corpuscles  under  the  microscope.  The 
operation  was  followed  by  a  tendency  to  syncope,  which  was  removed  by  the  free 
use  of  port  wine  and  brandy.  Jan.  IStt.— Feels  greatly  relieved  by  the  operation. 
Several  nodulated  swellings  can  now  be  felt  under  the  flaccid  abdominal  mtegu- 
ments,  especially  on  the  left  side.  Ja7i.  14Wi.— Though  greatly  reUeved,  complains 
of  great  weakness.  Jan.  loth.— Though  liberally  supplied  with  stimulants,  died 
this  morning  at  half-past  two,  apparently  from  exliaustion. 

Secfio  Cudaveris. — Thirty-five  hours  after  death. 

External  Appearaxces. — Great  emaciation.  Abdomen  flaccid,  she  having  been 
tapped  a  short  time  before  her  death,  and  190  ounce,?  of  serum  removed. 

Thorax. — The  external  surface  of  the  pericardium  contained  a  number  of 
cancerous  nodules,  varying  in  size  from  a  pepper-corn  to  that  of  a  small  bean,  of  a 
white  and  pinkish-white  colour.  The  internal  layer  of  the  pericardium  and  the 
heart  were  healthy.  The  right  pleura  contained  about  four  pints  of  serum.  The 
lung  was  compressed  and  pushed  up  against  the  spine.  Its  upper  fomth  was 
spongy,  but  most  of  the  three  inferior  fourths  were  carnified,  and  contained  httle 
air.  Scattered  over  the  pulmonary  pleura  were  numerous  cancerous  masses,  of  a 
rounded  or  oval  form,  varying  from  the  size  of  a  pin's  head  to  that  of  a  split  pea- 
They  were  of  a  clear  white  colour,  rose  abruptly  from  the  pleura,  and  were  gene- 
rally half  a  line  or  a  line  deep.  Some  of  them  had  a  slight  central  depression,  and 
in  many,  blood-vessels  could  be  seen.  The  costal  pleura  had  sunilar  nodules,  and  flat 
patches  covering  it,  some  of  the  latter  being  the  diameter  of  a  shilling.  The  apex  of 
right  lung  was  strongly  puckered,  and  contained  several  concretions  surrounded  by 
dense  pigment ;  the  rest  of  its  tissue  was  healthy.  The  left  lung  was  more  volu- 
minous than  the  right.  The  pleurse  at  the  apex  were  adherent  and  thickened.  On 
section  this  was  found  to  correspond  to  an  old  tubercular  cavity  of  the  size  of  a 
small  filbert,  also  surrounded  by  dense  tissue  loaded  with  pigment.  The  substance 
of  the  lung  was  otherwise  healthy,  and  the  pleura?  generally  presented  only  a  few 


510  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

small  cancerous  masses  scattered  over  them,  similar  to  those  on  the  opposite  side. 
The  bronchial  and  mediastinal  glands  were  healtlw. 

Abdomex. — There  were  two  or  three  pints  of  clear  fluid  in  the  abdominal  cavity- 
The  whole  of  the  peritoneum  (parietal  and  visceral),  was  studded  over  with  can- 
cerous masses.  The  great  omentum  was  shrivelled,  drawn  up,  and  converted  into  a 
thick  mass  of  opaque,  moderately  firm,  cancerous  matter,  the  substance  of  which 
contained  numerous  yellow  opaque  pouits.  The  transverse  colon  was  dragged  up 
towards  the  stomach,  and  much  compressed  by  this  mass.  All  the  adjoinmg  veins 
were  greatly  congested.  The  peritoneum  covering  the  lower  surface  of  the  dia- 
phragm was  lined  by  a  thick  layer  of  cancerous  matter,  which  appeared  to  have  been 
deposited  in  nodules,  which  were  so  thickly  placed  as  to  have  run  into  one  another, 
forming  a  layer  about  two  lines  thick.  At  other  parts  of  the  peritoneum,  nodules 
and  small  patches  of  cancerous  matter  were  scattered  about.  The  whole  of  the 
mesentery  was  studded  with  little  masses  from  the  size  of  a  grain  of  sand  to  that  of 
a  pepper-corn.  Similar  masses  were  found  in  the  serous  coat  of  the  small  intestines. 
The  meso-colon  and  meso-rectum  were  thickened  and  covered  with  cancerous  masses. 
The  uterus,  urinary  bladder,  and  ovaries  were  matted  together  by  cancerous  exuda- 
tion. None  of  the  abdominal  viscera  or  glands  were  involved  in  the  cancerous  dis- 
ease, which  was  exclusively  confined  to  the  serous  membrane. 

Microscopic  Examination-.— The  difiierent  nodules  of  cancer  presented  all  stages 
of  development  and  disintegration  of  the  cancer  cell ;  in  some  places  numerous  naked 
nuclei ;  in  others,  large  compound  cells ;  la  others,  debris  and  fatty  degeneration, 
forming  yellow  masses  of  the  reticulum. 

Commentary. — The  insidious  approach  and  development  of  so  large 
an  amount  of  cancerous  exudation  on  the  peritoneum  is  worthy  of 
observation.  It  is  very  possible  that  the  disease  existed  three  years  pre- 
vious to  her  admission  into  the  house,  when  the  hemorrhage  occurred 
from  the  mucous  membrane  of  the  stomach  and  bowels.  But  she 
rapidly  recovered,  and  remained  well  until  dropsical  symptoms  super- 
vened'in  consequence  of  the  pressure  of  the  indurated  cancerous  masses 
on  the  abdominal  veins,  inducing  etfasion.  At  no  time  was  there  any 
general  fever,  pain,  nor  tenderness  on  pressure.  In  this  respect  the  case 
strongly  contrasts  with  the  last.  Here,  with  extensive  disease  of  the 
peritoneum,  there  were  no  symptoms  of  peritonitis;  there,  with  the 
peritoneum  perfectly  healthy,  violent  symptoms  of  peritonitis  were  mani- 
fested. Indeed,  the  only  symptoms 'occasioned  were  those  resulting 
from  pressure  on  the  lungs,  by  the  accumulation  of  serum  in  the  perito- 
neal and  right  pleural  cavities.  The  orthopnoea  thus  occasioned  was  so 
distressing  as  to  induce  me  to  have  the  abdomen  tapped ;  and  it  is 
worthy  of  remark  that,  although  thereby  the  greatest  relief  was  expe- 
rienced, she  rapidly  sank.  Indeed,  it  seldom  happens  when,  in  ascites, 
resulting  from  organic  disease,  this  operation  is  had  recourse  to,  that 
death  is'long  delayed — a  remarkable  proof  of  the  fallacy  of  that  system 
which  is  based  on  the  treatment  of  symptoms.  Hence,  as  with  the 
large  bleedings  formerly  practised  for  the  cure  of  inflammations,  it  is, 
true  we  give  relief,  but  we  also  increase  the  mortality. 

In  a  case  very  similar  to  the  above,  occurring  in  a  young  man,  i3et.  20, 
admitted  under  my  care  during  the  winter  1858,  there  was  the  same 
universal  cancerous  peritonitis,  and  the  same  distension  of^  the  abdomen 
from  fluid  without  local  tenderness.  Instead  of  "  nutmeg  liver" — that  is, 
incipient  cirrhosis — however,  the  organ  presented  the  disease  in  a  more 


PEEITONITIS.  ■  511 

advanced  condition.  Difficulty  of  breathing,  notwithstanding,  was  never 
so  nro-ent,  the  plenrte  being  healthy,  and  three  weeks  before  death,  the 
abdominal  tension  spontaneously  disappeared,  so  as  to  enable  me  to  feel 
the  nodulated  omentum  through  the  abdominal  walls,  and  thus  deter- 
mine the  nature  of  the  case.  He  was  a  groom,  and  the  first  symptom 
of  the  disease  appeared  in  the  form  of  varicose  veins  in  the  lower  extre- 
mities. These  on  admission  were  enormonsly  swollen  and  tortuous, 
especially  in  the  popliteal  and  inguinal  regions,  where  they  formed 
tumours  the  size  of  pigeons'  eggs.  After  death  the  swellings  were  found 
to  consist  of  distended  veins  tilled  witli  firmly  clotted  blood  of  a  red 
brick  colour.  The  cause  of  the  varicosities  in  the  extremities  was  the 
pressure  occasioned  by  the  tight  and  thickened  omentum  over  the 
external  iliac  veins,  just  before  they  passed  mider  Poupart's  ligament. 
It  results  that  the  cancer  must  have  existed  in  the  abdomen,  when  he 
was  actively  pursuing  his  employment,  for  the  varicosities  appeared  a 
year  before  his  admission.  In  both  cases  the  ascites  may  have  been 
mainly  owing  to  the  hepatic  disease.     (See  also  Case  LXXVII.) 


SECTION  VL 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

Before  proceeding  to  narrate  and  comment  on  lesions  of  tlie  heart  and 
large  vessels,  allow  me  to  remind  you  of  some  of  the  rules  which  the 
laborious  researches  of  many  able  men  have  established  for  your  guidance 
in  the  diagnosis  of  cardiac  diseases.     They  are  as  follows  : — 

1.  In  health,  the  cardiac  dulness,  on  percussion,  measures,  immediately 
below  the  nipple,  two  inches  across,  and  the  extent  of  dulness  beyond 
this  measurement  commonly  indicates  either  the  increased  size  of  the 
organ  or  undue  distension  of  the  pericardium. 

"2.  In  health,  the  apex  of  the  heart  may  be  felt  and  seen  to  strike  the 
chest  between  the  fifth  and  sixth  ribs,  immediately  below  and  a  little  to 
the  inside  of  the  left  nipple.  Any  variations  that  may  exist  in  the  posi- 
tion of  the  apex  are  indications  of  disease  either  of  the  lieart  itself  or  of 
the  parts  around  it. 

3.  A  friction  murmur,  synchronous  with  the  heart's  movements,  indi- 
cates pericardial  or  exo-pericardial  exudation. 

4.  A  bellows  murmur  with  the  first  sound,  heard  loudest  over  the 
apex,  indicates  mitral  insufficiency. 

5.  A  bellows  murmur  with  the  second  sound,  heard  loudest  at  the  base, 
indicates  aortic  insufticiency. 

G.  A  murmur  with  the  second  sound,  loudest  at  the  apex,  is  very  rare, 
but  when  present  it  indicates — 1st,  Aortic  disease,  the  murmur  being 
propagated  downwards  to  the  apex ;  or,  2d,  Roughened  auricular  surface 
of  the  mitral  valves ;  or,  3d,  Mitral  obstruction,  which  is  almost  always 
associated  with  insufficiency,  when  the  murmur  is  double,  or  occupies  the 
period  of  both  cardiac  sounds. 

1.  A  murmur  with  the  firet  sound,  loudest  at  the  base,  and  propagated 
in  the  direction  of  the  large  arteries,  is  more  common.  It  may  depend, 
— 1st,  On  an  altered  condition  of  the  blood,  as  in  anaemia;  or,  2d,  On 
dilatation  or  disease  of  the  aorta  itself;  or,  3dly,  On  stricture  of  the 
aortic  orifice,  or  disease  of  the  aortic  valves, — in  which  case  there  is 
almost  always  insufficiency  also,  and  then  the  murmur  is  double,  or 
occupies  the'period  of  both  sounds.    I  have  also  seen  cases  which  satisfy 


DISEASES   OF   THE   CIRCULATORY   SYSTEil.  513 

rae  that  it  may  occasionally  depend  on  roughness  of  the  ventricular  sur- 
face of  the  mitral  valves,  and  on  coagulated  exudation  attached  to  the 
internal  surface  of  the  heart. 

8.  Ilvpertrophy  of  the  heart  may  exist  independently  of  valvular  dis- 
ease, but  this  is  very  rare.  In  the  vast  majority  of  cases  it  is  the  left 
ventricle  which  is  affected,  and  in  connexion  with  mitral  or  aortic  dis- 
ease. In  the  former  case  the  hypertrophy  is  uniform  with  rounding  of 
the  apex ;  in  the  latter,  there  is  dilated  hypertrophy,  with  elongation  of 
the  apex. 

Attention  to  these  rules  alone  will,  in  the  great  majority  of  cases, 
enable  you  to  arrive  with  precision  at  the  nature  of  the  lesion  present. 
In  cases  in  which  there  may  be  any  doubt,  you  will  derive  further 
assistance  from  an  observation  of  the  concomitant  symptoms,  such  as, — 
1st,  The  nature  of  the  pulse  at  the  wrist;  2d,  The  nature  of  the  pul- 
monary or  cerebral  derangements.  Thus,  as  a  general  rule,  but  one  on 
which 'you  must  not  place  too  much  confidence,  the  pulse  is  soft  or  irre- 
gular in  mitral  disease,  but  hard,  jerking,  or  regular  in  aortic  disease. 
Again  it  has  been  observed  that  cerebral  symptoms  are  more  common 
ami  urgent  in  aortic  disease,  and  pulmonary  symptoms  more  common 
and  urgent  in  mitral  disease. 

1  have  purposely  said  nothing  now  of  diseases  of  the  right  side  of  the 
heart,  and  of  a  few  other  rare  disordered  conditions  of  the  organ,  because 
I  am  convinced  that  an  appreciation  of  the  rules  above  given  is  the  best 
method  of  enabling  you  to  comprehend  and  easily  detect  any  exceptional 
cases  which  may  arise.  In  truth,  however,  I  have  remarked  in  our 
examinations  at  the  bedside  that  your  difficulty  is,  not  how  to  arrive  at 
correct  conclusions  from  such  and  such  data,  but  hoiv  to  arrive  at  the 
data  themseloes.  You  have  to  determine,— 1st,  By  percussion,  whether 
the  heart  be  of  its  normal  size  or  not ;  2d,  Whether  an  abnormal  murmur 
does  or  does  not  exist ;  3d,  If  it  be  present,  whether  it  accompanies  the 
first  or  second  sound  of  the  heart;  and  4thly,  At  what  place  and  in  what 
direction  the  murmur  is  heard  loudest,  these  points  ascertained,  the 
conclusion  flows  from  the  rules  previously  given.  But  no  instruction  on 
my  part,  no  reading  or  reflection  on  yours,  will  enable  you  to  ascertain 
these  facts  for  yourselves.  In  short,  nothing  but  percussing  the  cardiac 
region  with  your  ow.u  hands,  and  carefully  listening  to  the  sounds  with 
your  own  ears,  can  be  of  the  slightest  service,  and  the  sooner  you  feel 
convinced  of  this  truth  the  sooner  are  you  likely  to  overcome  these  pre- 
liminarv  difiiculties.  This  is  the  reason  why  a  series  of  cases  assembled 
in  the  ward  of  an  hospital  is  so  valuable.  By  careful  examination  of  them, 
you  can  at  once  convince  yourselves  of  the  accuracy  of  the  facts  affirmed 
by  others  to  exist, — reflect  on  the  probable  correctness  of  the  diagnosis 
formed  at  the  bedside,  watch  the  various  complications,  and  the  efl"ects 
of  treatment,  and  finally,  observe  how,  in  the  fatal  cases,  by  following 
the  rules  given,  the  accuracy  of  the  diagnosis  has  or  has  not  been  con- 
firmed by  post-mortem  examination. 

After  you  have  made  yourselves  familiar  with  the  ordinary  forms  of 
heart  disease,  you  will  find 'that  occasionally  very  puzzling  instances  occur 
where  the  above  rules  do  not  apply,  these'  exceptional  cases  should 
always  be  carefully  studied.  Indeed,  this  is  what  is  now  being  done  by 
the  cultivators  of  physical  diagnosis  throughout  Europe,  with  a  view,  if 

33 


514  DISEASES   OF   THE   CIECULATORT   SYSTEM. 

possible,  of  determining  the  characters  wliich  distinguish  disease  of  the 
right  from  disease  of  the  left  side  of  the  heart ;  those  indicative  of  lesions 
of  the  pulmonary  artery,  of  chronic  forms  of  pericarditis,  of  open  foramen 
ovale,  of  clots  in  the  ventricles  or  auricles,  etc.  etc.  Well  observed  cases 
of  these  rarer  diseases,  however,  are  still  too  few  to  enable  us  to  generalize 
confidently  regarding  them.  I  have  frequently  examined  exceptional 
combinations  of  signs  with  the  utmost  care,  and  then  been  denied  a  post- 
mortem examination,  or  again  have  stumbled  on  rare  forms  of  lesions 
after  death  in  cases,  where  during  life  sufficiently  careful  and  repeated 
examination  of  the  physical  signs  had  not  been  made  to  secure  accuracy. 
I  would  strongly  advise  you  to  attach  little  importance  to  the  record  of 
such  exceptional  cases,  and  never  to  record  such  yourselves,  unless  equal 
care  have  been  shown  in  the  examination  of  physical  signs  and  functional 
svmptoms  during  life  on  the  one  hand,  and  in  anatomical  investigation 
after  death  on  the  other. 


PERICARDITIS. 
Case  LXXXTII.* — Acute  Pericarditis — Recovery. 

History. — Jane  Stambroke,  aet.  25,  servant — admitted  January  7tli,  1857.  Six 
months  ago  she  entered  another  ward  in  the  Infirmary,  on  account  of  rheumatic 
pains  in  the  ankle  joints.  These  pains  were  unaccompanied  by  general  fever,  and 
there  is  no  evidence  that  the  heart  was  then  affected.  During  the  last  six  weeks, 
however,  she  has  experienced  considerable  dyspnoea,  palpitation,  and  uneasiness  over 
the  central  part  of  the  sternum,  increased  by  active  exertion,  or  on  ascending  stairs. 
Five  days  ago,  after  exposure  to  sudden  changes  of  temperature,  she  experienced 
towards  evening  a  distinct  rigor  and  increased  pain  in  the  prKCordia,  which  com- 
pelled her  to  desist  from  working,  and  retire  to  bed  at  an  earlier  hour  than  usual. 
The  next  day  she  felt  somewhat  easier,  but  on  the  following  one  the  symptoms 
increased  in  intensity,  and  have  continued  up  to  the  present  time.  Yesterday 
evening  six  leeches  were  applied,  and  caused  reliefj  which,  however,  was  not 
permanent. 

SviiPTOiis  ox  Acinssiox. — Cardiac  impulse  is  faintly  felt  between  the  fourth  and 
fifth  ribs.  Dulness  on  percussion,  at  the  level  of  nipple,  extends  transversely  four 
inches  from  the  right  edge  of  the  sternum,  which  is  its  internal  boundary.  On  auscul- 
tation a  loud  double  friction  murmur  is  audible,  over  and  limited  to  the  cardiac  organ, 
loudest  over  the  sternum  and  base.  The  systolic  and  diastolic  sounds  are  inaudi- 
ble in  consequence  of  the  loud  friction  murmurs.  Pulse  108,  regular  and  of  moderate 
strength.  She  cannot  lie  on  either  side,  and  prefers  the  sitting  to  the  recumbent 
posture.  Says  she  has  a  slight  cough  but  no  expectoration.  Percussion  elicits  com- 
parative dulness  over  the  two  lower  thirds  of  left  back,  and  there  is  audible  over 
the  same  space  increased  vocal  resonance  and  cegophony,  without  rales.  Inspiratory 
murmur  on  right  side  is  somewhat  harsh,  but  otherwise  normal ;  is  sleepless  in  con- 
bequence  of  cardiac  uneasiness  and  dyspnoea,  which  is  considerable.  Has  not  men- 
struated for  the  last  two  months,  but  the  other  fimctions  are  well  performed.  Warm 
fumentatiom  to  ie  constantly  applied  to  the  prcecordial  region. 

Progress   of   the   Case. — January  9th. — The  pains  and  dyspnoea  have  been 

*  Reported  by  Mr.  M'Leod  Pemberton,  Clinical  Clerk. 


PERICARDITIS.  515 

greatly  relieved  by  the  fomentations.  Xo  friction  murmur  audible.  The  urine 
densely  loaded  with  urates.  Pulse  80,  soft.  Nutrients  ivith  zvine.  §  ij.  Jan.  lOth  — 
No  pain  or  dyspnoea.  Friction  sound  slight,  and  only  audible  over  right  side  of 
cardiac  organ  towards  the  base.  Transverse  dulness  there  is  diminished  by  a  quar- 
ter of  an  inch.  Physical  signs  of  left  lung  the  same.  No  crepitation.  Chlorides  in 
the  urine  abundant.  Jan.  Uih — Xo  friction  audible  over  heart,  but  cardiac  sounds 
are  distant.  From  this  time  she  rapidly  became  well.  On  the  13th,  marked  dul- 
ness, increased  vocal  resonance,  and  oegophony  much  diminished  over  left  back. 
On  the  18th,  the  transverse  cardiac  dulness  measured  two  and  a  half  inches,  and 
there  remained  only  increased  sense  of  resistance  on  percussion  over  left  back,  with 
slight  oegophony.  On  the  23d,  complained  of  loss  of  appetite  and  slight  dyspeptic 
symptoms,  which  disappeared  the  following  day.  On  the  27th  she  walked  out  and 
did  not  experience  so  much  palpitation  or  dyspnoea  as  before  the  present  attack. 
Was  dismissed  Jan.  31st. 

Commeiitari/. — This  was  a  pure  case  of  pericarditis  in  a  rheumatic 
girl,  in  which  all  the  symptoms  aud  physical  signs  were  very  carefully 
examined.  The  disease  went  through  its  natural  stages  with  great 
rapiditv.  On  the  fifth  day,  when  she  was  admitted,  there  was  great 
distension  of  the  pericardium  from  exudation,  with  friction  sounds. 
Then  for  a  dav  these  were  absent,  probably  from  the  two  surfaces 
being  separated"  by  serum.  On  the  seventh  day,  distension  of  the  peri- 
cardium began  to' diminish,  and  there  was  slight  return  of  the  friction. 
From  this  time  there  was  rapid  decline  in  the  area  of  dulness,  which 
on  the  fifteenth  day  was  nearly  normal.  The  local  pain  she  experienced 
was  before  admission  treated  by  the  application  of  six  leeches,  but  was 
still  present  on  her  admission.  Warm  fomentations  to  the  part  removed 
it  at  once,  and  constituted  the  only  medical  treatment  she  was  subjected 
to  in  the  house.  Nutrients  of  course  were  given,  and  a  little  wine. 
The  pulmonary  physical  signs  were  probably  dependent  on  pressure  of 
the  lung  backwards  by  the  distended  pericardial  sac. 


Case  LXXXVIIL* — Pericarditis  and  Endocarditis — Hydropericardium. 

History. — Barney  Kilpatrick,  ajt.  25,  a  miner — admitted  July  8th.  18.50.  Xine 
weeks  ago  he  was  suddenly  seized  with  dyspnoea  and  a  feeling  of  weight  or  dull  pain 
in  the  cardiac  region.  A  fortnight  since,  this  became  much  more  acute,  and  has 
continued  up  to  the  time  of  admission.  For  five  years  he  has  been  much  exposed 
to  wet  and  changes  of  temperature,  but  never  had  rheumatism. 

Syitptoms  ox  Adiiissio.v. — Cardiac  dulness  measures  three  and  a  quarter  inches 
transversely-,  and  is  limited  above  by  the  margin  of  the  third  rib.  Apex  beats 
between  the  fifth  and  sixth  ribs,  two  inches  below,  and  considerably  to  the  right  of 
the  nipple.  All  over  the  dull  region  a  double  friction  sound  is  heard,  resembling  a 
roughened  beUows  murmur,  but  superficial.  Beyond  the  region  of  the  dulness  these 
murmurs  suddenly  cease.  Action  of  the  heart  regular.  Pulse  96,  regular,  small, 
and  feeble,  stronger  on  the  right  than  on  the  left  side.  The  slightest  movement 
induces  pain,  extending  from  the  cardiac  region  down  the  left  arm  to  the  fingers ; 
great  dyspnoea ;  no  cough  or  other  pulmonary  symptoms ;  no  fever ;  no  cerebral 
symptoms  or  tendency  to  syncope. 

*  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


516  DISEASES   OF  THE   CIRCULATORY   SYSTEM. 

Treatment  axd  Progress  of  the  Case. — Twelve  leeclies  were  ordered  to  be 
applied  to  the  cardiac  region,  and  a  calomel  and  opium  pill  to  be  taken  every  six 
hours.  On  the  11th,  the  friction  murmurs  were  much  louder  at  the  base  than  at  the 
apex.  The  pulse  108 ;  feeble  at  left  wrist ;  at  the  right  wrist  it  had  a  double  impulse, 
— a  pretty  strong  beat  being  followed  by  a  weaker  one.  §  vj.  of  hlood  to  he  drawn 
from  the  cardiac  region  by  cupping,  and  a  pill  to  he  taken  every  four  hours.  On  the 
13th  the  breath  had  a  mercurial  foetor.  Pulse  stronger;  less  dyspnoea;  friction 
murmurs  more  faint ;  pain  in  arm  diminished.  On  the  1 4th,  pulse  full ;  slight  fever; 
six  leeches  to  be  applied  to  the  cardiac  region ;  morphia  draught  at  night.  On  the 
15th.  friction  murmurs  only  heard  at  the  base;  anorexia;  can  take  no  food;  omit 
calomel  and  opium  pills.  \Gth. — Friction  murmurs  have  disappeared,  but  there  is  a 
soft  bellows  murmur  with  the  second  sound,  heard  at  the  base.  18//i. — Had  an 
attack  of  severe  dyspnoea  and  syncope ;  pulse  100,  regular,  but  feeble :  ^  iv  of  wme ; 
cardiac  dulness  increased.  \Wi. — Orthopnoea  ;  pulse  weak  and  fluttering ;  a  quiver- 
ing pulsation  felt  in  the  cardiac  region ;  iaintness ;  oedema  of  feet  and  legs.  Stimu- 
lants to  be  freely  administered.     Died  earl}'  in  the  morning  of  the  20th. 

Examination  of  the  body  was  not  allowed. 

Commentary. — This  was  a  well-characterised  case  of  pericarditis.  At 
first  the  eiidocardial  iiiunnur  was  masked  by  the  friction  sounds,  but,  as 
these  disappeared,  its  existence  became  apparent.  It  was  observed  that, 
as  the  mercury  atfected  the  system,  the  friction  murmur  diminished  ;  but 
there  is  every  reason  to  believe  that  this  was  not  so  much  owing  to 
absorption  of  the  exudation,  as  to  increase  in  the  amount  of  serous  effu- 
sion. To  the  combined  eftects  of  pressure  on  the  heart  from  liquid  with- 
out, and  incapability  of  performing  its  function  from  incompetency  of 
the  aortic  valve,  the  fatal  event  must  be  atti'ibuted. 

Since  this  case  occurred,  upwards  of  seven  years  ago,  I  have  satisfied 
myself  that  the  treatment  pursued  was  not  judicious,  and  that  the  local 
abstraction  of  blood,  with  administration  of  mercury  under  such  circum- 
stances, is  not  only  useless  but  injurious.  It  is  true  no  fair  comparison 
can  be  drawn  between  this  and  the  preceding  case,  inasmuch  as  here  we 
had  undoubted  valvular  lesion  complicating  the  pericarditis.  But  this 
ought  to  be  an  additional  reason  against  depletion.  I  have  given  it, 
however,  as  a  fair  example  of  cases  that  used  formerly  to  be  pretty 
common,  but  which  now,  owing  to  our  improved  pathological  views 
applied  to  practice,  are  somewhat  rare.  The  following  case  was  treated 
ditlerently. 


Case  LXXXIX.* — Acute  Pericarditis  followed  hy  Acute  Douhle  Pneumonia — Recovery 
— Aortic  Incompetence — Suhsequent  Articular  Rheumatism — Sudden  Death — 
Adherent  Pericardium — Fatty  Enlarged  Heart — Thickening  of  Aortic  Valves. 

History. — Jessie  Douglas,  fet.  22,  employed  in  a  paper  warehouse — admitted 
November  19th,  1855.  Has  never  been  very  healthy ;  has  had  several  attacks  of 
rheumatic  fever,  the  last  being  about  seven  years  ago.  On  the  9th  current,  after 
exposure  to  cold  and  damp,  she  was  seized  with  rigors  and  pain  in  the  back.  These 
disappearing,  were  succeeded  by  pain  and  slight  swelling  of  the  knees,  lasting  only 
for  a  few  days.     During  aU  this  time,  though  ill,  she  had  no  headache,  vomiting, 

*  Reported  by  Messrs.  Geo.  Robertson  and  R.  P.  Ritchie,  Clinical  Clerks. 


PERICARDITIS.  517 

nor  pain  in  the  chest,  but  the  shortness  of  breath  and  palpitation  to  whicli  she  is 
subject  became  aggravated.  She  was  under  medical  treatment,  and  got  purgative 
medicines,  but  was  neither  bled  nor  leeched. 

Symptoms  ox  Adjiissiox. — Apex  beats  distinctly  between  the  fourth  and  fifth 
ribs,  immediately  under  and  a  little  to  the  inside  of  the  nipple ;  heart's  impulse  is 
heaving,  and  sensibly  moves  the  whole  mamma ;  it  can  be  felt  but  very  indistinctly 
in  the  normal  position ;  there  is  no  thrilL  Transverse  dulness  at  the  level  of  the 
nipple  4f  inches.  Heart  sounds  are  exceedingly  indistinct,  and  muffled  at  the  apex, 
but  no  murmur  is  heard  there.  At  the  base  the  first  sound  is  almost  inaudible,  but 
with  the  second  there  is  heard  a  soft  blowing  murmur.  Pulse  80,  full,  regular, 
incompressible.  Breathing  is  rather  laboured ;  respirations  are  34  per  minute,  but 
regular;  there  is  shght  cough  and  no  sputum.  Percussion  is  everywhere  good; 
vocal  resonance  is  greater  under  the  left  than  under  the  right  clavicle ;  no  rale  is 
audible,  but  respiration  is  exaggerated  under  the  right  clavicle,  and  inspiration  is 
blowing  under  the  left.  She  speaks  languidly,  does  not  sleep,  and  on  sitting  up 
feels  faint.  She  is  thirsty,  and  has  no  appetite ;  the  bowels  are  open ;  catamenia 
are  regular.  Urine  is  neutral,  sp.  gr.  1018,  not  albuminous;  deposits  copious  urates 
and  phosphates;  contains  no  chlorides.  Patient  lies  on  her  back;  cheeks  rather 
flushed  ;  the  skin  warm  and  perspiring ;  no  pain  nor  swelling  of  any  joints.  Ordered 
half  an  ounce  every  fourth  hour  of  the  foUnwing : — IJ  LUiuor.  Amnion.  Acetai.  et  AqmB 
aa  3  ij. 

Progress  of  tue  Case. — Xovember  20(h. — At  the  apex,  the  cardiac  sounds  con- 
tinue exceedingly  indistinct  and  muffled.  At  the  base,  immediately  above  the 
nipple,  there  is  heard  with  each  cardiac  sound  an  exceedingly  soft  blowing  noise 
equal  in  intensity  and  duration ;  it  extends  over  a  considerable  space,  being  heard 
but  very  feebly  under  the  right  nipple.  Immediately  under  the  centre  of  both 
clavicles,  there  is  a  prolonged  blowing  noise,  occupying  the  period  of  both  sounds. 
Pulse  72,  full  and  somewhat  jerking;  palpitations  are  occasionally  urgent;  respi- 
rations 36,  laboured.  Ordered  ivjelve  leeches  to  be  applied  over  the  pnecordia.,  and 
subsequently  warm  fomentations.  21st. — The  leech  bites  bled  well.  There  is  great 
heaving  and  expansive  motion  of  the  whole  prjecordia ;  at  the  apex  murmurs  are 
indistinct — at  the  base  a  double  blowing  murmur,  most  clear  over  the  head  of  the 
sternum.  There  is  no  friction  audible — no  pain,  and  the  palpitations  are  not  increased. 
Pulse  80,  slightly  jerking,  but  weak.  She  cannot  sit  up  from  tendency  to  faint ;  is 
depressed  and  exhausted  in  her  aspect.  Urine  scanty ;  still  contains  no  chlorides. 
Ordered  three  ounces  of  wine  iviih  beef-tea;  to  be  kept  perfectly  quiet.  22d. — 
The  skin  is  covered  with  moisture ;  respirations  46 ;  pulse  84 ;  still  jerking  and 
weak.  The  apex  beats  exactly  under  the  fifth  rib,  a  little  to  the  inside  of  the 
nipple.  At  the  base  there  is  now  a  loud  creaking  which  is  double,  and  very  loud 
at  the  margin  of  the  sternum.  Transverse  dulness  3^  mches.  Ordered  to  discon- 
tinue the  saline  mixture.  In  the  evening  loud  friction  was  audible  at  the  apex 
as  well  as  at  the  base,  and  the  apex  beat  had  fallen  about  two  lines  below  and 
to  the  inner  side.  23d — Pulse  72,  of  same  character;  respirations  35.  At  the 
base  of  the  cardiac  organ,  instead  of  the  double  friction  heard  yesterday,  there 
is  now  a  single  continuous  creaking.  The  same  sound  is  audible  at  the  apex. 
24:th. — Pulse  80,  still  shghtly  jerking,  but  soft;  respirations  36;  apex  as  yesterday. 
There  is  a  continuous  churning  friction  at  base;  at  the  apex  it  is  heard,  but  less 
loud  and  continuous.  5  Sjnr.  ^Iher.  Nitrici  3  iij ;  Tinct.  Colchici  3  j ;  Aqxus 
§  vss ;  M.  One  ounce  thrice  a-day.  Also  ^.  Pulv.  Opii  gr.  iij ;  Extract.  Catechu 
gr.  XV ;  Confect.  Rosar.  q.  s.  ut  fiat  massa  in  pilulas  sex  dividenda ;  one  to  be  taken 
every  sixth  liour.  2oth. — The  same  friction  murmur ;  pulse  80  :  respirations  36 ; 
m"ine   is   hyperhthic,    and   still   contauis   no   chlorides.     2(ith. — Pulse   82,   slightly 


518  DISEASES   OF   THE   CIRCULATOEY   SYSTEM. 

jerking,  more  compressible;  respirations  32;  skin  chy  andhot;  tongue  moist ;  has 
no  appetite ;  urine  the  same  in  character ;  the  friction  is  less  churning  and  continuous, 
and  occurs  more  with  the  fii'st  sound.  28<7i. — At  the  visit  to-day,  dulness  is  detected 
in  the  left  scapular  region  near  the  inferior  angle,  over  a  space  the  size  of  the  hand, 
with  crepitation,  and  pealing  vocal  resonance.  Friction  in  cardiac  region  is  now 
diminishing  both  in  intensity  and  duration.  Ordered  three  additional  ounces  of  wine. 
(From  this  day  commenced  an  intercurrent  attack  of  pneumonia,  affecting  the  left 
lung,  terminatuig  in  seven  days.  Besides  dulness,  crepitation,  and  increased  vocal 
resonance,  there  were  on  the  fourth  and  fifth  days  a  friction  murmur  at  the  base  of 
the  left  lung.  The  chlorides  began  to  reappear  in  the  urine  on  the  fourth  day.  A 
blister  vjas  aijplied  (3  by  4)  to  the  right  side  anterioiiy  on  the  29</i,  and  of  the  same 
size  to  the  left  lateral  region  on  Dec.  2d.)  Dec.  2d. — On  percussion,  the  transverse 
cardiac  dulness  is  3 J  inches ;  the  apex  beats  feebly  between  the  fifth  and  sixth  ribs. 
At  the  base,  one  long  rough  prolonged  sound  is  heard,  and  at  the  level  of  the  nipple 
this  is  plainly  connected  with  a  second  of  a  friction  character.  Over  the  centre  of 
the  sternum,  on  a  level  with  the  nipple,  this  hoarse  blowing  (or  friction  ?)  is  loudest, 
and  is  still  audible  at  the  right  of  the  sternum  within  \l  Inch  of  the  right  nipple. 
Pulse  96,  still  jerking  and  soft.  Dec.  &th. — Considerable  dulness  detected  to-day  on 
the  right  side  from  the  inferior  angle  of  scapula  to  the  base.  Respiration  is  almost 
inaudible,  and  is  faintly  bronchial.  Over  area  of  dulness  a  little  tine  crepitation  may 
also  be  detected  on  inspiration,  and  vocal  resonance  is  increased.  Pulse  126,  soft, 
jerking;  respirations  52 ;  great  dyspnoea.  (From  this  attack  of  pneumonia  on  the 
right  side,  the  patient  began  to  recover  on  the  seventh  day.  Throughout  the  whole 
course  of  it,  the  chlorides  in  the  urine  were  abundant ;  there  was  little  cough  or 
sputum.)  Dec.  \2th. — The  cardiac  friction  murmur  has  totally  disappeared  from  the 
apex.  At  the  base  a  blowing  murmur  is  now  heard  with  the  second  sound,  the  first 
being  free  from  murmur.  2Qth. — This  morning,  about  9.30,  the  patient  having 
assumed  the  recumbent  position  for  a  few  minutes,  violent  palpitations  came  on,  and 
forced  her  to  sit  up ;  she  felt  as  if  about  to  faint,  and  was  so  agitated  as  to  be  almost 
unconscious.  At  11  a.m.,  the  palpitation  had  somewhat  subsided,  but  the  cardiac 
action  was  still  very  violent,  shaking  the  whole  person,  and  causing  severe  pain  in 
the  chest.  Pulse  almost  continuous,  beating  about  180  times  in  a  minute,  jerking, 
and  incompressible ;  no  difficulty  of  breathing ;  no  aflection  of  the  head  ;  face  pale 
and  anxious ;  patient  restless,  and  occasionally  moaning.  The  urine  passed  soon 
after  this  paroxysm  is  scanty,  of  brick  colour,  turbid,  clears  up  on  application  of  heat, 
but  on  further  heating  and  being  fully  acidified,  a  slight  coagulum  is  obtained.  From 
this  paroxysm  she  recovered  towards  the  evening,  under  the  use  of  Ammoniated 
Tincture  of  Valerian  and  Sol.  Mur.  Morphice.  Zlst. — Patient  now  sits  up  for  about 
two  hours  every  day,  and  begins  to  be  very  hungry.  January  1st. — Cardiac  signs 
are  the  same  as  at  last  report ;  at  the  apex  nothmg  but  a  dull  impulse  is  heard ;  at 
the  base  there  is  still  the  blowing  with  the  second  sound.  From  this  date  she  gra- 
dually increased  in  strength,  moving  about  in  the  ward  and  occasionally  taking 
walks  in  the  town.  The  pulse  90  to  100  per  minute ;  was  easily  raised  to  100  or 
120  by  excitement.  Palpitations  also  were  readily  caused  by  any  surprise,  lasting 
for  about  fifteen  minutes,  and  accompanied  by  a  marked  soreness  along  the  sternum. 
On  the  15th  of  February  it  is  reported  no  change  in  the  cardiac  sounds  had  occurred. 
The  transverse  dulness  2f  inches;  the  pulse  96,  fuU  and  regular,  retains  its  jerking 
character.     Is  discliarged  much  relieved  on  the  17  th  February. 

She  was  re-admitted  (under  the  care  of  Dr.  Christison)  on  the  29th  of  February, 
labouring  under  an  attack  of  articular  rheumatism ;  she  gradually  became  conva- 
lescent, but  continued  weak,  easily  agitated,  with  painful  palpitations  and  threaten- 
ino-  of  syncope.    The  blowing  murmur  with  the  second  sound  at  the  base  continued, 


PERICARDITIS.  519 

but  the  most  careful  examinatioir,  by  inspection,  percussion,  or  auscultation,  failed 
to  elicit  any  other  physical  sign,  the  dulness  being  still  3|  inches  across.  In  this 
condition  she  continued  in  the  ward,  moving  about,  and  in  tolerable  health,  when 
on  the  evening  of  May  14th  she  suddenly  started  up  with  a  cry,  and  immediately 
fell  back,  pale,  gasping,  and  almost  pulseless,  and  expu-ed  within  three  minutes,  not- 
withstanding the  sedulous  administration  of  restoratives  and  stimulants. 

Sectio  Cadaveris. —  Thirty-nine  hours  after  death. 

Thorax. — The  pericardium  was  found  universally  adlierent.  The  heart  was 
uniformly  enlarged,  weighing  twenty-eight  ounces.  On  passing  a  stream  of  Avater 
down  the  aorta,  it  escaped  very  freely  into  the  ventricle.  On  examination  the 
aortic  semilunar  valves  were  found  thickened  and  shortened.  There  were  no  vegeta- 
tions on  the  valves.  The  auriculo- ventricular  orifices,  especially  on  the  right  side, 
were  a  little  dilated.  The  lelt  ventricle  was  very  much  dilated,  and  its  waUs  were 
fully  of  the  normal  thickness.  The  right  ventricle  was  of  normal  dimensions.  The 
lungs  were  congested  posteriorly  and  inferiorly,  but  were  otherwise  everywhere 
natural.  The  muscular  substance  of  the  heart  was  everywhere  of  a  pale  fawn 
colour,  soft,  and  easily  breaking  down  under  the  finger. 

Abdoiiex. — The  abdominal  organs  were  natural. 

Microscopic  ExAiiixATiox. — The  pericardial  adhesions  were  composed  of  well- 
formed  areolar  texture,  in  firm  bands  aggregated  closely  together.  The  substance 
of  the  heart  presented  all  stages  of  the  muscular  fatty  transformation ;  the  fasciculi 
in  most  places  being  brittle  and  the  transverse  stride  obscure,  whUe  here  and  there 
fatty  granules  were  numerous,  displacing  more  or  less  of  the  sarcous  substance. 

Commentary. — This  case  was  carefully  observed  for  nearlv  a  period 
of  six  months.  On  admission  it  was  evident  that  a  pericarditis  existed 
with  such  distension  of  the  pericardium,  that  the  two  diseased  surfaces 
did  not  rub  upon  one  another,  so  as  to  occasion  friction  murmurs.  The 
pulse  was  full  and  jerking,  but  the  exact  character  of  the  valvular 
lesion  could  not  then  be  determined.  There  was  also  dyspnoea,  and 
with  a  view  of  diminishing  this  and  other  symptoms,  twelve  leeches 
were  applied,  with  the  etfect,  however,  of  rendering  her  weak  and 
faint.  Wine,  nutrients,  and  quietude  were  immediately  ordered,  and 
subsequently  constituted  the  treatment.  The  following  day  the  peri- 
cardial distension  began  to  diminish,  and  a  returning  friction  Biurmur 
to  appear.  As  the  pericarditic  signs  decreased,  the  evidence  of  aortic 
incompetency  became  more  evident,  and  latterly  a  prolonged  blowing 
with  the  second  sound  at  the  base  was  the  permanent  sign  of  aortic 
valvular  lesion.  She  also  suffered  from  two  distinct  attacks  of  pneu- 
monia, cue  on  the  left,  and  then  subsequently  on  the  right  side,  durino- 
the  whole  of  which  time  wine  with  nutrients  were  assiduously  adminis- 
tered, with  the  effect  of  conducting  her  favourably  throuo-h  these  for- 
midable complications.  All  who  witnessed  the  case  were  satisfied  that 
this  woman,  during  these  two  pneumonic  attacks,  in  both  of  which 
were  present  all  the  characteristic  symptoms  and  physical  sio-ns  of  the 
disease,  owed  her  life  to  good  nourishment  and  stimulants,  and  that 
the  slightest  approach  towards  an  antiphlogistic  treatment  would  have 
been  fatal.  It  was  further  observable,  that  at  this  time  the  pulse  was 
full  and  jerking — many  would  have  called  it  hard — so  that  she  pre- 
sented   what   has   frequently   been    described  as  the  symptoms   of  an 


520  DISE.iSES   OF  THE   CIECULATORY  SYSTEM. 

exquisite  case  of  pneumonia;  in  shoit,  that  very  group  of  symptoms 
in  -which  writers  have  advised  us  to  bleed  largely.  I  have  myself  no 
doubt,  that  such  cases  with  aortic  disease  and  dyspnoea  were,  pre- 
vious to  the  days  of  physical  diagnosis,  regarded  as  typical  examples 
of  pneumonia,  were  bled  largely,  and  served  to  swell  the  great  mor- 
tality which,  as  we  have  previously  shown,  characterised  a  former 
practice.  Under  an  opposite  treatment,  however,  she  gradually  re- 
covered, and  became  so  well  (though  still  labouring  under  the  aortic 
incompetency  with  tendency  to  palpitation),  that  she  insisted  on  going 
out.  She  was  so  imprudent,  however,  as  again  to  catch  articular 
rheumatism,  and  re-entered  the  Infirmary ;  the  cardiac  physical  signs 
and  symptoms,  however,  remaining  unchanged.  She  again  recovered, 
but  died  suddenly  from  a  fatal  syncope.  On  examination  of  the  body, 
the  con-ectness  of  all  the  facts  observed  was  confirmed,  and  the  nature 
of  the  case  rendered  perfectly  clear.  The  two  layers  of  the  pericar- 
dium were  eveiTwhere  adherent;  the  aortic  valves  were  thickened 
and  incompetent,  explaining  the  persistence  of  the  valvular  murmur 
and  jerking  pulse;  the  left  ventricle  was  hypertrophied,  as  shown  by 
percussion  ;  and  the  muscular  substance  of  the  heart  was  fatty,  account- 
iue:  for  the  sudden  death. 


Case  XC* — Acute  Pericarditis  supervening  on  Phthisis. 

History. — Edward  Campbell,  xt.  30,  a  porter — admitted  September  5th,  1856. 
For  twelve  years  has  been  of  very  intemperate  habits,  unsettled  in  his  occupation, 
and  often  insufficiently  nourished.  About  one  mouth  ago  he  first  noticed  a  short 
dry  cough,  attended  ^"ith  little  expectoration  till  a  few  days  ago,  when  it  became 
rather  copious  and  yellow.  Four  days  ago,  the  sputum  for  the  first  time  was  tinged 
with  blood ;  about  the  same  time  the  stools  became  frequent  and  loose,  and  severe 
night  sweats  appeared.  He  has  been  subject  for  some  time  to  shiverings,  but  can- 
not remember  any  special  rigors  ushering  in  the  present  attack. 

Syjiptoms  ox  Admissiox. — There  is  marked  dulness  on  percussion  at  the  apex 
of  left  lung,  and  lateraUy  in  the  axillary  region.  There  is  also  cracked-pot  resonance 
over  the  left  front,  from  the  first  to  the  fourth  intercostal  space.  On  auscultation, 
there  are  coarse  moist  rales,  during  inspiration  and  expiration,  over  the  whole  left 
lung,  anteriorly,  laterally,  and  posteriorly,  with  increase  of  vocal  resonance,  amount- 
ing to  bronchophony  superiorly.  Over  the  lower  third  of  the  left  lateral  region, 
there  is  friction  with  inspiration.  The  right  lung  gives  the  normal  results  on 
auscultation  and  percussion.  The  sputum  is  copious,  frothy,  and  streaked  with 
blood;  considerable  dyspnoea;  the  cardiac  organ  is  healthy;  the  pulse  is  112, 
rather  incompressible ;  the  appetite  bad ;  the  bowels  are  regular ;  the  skin  hot ; 
the  face  of  a  purplish  hue ;  the  patient  is  emaciated,  weak,  and  lies  on  his  back ; 
does  not  sleep  well ;  there  is  great  treraulousness  of  the  limbs ;  the  urine  is  not 
coagulable,  and  it  contains  abundant  chlorides;  sp.  gr.  1020. 

Progress  of  the  Case. — September  5th-21st. — Has  been  treated  with  small 
doses  of  antimony,  and  a  blister  two  inches  square  over  left  mammary  region.  The 
strength  has  been  supported  by  nutritious  diet  and  wine,  or  occasionally  gin.  On 
the  11th,  the  sputum  was  carefully  examined,  and  yellow  elastic  tissue  was  dis- 

*  Reported  by  Dr.  Thorburn,  Resident  Physician,  and  H.  X.  M'Laurin,  Clinical 
Clerk. 


PERICARDITIS.  521 

covered  under  the  microscoi^e.  The  physical  signs  on  the  left  side  are  very  slightly 
altered ;  the  rales  are  less  numerous  ;  there  is  more  bronchial  breathing.  At  the 
right  apex  there  is  now  dulness,  harsh  respiration,  and  occasional  crepitation  at  close 
of  the  inspiratory  murmur.  The  fever,  though  still  great,  has  considerably  abated. 
Pulse  generally  120,  sotl.  From  Sept.  21st  to  30th,  the  pulmonarv  phenomena 
were  little  altered,  although  they  were  subject  to  remissions,  but  the  diarrhoea,  which 
the  patient  had  before  only  slightly  experienced,  became  very  troublesome.  Oct. 
\st. — To-day  a  distinct  double  friction  murmur  is  audible  aU  over  the  cardiac 
region,  soft  at  the  base,  more  coarse  and  loud  towards  the  apex.  The  cardiac  dul- 
ness on  percussion  is  extended — externally  it  cannot  be  limited,  but  internally  it 
reaches  to  the  centre  of  sternum.  No  fremitus;  pulse  128,  feeble,  intermittent, 
and  compressible;  respirations  36  per  minute;  voice  hoarse;  cough  painful; 
sputum  purulent ;  patient  weak,  but  feels  no  pain  anywhere,  and  expresses  himself 
as  being  so  well,  that  he  is  even  anxious  to  go  out  and  see  a  friend.  Has  no  appe- 
tite ;  the  diarrhoea  continues.  Od.  2d  to  9th. — The  pericardial  friction  continues 
distinct.  There  is  also  pleural  friction  murmur  on  the  left  lateral  region  more  dis- 
tinct and  extensive  than  on  admission ;  the  right  side  is  duU  at  the  apex,  with 
moist  rales  during  inspiration ;  to-day  there  are  friction  sounds  during  expiration 
at  the  right  base.  Oct.  9th  to  llth. — The  auscultatory  phenomena  are  unaltered. 
The  moist  rales  in  lung  are  more  coarse  and  bubbling ;  dj^spncea  is  intense ;  respi- 
rations 60  per  minute ;  the  face  is  livid ;  the  j^ulse  more  and  more  weak,  becoming 
imperceptible.     Oct.  11th. — Died  this  morning. 

Sectio   Cadaveris. — Fifty-one  hours  after  death. 

The  body  was  emaciated. 

THOR-iX. — The  left  lung  was  infiltrated  throughout  with  grey  tubercle ;  at  the 
apex  there  was  great  condensation  around  three  or  four  cavities  containing  pus,  the 
largest  being  the  size  of  a  hen's  egg.  Numerous  smaller  cavities  existed  through- 
out the  upper  lobe,  which,  with  the  cut  bronchi,  poured  out  abundant  pus  on  the 
texture  being  squeezed.  The  right  lung  was  also  infiltrated  with  grey  tubercle 
throughout  the  upper  lobe ;  at  the  apex  there  were  two  cavities  the  size  of  hazel 
nuts.  Its  inferior  lobe  was  thinly  scattered  witli  the  same  tubercle,  and  was  greatly 
engorged  mth  blood  and  serum.  Universal  adhesions  on  both  sides.  Both  layers 
of  the  pericardium  were  covered  with  villous  h-mph,  generally  about  one-eighth  of 
an  inch  in  thickness.  Between  them  were  about  two  ounces  of  serum.  The  valves 
and  substance  of  the  heart  were  healthy. 

Abdomex. — The  abdominal  organs  were  healthy. 

Microscopic  Examixatiox. — The  structure  of  tlae  villous  lymph  in  this  case 
was  very  carefully  examined,  and  Fig.  380,  p.  267,  is  a  representation  of  the  struc- 
ture. The  villi  varied  greatly  in  length  and  size,  and  could  be  perceived  by  the 
naked  eye.  Individually  they  were  of  pulpy  consistence,  consisted  of  a  delicate 
membrane,  covered  in  many  places  by  layers  of  pavement  epithelium  (Fig.  380,  h). 
Their  substance  consisted  of  an  aggregation  of  fibre  cells  in  all  stages  of  develop- 
ment, several  of  them  were  floating  loose  in  the  field  of  the  microscope  (Fig.  380,  c). 
On  the  addition  of  acetic  acid  the  whole  became  verj-  transparent,  showing  the 
mere  outline  of  the  villi,  with  fusiform  nuclei  imbedded  in  them.  Here  and  there 
they  contained  transparent  spaces  or  vacuoles,  having  in  some  transverse  markings 
or  folds  externally  (Fig.  380,  a,  a).  The  heart  was  subsequently  carefully  injected 
by  Professor  Goodsir,  and  portions  of  it  may  now  be  seen  in  the  University 
Museum,  with  the  layer  of  lymph  nearest  the  muscle  containing  a  rich  plexus  of 
vessels  filled  with  coloured  size. 


522  DISEASES   OF  THE   CIRCULATORY   SYSTEM. 

Commentary. — On  the  admission  of  this  man  (September  5),  he 
was  labouring  under  intense  fever.  He  had  cough  and  expectoration 
tinged  with  blood;  dyspnoea;  livid  face;  hot  pungent  skin;  pulse  112, 
firm ;  dulness  with  cracked-pot  sound  on  percussion  over  left  chest 
antei-iorly;  and  coarse  moist  rales  during  inspiration  and  expiration. 
These  were  the  symptoms  of  acute  pneumonia  in  its  suppurative  stage. 
On  the  other  hand,  the  disease  was  described  to  have  come  on  a  month, 
before  with  dry  cough ;  there  was  no  distinct  rigor  ushering  in  the 
attack ;  and  the  chlorides  in  the  urine  were  abundant.  Hence  it 
might  be  a  case  of  acute  tuberculosis.  His  general  aspect  taught  us 
notliing,  as,  without  being  robust,  he  was  by  no  means  emaciated.  He 
was  treated  with  gentle  salines,  in  order  to  moderate  the  excessive 
fever;  whilst  wine,  gin,  and  nutrients  were  liberally  administered  to 
support  his  strength.  This  treatment  succeeded  in  somewhat  diminish- 
ing the  fever.  On  the  6th  day  after  his  admission,  I  carefully 
examined  the  sputum  with  the  microscope,  and  found  it  to  contain 
abundant  ti'agments  of  lung  tissue,  mingled  with  numerous  pus  and  a 
few  blood  corpuscles.  This  fact  first  demonstrated  the  phthisical 
character  of  the  disease.  Subsequently  the  pneumonic  symptoms  dis- 
appeared ;  dulness  Avith  moist  rales  became  limited  to  the  apices  of 
both  lungs,  and  the  thoracic  physical  signs  were  only  examined  from 
time  to  time.  At  the  visit  of  the  1st  of  October,  a  double  friction 
murmur  was  discovered  to  exist  all  over  the  cardiac  region,  so  distinct 
as  at  once  to  satisfy  me  that  pericarditis  was  already  fully  established. 
It  was  unaccompanied  by  pain,  palpitation,  or  any  local  functional 
symptom  whatever,  so  that,  without  the  physical  sign  of  friction, 
attention  would  never  have  been  directed  to  it.  Indeed,  about  this 
period,  there  had  been  a  remission  in  the  febrile  symptoms,  there  was 
less  cough,  and  he  felt  so  much  better  that  great  difficulty  was  expe- 
rienced in  making  him  keep  his  bed,  and  even  retaining  him  in  the 
house.  The  phthisical  symptoms,  however,  continued,  the  diarrhoea 
becanae  colliquative,  exhaustion  came  on,  and  he  suidc,  without  having 
exhibited  one  svmptom  of  heart  complaint  in  addition  to  the  physical 
signs.  On  examining  the  body,  besides  the  pulmonary  lesion,  the  heart 
presented  a  shaggy  layer  of  lymph  covering  the  whole  of  both  pericar- 
dial surfaces.  These  were  already  vascular,  while  their  surfaces  were 
covered  with  epithelium,  and  they  must  have  been  actively  engaged  in 
absorbing  the  serum  which  separated  them,  wliich  was  small  in  amount. 
Here,  then,  we  have  a  remarkable  example  of  a  true  acute  inflamma- 
tion of  a  serous  surface  coming  on  under  our  eyes,  which  was  detected 
by  physical  signs  alone,  and  was  unaccompanied  by  any  functional 
symptoms  whatever.  The  only  treatment  indicated  in  this  case  was 
to  suppoil  the  general  strength.  As  there  were  no  local  symptoms, 
topical  remedies  were  evidently  unnecessary. 

In  this  case,  also,  we  remark  an  exception  to  the  general  laws, 
supposed  to  govern  exudations,  viz.,  that  in  a  phthisical  pei'son,  while 
tubercle  was  throw^n  into  the  lungs,  an  inflammatory  exudation  was 
thrown  out  in  the  pericardium  (See  Case  L.  p.  428).  Here,  how- 
ever, it  was  observable  that  when  the  pericarditis  appeared,  his 
general  health  had  temporarily  improved,  and  he  was  taking  generous 
diet,  a  circumstance  which,  as  previously  explained,   p.  139,  may  serve 


PEKICARDITIS.  523 

to  account  for  the  altered  constitution  of  tLe  exuded  matter.  It  must 
be  obvious  however  from  this,  as  well  as  from  many  other  observations 
previously  made,  that  a  true  inflammation  has  no  necessary  connection 
with  robust  constitutions,  and  that  it  may  come  on  at  the  close  of  the 
most  exhaustino-  maladies. 


Case   XCI.* — Ascites — Anasarca — Adherent    Pericardium    vjiih    Fatty    Atrophied 
Heart —  Congested  Liver. 

History. — John  Toung,  jet.  19.  a  farm  servant — admitted  April  16th,  1855. 
Nine  months  ago  he  felt  pains  in  the  right  hypoehondrium,  and  shortly  afterwards 
his  abdomen  began  to  swell.  Under  medical  treatment  the  swelling  subsided, 
returning  when  medicines  were  discontinued,  and  again  subsiding  under  medical 
treatment.  It  has  increased  a  third  time,  and  has  induced  him  to  apply  for 
admission. 

Symptoms  ox  Admissiox. — He  is  a  stout  person,  with  a  protuberant  abdomen, 
no  oedema  of  integument,  and  very  slight  yellow  tint  of  the  sclerotic.  He  says 
there  has  been  swelling  of  the  legs.  Tongue  moist,  and  a  little  coated;  appetite 
good ;  no  d3'sphagia  nor  vomiting.  The  area  of  hepatic  dulne.ss  cannot  be  deter- 
mined, owing  to  the  dulness  of  percussion  over  the  abdomen.  On  percussion,  the 
distension  of  the  abdomen  is  seen  to  be  owing  to  an  accumulation  of  fluid  which 
gravitates  to  the  dependent  portions.  Bowels  are  regular.  Cardiac  sounds  normal. 
Area  of  cardiac  dulness  is  not  stated.  Pulse  80,  of  good  strength.  On  ausculta- 
tion, sibilant  rales  are  heard  aU  over  his  chest.  He  expectorates  a  good  deal  of 
tough  frothy  mucus.  Complains  of  dyspnoea  and  cough,  especially  after  meals. 
Urine  scanty  (only  12  ounces  during  the  last  24  hours),  of  natural  colour,  with 
exceedingly  slight  trace  of  albumen.  Is  wdered  a  sqvAH  and  digitalis  ^^ill  thrice  a 
day. 

Progress  of  the  Case. — April  19th. — Urine  not  increasing.  Is  ordered  to  apply 
over  his  belly,  spongio-piline  soaked  in  an  infusion  of  digitalis,  four  times  strong^' 
than  usvmI.  2oth. — Coughs  less,  and  expectoration  is  more  easy,  but  urine  has  not 
increased.  A  papular  eruption  has  appeared  over  abdomen  from  the  action  of  the 
spongio-piline.  29th. — Has  had  frequent  watery  evacuations  without  griping,  and  with 
only  slight  nausea  under  the  action  of  elaterium,  in  the  dose  of  one-sixth  and  one-fourth 
of  a  grain.  Jlay  2d. — The  spongio-ptline  was  ordered  to  be  removed,  as  it  appears 
to  cause  irritation  of  the  integument.  3d. — The  cardiac  sounds  are  healthy  at  apex 
and  base.  The  abdomen  is  less  tense.  The  upper  border  of  the  area  of  hepatic 
dulness  is  not  higher  than  usual.  The  lower  cannot  be  determined.  The  urine  is 
not  coagulable.  9ih. — Has  felt  more  comfortable;  the  ascites  appears  slowly 
increasing.  Is  ordered  half  a  drachm  of  compound  jalap  powder.  ll/7i. — Has  felt 
relieved  as  usual  after  purgation ;  the  urine  is  slightly  increased.  The  feet,  legs 
thighs,  and  scrotum,  are  now  oedematous.  Haheat  Potass.  Bitart.  3j  ter  indies. 
IZth. — The  general  anasarca  is  increasing.  Dyspnoea  is  greater.  Urine  quite  free 
from  albumen.  Pulse  68,  irregular  and  weak.  Bowels  costive,  l^th. — Bowels  have 
been  kept  freely  open  by  the  administration  of  purgatives,  chiefly  of  Extract.  Elater., 
in  doses  of  one-sixth  and  one-fourth  of  a  grain.  Anasarca  is  not  quite  so  great, 
and  micturition  is  more  easy,  notwithstanding  the  oedematous  condition  of  penis  and 
scrotum.  To  take  one-drachm  doses  of  Bitart.  Potasses  2\st. — Xot  so  weU  to-day: 
feels  uneasy  in  horizontal  position ;  is  to  get  a  special  pillow  for  the  support  of  hia 

*  Reported  by  Mr.  Robert  Byers,  Clhiical  Clerk. 


524  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

shoulders  and  head.  Pulse  88,  weak  and  intermittent.  24?/;.— Pulse  84,  weak  and 
irregular;  urine  24  ounces  in  24  hours;  sp  gr.  1028;  contains  no  albumen.  The 
abdomen  is  becoming  evidently  by  degrees  more  and  more  distended.  2oth. — Feels 
mucli  the  same  as  yesterday;  cannot  lie  down  in  horizontal  position.  Urine  27 
ounces,  not  in  tlie  least  coagulable.  '2Sth. — Urine  continues  to  range  from  20  to  28 
ounces  per  diem ;  sp.  gr.  1021 ;  no  traces  of  albumen.  Feet  and  Umbs  enormously 
swollen.  3lst. — Urine  diminished  in  amount;  cough  is  pretty  severe.  Ortliopnoea 
continues ;  pulse  94,  weak  and  intermittent.  Patient  is  becoming  exhausted,  does 
not  even  take  the  food  for  which  he  has  an  appetite,  from  the  distressing  sensation 
of  the  tenseness  of  his  abdomen.  5  Spir.  JEther.  Sulph.;  Ammonice  s&>quicarb.  a.a. 
3  ss ;  Aqute,   §  vj ;  one  ounce  every  third  hour.     June  3c?. — Died  to-day. 

Sectio  Cadaveris. — Fifty-six  hours  after  death. 

Bodj-  anasarcous.  Face  swollen  and  cedematous ;  some  hemorrhage  from  the  nose. 
Limbs  cedematous  ;  abdomen  protuberant  and  fluctuating ;  great  cadaveric  livor. 

Thorax — The  right  pleura  contained  nearly  two  pints  of  clear  serum  ;  the  left  one 
pint.  The  lower  lobe  of  the  right  lung  was  compressed  and  non-crepitant,  and  the 
margin  of  the  other  lobes  emphysematous;  otherwise  both  lungs  natural.  The 
pericardium  was  found  to  be  firmly  adherent  over  the  whole  surface.  It  was  much 
thickened,  varying  from  two  lines  to  two  and  a  half,  and  it  was  of  fibrous  or  almost 
cartilaginous  consistence.  The  heart  itself  was  about  the  normal  size,  but  its  walls, 
particularly  those  of  the  left  ventricle,  were  rather  thinner  than  natural,  being  less 
than  two  lines  at  the  apex.  The  valves  and  endocardium  were  healthy ;  the  mus- 
cular tissue  was  of  a  pale  fawn  colour. 

Abdomen'. — Contained  three  gallons  of  clear  serum.  Liver  weighed  3  lb.  and 
2  oz.  Its  hepatic  vessels  were  congested,  so  that  the  organ  presents  on  section  a 
nutmeg  appearance.  The  spleen  soft,  weighed  6^  oz.  ;  but  was  healthy.  The  two 
kidne^-s  weighed  each  10^  oz. ;  and  were  quite  healthy.  The  whole  alimentary 
canal  was  carefully  examined,  but  with  the  exception  of  congestion  of  the  mucous 
membrane  in  the  lower  two-thirds  of  the  rectum,  was  found  to  be  quite  healthy. 
The  large  arteries  and  veins  of  the  neck,  chest,  abdomen,  and  pelvis,  were  also 
minutely  examined  and  found  healthy. 

Microscopic  ExAJiiXATioy. — The  striae  in  many  of  the  cardiac  muscular  fibres 
were  indistinct,  and  numerous  minute  oU  globules  were  visible  within  the  sarcolemma. 
The  hepatic  cells  contamed  somewhat  more  bihary  and  fatty  matter  than  usual  But 
in  almost  aU  of  them  the  nuclei  could  be  seen.     The  renal  structure  was  normal 

Comvfientary. — The  history  and  symptoms  of  this  man  induced  me  to 
consider  his  disease  as  essentially  hepatic.  According  to  his  account  it 
commenced  with  ascites  nine  months  before  admission,  and  was  followed 
by  oedema  of  the  legs  and  general  anasarca.  On  taking  charge  of  the 
case  in  May,  however,  I  could  not  detect  any  alteration  in  the  size  of  the 
liver,  or  any  uneasiness  in  the  right  hypochondrium.  The  heart  was 
carefully  examined  and  found  to  be  healthy,  and  at  no  time  had  he  ever 
complained  of  that  organ.  The  lungs  presented  evidence  of  slight  bron- 
chitis, which  could  never  be  supposed  to  have  occasioned  the  dropsv. 
The  urine  when  scanty  contained  a  slight  trace  of  albumen,  which  after- 
wards disappeared.  At  no  time  did  the  case  resemble  one  of  Bright's 
disease,  and  the  kidneys  after  death  were  quite  healthy.  The  rapidly- 
advancing  dropsy  was  the  source  of  danger  in  this  case.  As  diuretics 
had  no  effect,  hydragogue  cathartics  were  had  recourse  to,  and  although 
these  produced  temporary  relief,  the  anasarca  went  on  steadily  increasing. 


PERICARDITIS.  525 

and  he  died.  On  examining  the  body,  the  liver  was  found  to  be  simply 
cono-ested,  while  its  structure  had  undergone  little  alteration;  the  peri- 
cardium was  universally  adherent,  and  somewhat  thickened  ;  the  lungs 
collapsed  posteriorly,  with  slight  emphysema  anteriorly.  It  seems  to  me 
that  the  congested  liver  and  the  chief  pulmonary  lesions  were  the  results 
rathei'  than  tlie  causes  of  the  anasarca,  and  that  the  tnie  origin  of  the 
disease  must  be  referred  to  the  cardiac  lesion.  During  life,  it  is  true, 
there  were  no-  symptoms  or  physical  signs  to  indicate  that  the  heart  was 
diseased.  But  it  became  apparent  after  death  that  he  must  have  had  an 
extensive  pericarditis,  and  we  have  previously  seen  that  such  may  occur 
without  any  symptoms  at  all.  This,  as  in  the  case  of  Douglas,  led  to 
fatty  degeneration  of  the  organ,  with  atrophy,  however,  instead  of  enlarge- 
ment ;  and  the  result  was  that,  instead  of  dying  suddenly  as  in  her  case, 
such  slow  languor  of  the  circulation  was  occasioned,  as  to  produce  the 
venous  congestion  in  the  liver  and  lungs,  which  in  its  turn  occasioned  the 
anasarca.  In  most  cases  where  enlargement  of  the  heart  follows  adhe- 
rent pericardium,  I  have  noticed  the  existence  of  valvular  disease.  In 
the  present  case  the  valves  were  healthy,  and,  instead  of  hypertrophy, 
there  was  atrophy. 


Case  XCII.* — Rheumatic  Pericarditis. 

History. — Jane  Beaton,  aet.  13,  a  thin,  weak  girl — admitted  November  30tb,  1853. 
She  states  that  two  years  ago  she  was  confined  to  bed  for  a  month  with  acute  rheu- 
matism, some  time  after  which,  she  cannot  say  precisely  when,  she  observed  that 
her  heart  was  wont  to  beat  very  quickly.  The  impulse  also  was  distinctly  seen  by 
her  on  undressing  before  going  to  bed.  She  had  never  suffered  before  from  any  car- 
diac uneasiness,  pain,  or  dyspnoea,  and  asserts  tliat  she  was  able  to  run  about  as  well 
as  the  otiier  cliildren  at  school,  until  the  commencement  of  the  present  illness.  Three 
weeks  ago,  after  no  unusual  exposure  to  cold,  so  far  as  she  was  aware,  she  felt  weak, 
lost  her  appetite,  and  went  to  bed  early.  Next  day  she  could  not  move  in  conse- 
quence of  pain  in  both  hip  joints,  and  in  two  days  the  knees,  wrists,  elbows,  and 
shoulders  were  also  affected.  The  knees  were  much  swollen,  but  not  red.  In  eight 
days  the  pains  abated,  and  have  not  since  returned.  Since  then  she  has  been  subject 
to  cough,  with  a  white  frothy  expectoration,  but  has  had  no  pain  in  the  chest,  dys- 
pnoea, or  palpitation. 

Symptoms  on  Admission. — The  cardiac  impulse  is  seen  and  felt  in  the  third,  fourth, 
and  fifth  intercostal  spaces,  so  low  as  one  and  three-fourths  of  an  inch  below,  and 
to  the  outside  of  the  nipple.  It  is  strong,  but  unaccompanied  with  fremitus.  Per- 
cussion causes  slight  pain.  Cardiac  dulness  w^as  much  increased,  extending  to  the 
right  side  of  sternum,  but  its  exact  limits  were  not  determined.  AH  over  the 
cardiac  region  there  was  a  double  friction  murmur,  appearing  close  to  the  ear,  and 
of  a  fine  grating  character,  but  very  distinct.  Over  the  manubrium  of  the  sternum 
is  a  single  blowing  murmur,  apparently  wdth  the  first  sound.  The  second  sound 
cannot  be  heard.  Pulse  136,  regular,  of  good  strength  and  somewhat  jerking.  The 
chest  expands  equally  on  both  sides,  percussion  normal.  Respiration  harsh  and 
sibilant  over  right  pulmonary  apex,  over  left  apex  normal.  Posteriorly  respiratory 
sounds  healthy.     She  has  slight  cough,  with  trifling  mucous  expectoration.     Does 

*  Reported  by  Dr.  David  Cbristisou,  Resident  Physician,  and  Mr.  James  Walker, 
Clinical  Clerk. 


526  DISEASES   OF   THE    CIRCULATORY   SYSTEM. 

not  complain  of  dyspnoea,  but  the  breathing  is  evidently  somewhat  accelerated. 
Tongue  clean.  Appetite  somewhat  impaired ;  shght  thirst.  Bowels  regular.  No 
headache ;  does  not  sleep  well,  but  no  startlngs  at  night.  Face  flushed  ;  no  anxiety 
of  countenance ;  skin  hot  and  dry ;  often  sweats  at  night ;  no  oedema  of  limbs. 
Other  functions  normal.  Eight  leeches  to  he  applied  to  the  prcecordial  region,  and  a 
sixth  of  a  grain  of  Tartrate  of  Antimony  to  he  given  in  solution  every  third  Iwur. 

Progress  of  the  Case. — December  \st. — Pulse  more  soft.  To  discontinue  the 
antimony.  IJ  Calomel,  gr.  xxiv ;  Pidv.  Jacobi,  gr.  xxiv ;  Pulv.  OpU,  gr.  iii.  M,  et 
divide  in  chartula-s  xij.  One  to  he  taken  every  four  hours.  Dec.  3d. — Friction  mur- 
murs much  diminished.  Cardiac  dulness  apparently  increased.  Urine  loaded  with 
lithates.  Cough  continues.  5  ^P-  ^Elher.  Nit.  3  iij ;  Pot.  Acet.  3  ij ;  Alist.  Scillce, 
§  vss.  M.  A  table-spoonful  to  be  taken  every  four  hours.  Dec.iih. — Careful  examina- 
tion determined,  that  the  cardiac  dulness  measures  five  inches  transversely,  com- 
mencing half  an  inch  outside  the  left  nipple,  and  extending  across  the  sternum  to  an 
inch  and  a  half  from  the  right  nipple.  Friction  is  now  only  audible  over  the  margin 
of  dulness  on  the  right  side.  A  soft  blowing  murmur  is  audible,  synchronous  with 
the  impulse  over  a  space  two  inches  in  dianleter  below  the  nipple.  At  the  base  a 
harsher  blowing  is  heard,  which  alternates  with  the  soft  murmur  at  the  apex.  It  is 
propagated  in  the  direction  of  the  large  vessels,  and  is  very  audible  under  the  centre 
of  the  right  clavicle.  Pulse  120,  soft,  and  sliglitly  jerking.  Ko  pain  or  dyspnoea, 
Crums  not  affected  by  the  mercurial  powder.s,  but  complains  of  tormina  and  slight 
diarrhoea.  Discontinue  the  powders,  and  apply  a  blister  (3  by  4)  over  the  sternum. — 
Dec.  I2th. — Dulness  somewhat  diminished.  Double  friction  is  again  very  loud  over 
the  base  of  the  heart,  Dec.  \5th. — Dulness  much  decreased;  friction  has  dis- 
appeared. Dec.  I9th. — Dulness  now  only  measures  three  inches  transversely  across. 
Dec.  2Sth. — Has  been  doing  well,  and  taking  her  food  regularly.  The  cough  and 
expectoration  have  nearly  disappeared,  and  the  harshness  of  breathing  on  the  right 
side  has  much  diminished.  Last  night  was  seized,  without  apparent  cause,  with 
violent  palpitation,  a  sense  of  suffocation,  and  coldness  of  the  body,  which  continued 
for  an  hour.  Brandy  and  sulphuric  oither  ivere  given,  and  hot  bottles  ajyplied  to  the 
feet.  To-day  she  is  tranquil  as  usual.  Impulse  is  undulating  between  fourth  and 
sixth  ribs.  The  blowing  at  the  apex  is  more  harsh  and  prolonged.  Above  the 
nipple,  on  a  level  with  the  margin  of  sternum,  there  is  a  superficial  blowing, 
occupying  the  period  of  both  sounds.  It  is  no  longer  audible  under  the  clavicle. 
No  retraction  of  the  intercostal  space  over  the  undulation  visible  between  the  fourth 
and  sixth  ribs.  January  lAtJi. — Since  last  report,  the  attacks  of  palpitation  and 
dyspnoea  have  recurred  occasionally  at  night,  apparently  excited  by  any  unusual 
circumstance.  Puerile  respiration  still  continues  on  the  right  side,  but  all  pul- 
monary disorder  otherwise  has  ceased.  There  is  now  heard,  both  at  the  apex  and 
at  the  base,  one  loud  blowing  murmur,  synchronous  with  the  impulse,  occupying 
the  period  of  both  sounds.  That  at  the  base  is  harder  and  more  clanging  in  cha- 
racter than  that  at  the  apex,  and  ceases  suddenly  on  carrying  the  stethoscope  to  the 
articulations  of  the  third  and  fourth  right  ribs  with  the  sternum.  Pulse  128,  soft. 
She  is  easily  agitated ;  otherwise  the  same,  but  says  she  is  better.  Wine  3  ij  daily. 
March  ISth. — Since  last  report,  has  been  greatlj'-  better,  and  has  had  comparatively 
few  attacks  of  dyspnoea  and  palpitation.  To-day  the  impulse  is  felt  distincth^  between 
the  sixth  and  seventh  ribs,  a  little  to  the  outside  of  a  line  drawn  vertically  from  the 
nipple.  Over  this  point  a  double  blowing  murmur  is  heard,  that  with  the  second 
sound  being  longest  and  somewhat  distant.  This  blowing  increases  in  intensity  and 
loudness  as  the  stethoscope  is  carried  obliquely  upwards  towards  the  sternum,  and 
reaches  its  maximum  over  the  articulation  of  the  third  left  costal  cartilage  with  the 
sternum.     At  this  point  the  murmur  is  prolonged,  occupying  the  period  of  both 


PERICARDITIS.  527 

sounds.  It  suddenly  ceases  as  the  stethoscope  approaches  the  clavicles  on  both 
sides,  and  is  inaudible  over  the  large  vessels.  Pulse  120,  of  good  strength,  jerking; 
no  venous  pulse.  April  llth. — Has  continued  the  same,  but  insists  on  leaving  the 
Infirmary,  and  is  in  consequence  dismissed. 

Commentary. — This  was  an  exceedingly  interesting  case  of  pericarditis 
and  endocarditis,  the  former  of  which  apparently  terminated  in  adhesions, 
while  the  latter  underwent  a  variety  of  organic  changes,  which  were  in- 
dicated  by  physical   signs,   and  were   carefully   recorded  in  successive 
examinations.     From  these  it  seems  probable  that  there  was  gradually 
developed  considerable  hypertrophy  of  the  left   ventricle,  the  apex  of 
which   descended  downwards  and  outwards,   whilst  the  pulse  became 
more  and  more  jerking.     The  aortic  orifice  was  apparently  constricted ; 
and  it  is  curious  to  observe,  that  whilst  the  murmur  at  the  base  at  first 
was   propagated  upwards  in  the  course  of  the  large  vessels,  it  subse- 
quently   was    propagated    downwards   towards   the    apex,    and    ceased 
abruptly  above  the  margin  of  a  certain    area.     The    kind    of  organic 
lesion   which    gradually   forming  ultimately  produced  this  result,  it  is 
useless  speculating  about,  although  it  must  be  evident  that  the  aorta 
itself  above  the  valves  could  not  have  been  implicated.     At  one  time 
it  appeared  to  me  probable  that  the  pulmonary  valves  were  affected, 
but  a  careful  consideration  of  all  the  circumstances  obliges  me  to  negative 
this  supposition.     Again,  tlie  pressure  of  the  pericardial  exudation  might 
have  produced  the  murnuir  at  the  base.     The  constant  blowing  murmur 
at  the  apex  indicated  mitral  insufiiciency,  a  lesion  which  could  not  have 
been  so  intense  as  the  aortic  disease,  as  the  murranr  was  always  more 
soft,  and  could  easily  be  distinguished  from  the  one  at  the  base.    Indeed 
it  seemed  as  if  this  remained  almost  stationary,  whilst  the  aortic  lesion 
at  length  became  the  predominant  one.     I  heard  some  few  weeks  after 
her  dismissal  that  this  girl   was  dea<l,   but  under  what  circumstances 
could  not  be  ascertained.     No  doubt  after  the  long  observation  and  suc- 
cessive careful  examinations  this  case  underwent,  much  might  have  been 
learnt  from  a  post-mortem  examination.      The  disappointment  which 
medical  men  too  frequently  experience  in  this  particular,  doubtless  con- 
stitutes an  argument  with  some  in  favour  of  supineness,  and  must  at  all 
times  tend   to   check  that  habit  of   accurate   observation,  which  is  so 
essential  for  working  out  the  difficult  problems  still  unsolved  in  the  dia- 
gnosis of  cai'diac  diseases. 

Pericarditis  consists  of  an  exudation  into  the  pericardial  sac  :  the 
fibrin  of  which  coagulates  and  attaches  itself  to  the  membrane,  while 
the  serum  is  accumulated  in  the  centre.  Changes  now  occur  in  con- 
sequence of  which  the  solid  portion,  or  layer  of  lymph  as  it  is  called, 
assumes  a  villous  structure  and  becomes  vascular,  whereby,  in  the 
majority  of  cases,  the  fluid  is  absorbed,  and  the  two  false  membranes 
unite  to  form  an  adherent  pericardium.  These  changes  are  described 
and  figured,  pp.  26G,  267.  (Figs.  379,  380.)  This  result,  however, 
maybe  prevented  by  two  circumstances: — 1st,  The  exudation  may  be 
small  in  quantity  and  limited  in  extent,  when  it  is  transformed  into 
fibrous  tissue,  becomes  covered  with  a  true  serous  membrane,  and  there 
is  no  adhesion  with  the  opposite  surface.     This  constitutes  the  white 


528  DISEASES   OF  THE   CIRCULATORY   SYSTEM. 

patches  so  frequently  observed  on  the  heart  in  examining  bodies  after 
death,  and  they  are  equally  frequent  on  otlier  serous  membranes.  2d, 
The  amount  of  exudation  may  be  very  great,  the  distension  of  the 
pericardial  sac  extreme,  and  the  transformation  into  vascular  absorbing 
villi  thereby  prevented.  Under  such  circumstances,  the  mass  of  fluid 
remains  stationary,  passes  into  pus,  or  even  increases,  in  consequence  of 
dropsical  effusion  from  pressure  on  the  veins,  and  a  so-called  chronic 
pericarditis,  or  pericarditis  with  effusion  (hydro-pericardium),  is  esta- 
blished. 

Auscultation  and  percussion  are  our  guides  to  a  knowledge  of  peri- 
carditis in  the  living  subject.  With  their  aid  the  physician,  if  called  in 
at  the  commencement,  can  trace  the  progress  of  the  disease  through  the 
stages  of  commencing  exudation  with  friction,  gradual  pyriform  enlarge- 
ment with  or  without  friction,  absorption  and  disappearance  of  the  serum 
with  returning  friction,  and  final  adhesion  of  the  two  surfaces.  This 
was  accurately  done  in  Cases  LXXXIX.  and  XCI.  An  adherent  peri- 
cardium, or  a  limited  exudation  confined  to  the  posterior  surface  of  the 
lieart,  is  detectable  by  means  of  physical  signs  with  extreme  rarity.  It 
is  admitted  that  occasionally  a  pericardial  may  closely  resemble  a  valvular 
murmur,  but  then  the  former  is  superficial,  often  intensified  by  pressure 
of  the  stethoscope,  is  not  permanent,  and  is  liable  to  be  att'ected  by  pos- 
ture, and  by  the  greater  or  less  energy  of  the  cardiac  contractions. 

As  regards  percussion,  it  is  necessary  to  remember  that  when  the 
amount  of  fluid  is  small,  say  from  two  to  four  ounces,  the  pericardial  sac 
is  not  distended,  but  remains  flaccid.  The  fluid  gravitates  towards  the 
lower  end,  and  produces  the  appearance  repi-esented  in  Fig.  412,  In 
cases  of  acute  general  pericarditis,  such  as  Cases  LXXXVII.  and 
LXXXIX.,  the  amount  of  fluid  may  reach  from  ten  to  twenty  ounces, 
when  the  pericardium  is  distended,  becomes  pyriform  with  the  base  down- 
wards, as  represented  Fig.  413.  In  such  cases  it  may  be  determined  by 
percussion,  to  extend  upwards  to  the  top  of  the  sternum,  and  downwards 
to  below  the  xiphoid  cartilage.  It  may  pass  to  the  right  of  the  sternum 
on  one  side,  and  left  of  the  nipple  on  the  other,  more  or  less  displacing 
the  lungs,  especially  pressing  backwards  on  the  left  one.  In  chronic 
pericarcUtis  or  hydro-pericardium,  more  than  three  pints  of  fluid  have 
been  found  m  the  sac,  in  which  case  the  pyramidal  form  of  acute  peri- 
carditis is  lost,  and  it  becomes  globular,  as  in  Fig.  414.  In  such  cases 
it  encroaches  so  far  on  the  left  lung  as  to  push  it  entirely  backwards. 
The  liver  and  stomach  are  at  the  same  time  displaced  downwards  to  a 
great  extent,  by  the  descent  of  the  central  tendon  of  the  diaphragm. 
Hence  the  epigastric  prominence,  and  the  pain  on  pressure  in  the  epigas- 
trium, sometimes  observed  in  cases  of  pericarditis.  While  the  increasing 
eft'usion  into  the  pericardium  displaces  the  lungs,  liver,  and  stomach,  it 
also  causes,  especially  in  the  young,  prominence  of  the  lower  sternum 
and  adjoining  left  costal  cartilages,  and  widening  of  the  left  intercostal 
spaces.  If  very  extensive,  it  presses  backwards  and  upwards  on  the 
bifurcation  of  the  trachea,  causing  extreme  dyspnoea.  In  such  cases, 
relief  is  experienced  by  sitting  up  and  leaning  forward  in  bed,  when  the 
pressure  on  the  trachea  is  removed  by  the  gravitation  of  the  fluid  down- 
wards and  forwards. — (Sibsou.)  Pressure  on  the  oesophagus  may  also 
occasion  more  or  less  dysphagia. 


PERICARDITIS.  529 

Functional  symptoms,  liowever  they  may  induce  us  to  suspect,  can 
never  alone  positively  enable  us  to  affirm  the  existence  of  pericarditis. 
They  are  very  variable  in  different  cases,  and  appear  to  me  to  be 
dependent  more  on  the  general  susceptibility  of  the  nervous   svstem. 


than  on  anything  else.  Moreover,  we  have  seen  that  the  symptoms  of 
local  pain,  dyspnoea,  and  so  on,  are  often  absent.  In  the  case  of  Camp- 
bell (Case  XC.)  while  the  friction  murmur  told  its  tale  with  the 
greatest  clearness,  he  denied  that  anything  was  wrong  with  his  heart 
whatever,  and  yet  after  death  the  two  pericardial  surfaces  were  found 


Fig.  412.  Flaccid  pericardium  with  small  amount  of  Mid.— (Sihson.) 
Fi.tr.  413.  DLstended  pericardium,  of  a  pyrifonn  shape,  as  an  ordinary  pericarditis. 
— (Sibsoa.) 

34 


530  DISEASES   OF  THE   CIRCULATORY   SYSTEM. 

covered  with  soft  shaggy  lyiupli.    In  Case  XCL,  where  after  death  there 

was  adherent  pericardium  leading  to 
general  anasarca,  the  man  could  not 
remember  that  he  ever  was  atfccted 
in  anv  wav  with  cardiac  disorder. 
(See  also  Case  LXXXVIII.)  This 
important  fact  has  been  noticed  by 
many  physicians — thus  "acute  peri- 
carditis is  often  so  latent  as  to  be 
discoverable  only  by  physical  signs." 
— (Sfokes.)  "The  disease  may 
be  absolutely  latent  from  first  to 
last.  I  have  known  patients  with 
several  ounces  of  fluid  and  ex- 
udation matter  in  the  pericardium, 
grow  irritated,  when  inquiries  were 
made  about  symptoms  connected 
with  the  hearty— (Walshe.)  But 
the  cases  of  Douglas  and  Young, 
which  have  been  recorded,  must 
satisfy  us  that  pericarditis  is  a  most 
serious  complaint.  The  adhesions 
which  form  often  more  or  less  embar- 
rass the  action  of  the  heart,  and  above 
all,  impede  its  normal  nutrition;  in 
the  one  case  they  caused  general 
dropsy,  and  in  the  other  fatty  de- 
generation of  the  texture  of  the 
heart. 

Much  has  been  written  as  to  the 
complications  of  pericarditis.  Its 
association  with  acute  rheumatism  is  so  common,  that  some  have  classi- 
fied cases  into  rheumatic  and  non-rheumatic  (^Ornurod,  Markham.) 
The  causes  of  this  association  are  as  yet  unknown.  Dr.  Taylor  further 
sought  to  establish  a  relation  between  pericarditis  and  Bright's  disease. 
Thus,  out  of  38  of  his  cases,  20  occurred  in  the  progress  of  acute 
rheumatism,  and  ten  were  complicated  with  renal  disease.  It  so  hap- 
pens, that  in  none  of  my  cases  of  pericarditis  has  there  been  a  com- 
plication with  Bright's  disease,  and  yet  this  last  lesion  is  so  common 
in  Edinburgh,  that  it  is  scarcely  conceivable,  if  it  Avere  really  a  cause  of 
the  former,  that  it  should  have  escaped  my  notice.  Dr.  Christison  also 
says,  in  his  work  on  "Granular  Degeneration  of  the  Kidneys"  (p.  94), 
that  "pericarditis  is  seldom  seen  among  the  sequela?."  We  cannot, 
therefore,  be  too  cautious  in  reasoning  as  to  the  causes  and  treatment  of 
pericarditis  from  the  supposed  conditions  of  the  blood  with  which  it  is 
thought  to  be  associated.  Complications  with  pleurisy,  pneumonia,  and 
pulmonary  emphysema  arc  much  to  be  dreaded,  especially  as  regards 
the  ultimate  effects  on  the  heart  itself,  althouoh  thev  may  not  prove 
immediately  fatal.     (See  also  Cases  CYIL,  CVIIL,  and'CX.)' 

Fig.  414.  Excessive  distension  of  pericardium,  as  in  chronic  pericai'ditis  or  hydro- 
pericardium. — {Sibson.) 


PERICARDITIS.  531 

The  treatmeut,  like  that  of  all  other  forms  of  acute  inflammation  up 
to  a  recent  period,  was  at  first  antiphloo-i-?tic,  but,  for  the  reasons  previ- 
ously o-iven  (p.  263),  this  is  no  longer  the  rule.  Case  LXXXVII. 
demonstrates  how,  in  a  tolerably  healthy  person,  the  disease  passes 
rapidly  throucrh  its  natural  progress.  But  should  there  be  depression  of 
the  vital  powers,  stimulants  and  nutrients  are  demanded,  as  in  Case 
LXXXIX.  If  there  be  local  pain,  the  application  of  a  few  leeches,  or, 
what  is  often  better,  of  warm  fomentations  or  a  hot  poultice,  tends  to 
relieve  it.  Quietude  of  body  and  mind  is  essential  to  the  treatment. 
In  Touno-  persons  especially,  unnecessary  physical  examination  should  ba 
carefully  avoided.  If  the  principle  of  practice  formerly  put  forth  be 
correct  "(p.  2G4),  viz.  that  a  true  inflammation  cannot  be  cut  short,  and 
that  the  only  end  of  judicious  medical  practice  is  to  conduct  it  to  a 
favourable  termination,  we  should  expect  its  truth  to  be  manifested  in 
such  a  disease  as  pericarditis.  Xow  this,  I  think,  we  do  see.  Contrast 
the  treatment  of  Hope  w-ith  that  of  Stokes,  and  what  a  difference  is 
observable.  The  former  energetic  in  lowering  remedies,  the  latter  cau- 
tious, and  constantly  warning  us  not  to  proceed  too  far.  Though  he 
recommends  blood-letting,  it  can  only  be  practised  with  his  consent  at  a 
time,  to  an  extent,  and  under  circumstances  when  obviously  it  is  likely 
to  do  no  harm.  On  the  other  hand,  he  points  out  how,  in  some  circum- 
stances, "even  a  vigorous  action  of  the  heart,  a  jei-king  pulse,  and  an 
increased  action  of  the  carotids,  do  not  necessarily  contra-indicate  wine  ;"* 
and  remarks,  "that  the  omission  of  that  active  antiphlogistic  treat- 
ment, still  so  often  employed  in  the  first  stages  of  inflammation,  might 
be  of  no  great  detriment"  to  the  patient."f  For  my  own  part,  I  am 
satisfied  that  there  are  no  circumstances  in  which  an  antiphlogistic 
practice  can  diminish  the  progress  of  the  disease,  whilst  in  the  vast  ma- 
joritv  of  cases  it  does  positive  harm,  by  checking  the  vital  force,  so 
necessary  for  enabling  the  patient  to  struggle  through  his  malady. 

It  has  been  supposed  that  the  action  of  mercury  has  an  especial  ten- 
dency to  favour  absorption  in  cases  of  pericarditis,  not  only  of  the  serum, 
but  of  the  organised  lymph  itself.  I  have  now  given  it  in  many  cases, 
two  of  which  are  recorded  at  length  (Cases  LXXXVIII.  and  XCIL),  but 
could  never  satisfy  myself  that  it  had  the  slightest  influence  in  forward- 
ing or  modifying  the  natural  changes  which  occur.  The  best  evidence 
on  this  subject,  however,  is  to  be  derived  from  a  careful  analysis  of  forty 
cases  of  acute  rheumatic  pericarditis,  by  the  late  Dr.  John  Taylor,  in 
which  mercurial  ptvalism  was  produced  with  the  following  results  : — 
1st,  Ptvalism  was  not  followed  by  any  abatement  of  the  pericarditis  in 
twelve  cases.  2d,  In  one  case  ptyalism  was  followed  by  speedy  relief. 
3d,  In  two  cases  ptyalism  was  followed  by  a  diminution,  and  then  gradual 
cessation  of  pericardial  murmur.  4th,  In  one  case  pericardial  murmur 
had  been  diminishing  for  some  days  before,  and  it  ceased  soon  after 
ptvalism  was  produced,  oth,  In  one  case  pericarditis  and  pneumonia 
both  increased  in  extent  and  intensity  after  ptyalism.  6th,  In  four  cases 
pneumonia  supervened  after  the  establishment  of,  and  therefore  was  not 
prevented  bv,  ptvalism.  Was  it  amsed  by  it  ?  Vth,  In  three  cases  endo- 
carditis supervened  after  ptyalism.    8th,  In  six  cases  ptyalism  was  followed 

*  Stokes  on  Diseases  of  the  Heart,  etc,  1st  edit.  p.  89. 
f  Ibid.  p.  15. 


532  DISEASES   OF   THE   CIRCULATOEY   SYSTEiT. 

by  pericarditis.  9tli,  In  one  case  ptyalism  could  not  be  produced,  and 
yet  the  pericarditis  went  on  fiivourably.  10th,  In  two  cases  ptvalism 
■was  followed  by  extensive  pleuritis.  lith.  In  one  case  ptyalism  was  fol- 
lowed by  erysipelas  and  inflammation  of  the  larynx.  12th,  In  two  cases 
rheumatism  continued  long  after  ptyalism  was  produced.*  Thus  out  of 
the  forty  cases  only  four  can  be  said  to  have  become  better  after  the 
mercurial  action  on  the  system  was  established,  and  in  these  there  can 
be  little  doubt  that  it  was  purely  a  matter  of  coincidence.  Indeed  I 
have  often  observed  in  hospital  cases,  that  when  mercury  has  been  said 
to  be  most  successful,  its  physiological  action  has  been  established  just 
about  the  time  when,  during  the  natural  progress  of  the  disease,  the  fric- 
tion or  blowing  murmur  may  be  expected  to  cease. 

It  seems  to  me  impossible  to  reconcile  these  positive  facts  with  the 
strong  opinions  of  some  eminent  physicians  as  to  the  good  eftects  of 
mercury  in  pericarditis.  "If  a  person,"  sa^ys  Graves,  "is  seized  with 
very  acute  pericarditis,  how  unavailing  will  be  our  best-directed  efforts 
unless  they  be  succeeded  by  a  speedy  mercurialization  of  the  system!" 
The  case  of  Stambi'oke  (Case  LXXXYII.)  is  alone  a  sufficient  answer 
to  such  a  remai-k,  not  to  mention  the  researches  of  Louis,  who  demon- 
sti-ated  that  only  one  out  of  six  cases  was  iatal  when  tliev  were  left 
entirely  to  nature. 

Acute  pericarditis,  therefore,  should  be  treated  according  to  the  oene- 
ral  principles  previously  referred  to.  During  the  acute  febrile  symptoms, 
salines  and  quietude.  If  there  be  much  local  pain,  a  few  leeches  and 
local  warmth.  If  there  be  excited  action  and  dyspnoea,  fether  and  mor- 
phia, and  as  early  as  possible  nutrients  and  wine  to  support  the  vital 
changes  whicli  it  is  necessary  for  the  exudation  to  go  through,  so  as  to 
favour  absorption.  Active  purgatives  should  be  avoided,  and  I  am  by 
no  means  sure  that  blisters  are  of  any  avail.  My  experience  induces  me 
to  concur  with  a  remark  of  Dr.  Markham,  viz.,  "  that  rheumatic  pericar- 
ditis is  an  inflammation  attacking  rather  those  of  weak  than  of  strong- 
constitution  ;  that  it  is  much  more  common  in  the  delicate  and  voung 
than  in  vigorous  persons  at  the  prime  or  middle  periods  of  life ;  that  the 
degree  of  inflammation,  that  is,  the  general  febrile  leaction  and  the  local 
exudation,  is  also  greater  in  them  than  in  the  strong  ;  and  moreover  that 
the  disease  is  more  fatal.f 


YALYrLAR  DISEASES   OF  THE  HEART. 

Although  morbid  anatomists  have  described  a  variety  of  lesions  whicli 
may  cause  imperfect  action  of  the  valves  of  the  heart,  I  pi-efer  o-rouping 
them  together  under  one  head.  However  they  originate,  whether  from 
mechanical  rupture,  from  endocarditis,  deposits  of  fibrin,  morbid  growths, 
or  other  cause,  they  practically  amount  to  the  same  thing.  The  disease 
is  imperfect  valvular  action,  and  the  duty  of  the  physician  is  to  prevent 
as  much  as  possible  the  consequences  which  this  is  likely  to  occasion. 

*  Brit,  and  For.  Med.  Review.     Yol.  24. 

f  Markham  on  Diseases  of  the  Heart,  etc.     P.  103. 


VALVULAR   DISEASES   OF   THE   HEART.  533 

It  is  also  liis  duty — while  taking  every  advantage  of  the  laborious  eftoils 
which  have  been  made  to  place  the  physical  diagnosis  of  those  valvular 
injuries  on  an  exact  basis — to  remember  that  perfection  is  far  from  hav- 
iug  been  reached.  Careful  observations  are  still  required  to  clear  up 
many  doubtful  points,  and  to  unravel  the  difiiculties  which  arise  from 
complication  of  injuries  in  the  mechanism  and  vital  properties  of  so 
important  an  organ.  Hence,  notwithstanding  the  admirable  monographs 
which  have  been  published  on  this  subject,  constant  research  is  necessary, 
not  only  to  conlirm  what  is  already  known,  but  to  determine  with  pre- 
cision points  that  are  doubtful,  and  conditions  as  yet  scarcely  recoo-niza- 
ble.  '•  A  time  may  come,"  says  Stokes,  "  when  the  science  of  diagnosis 
will  be  carried  to  such  perfection,  that  we  shall  unfailingly  dete^-mine 
not  only  the  condition  of  eacli  portion  of  the  heart,  but  discover  the  rise 
and  watch  the  progress  of  every  intei'stitial  change  in  its  structure,  and 
every  mutation  of  its  vitality."*  If  so,  it  can  only  be  done  by  the  care- 
ful study  and  analysis  of  individual  cases. 

Case  XCIII.f — Incompetency  of  Amiic  Valves— Dilated  Hi/pertropTiy  of  Left  Ven- 
tricle—Dilatation of  Ascending  Portion  of  Aortic  Arch — Chronic  Arteritis  ivith 
Aneurismal  Pouches. 

History.— William  M-Ritchie,  tet.  ?,S,  fireman  on  board  a  Newcastle  steamer, 
entered  the  clinical  ward,  complaining  of  palpitation,  dyspnoea,  and  cough,  on  the 
4th  of  January,  1850.  At  that  time  it  was  ascertained  that  the  cardiac  dulness  was 
of  unusual  extent,  and  that  a  blowing  murmur  existed  with  the  second  sound  at 
the  base  of  the  heart.  He  remained  in  the  house  under  treatment  until  February 
2d,  when  all  tlie  urgent  symptoms  having  left  him,  he  was  dismissed.  He  was 
re-admitted  on  the  14th  of  March,  the  palpitation,  cough,  and  dyspnoea  having 
returned,  together  with  anasarcous  swelling  of  the  abdomen  and  inferior  extremities. 

Symptoms  ox  Admissiox. — On  percussion,  the  cardiac  dulness  measures  four 
inches  transversely-.  The  apex  beats  between  the  sixth  and  seventh  ribs  external 
to  the  nipple.  The  carotid  and  subclavian  arteries  beat  strongly.  A  loud  and  pro- 
longed bellows  murmur  is  heard  with  the  second  sound,  loudest  at  the  base  of  the 
heart,  and  propagated  in  tlie  course  of  the  large  arteries.  First  sound  is  normal  in 
character.  Pulse  70,  regular,  hard,  and  jerkmg.  Respiration  hurried;  cough  and 
dyspnoea  urgent;  inspiration  harsh;  expiration  prolonged;  face  livid;  pain  and 
dizziness  in  the  head ;  occasionally  loss  of  vision ;  disturbed  sleep ;  nausea  and 
anorexia ;  abdomen  considerably  swollen  from  ascites ;  mferior  extremities  oedema- 
tous ;  legs  cold. 

Progress  of  the  Case. — During  April  the  symptoms  continued  with  more  or 
less  intermission.  In  May  he  became  liable  to  attacks  of  syncope,  accompanied 
with  angina  and  palpitations.  In  the  beguiniug  of  June  it  was  observed  that  the 
bellows  murmur  with  the  second  sound  assumed  a  rougher  character  over  the  arch 
of  the  aorta.  He  also  complained  of  dysphagia  and  a  pulsation  in  his  throat,  which 
obliged  him  to  keep  his  head  in  a  particular  position.  On  the  14th  he  was  seized 
with  an  unusually  severe  attack  of  angina  and  syncope,  which  in  ten  minutes  was 
fatal.  The  treatment  consisted  principally  in  the  exhibition  of  a  variety  of  expec- 
torants and  antispasmodics,  of  which  a  draught  containing  ten  minuns  of  chloroform, 

*  Markham  on  Diseases  of  the  Heart,  etc.,  p.  342. 
f  Reported  by  Mr.  Hugh  M.  Balfom-,  Clinical  Clerk. 


534  DISEASES   OF  THE   CIRCULATOEY   SYSTEM. 

and  a  teaspoonful  of  Tr.  Cardam.  Co.  aftbrded  Lira  most  relief.     A  few  leeches  were 
also  applied  occasionally  to  the  cardiac  region. 

Sectio   Cadaveris. — Forty  hours  after  death. 

Thorax. — The  pericardium  contained  three  ounces  of  serous  fluid  There  was 
hj-pertrophy  with  dilatation  of  the  left  ventricle  of  the  heart,  in  consequence  of 
which  the  organ  weighed  1  lb.  4  oz.,  and  its  transverse  diameter  measured  five  inches. 
The  mitral  valve  was  healthy.  The  aortic  valves  were  considerably  thickened  and 
curled  inwards.  Immediately  above  them  the  aorta  was  unusually  dilated,  the 
diameter  of  its  calibre  being  two  and  a  quarter  inches.  "Water  poured  upon  the 
aortic  valves  from  above  passed  through  the  orifice  without  apparently  receiving  any 
impediment.  One  inch  below  the  origin  of  the  left  subclavian  there  was,  an  aneu- 
rismal  pouch,  the  size  of  a  walnut,  projecting  half  an  inch  from  the  general  outline 
of  the  vessel.  The  arteria  innomiuata,  and  the  origin  of  the  right  carotid  artery, 
were  also  somewhat  dilated,  and  tiiere  was  an  aneurismal  dilatation  of  the  aorta 
opposite  the  superior  mesenteric  artery.  The  aorta,  the  coronary,  and  several  of 
the  larger  arteries,  were  roughened  internally  by  atheromatous  deposits.  The  lungs 
were  emphysematous  anteriorly,  and  oedematous  at  their  apices. 

Head. — Brain  pale  ;  slight  subai'achnoid  eflusion  ;  cerebral  arteries  slightly 
atheromatous. 

Abdomen. — Abdominal  organs  healthy. 

Case  XCIV.* — Incompetmcy  of  Ao7iic   Valves-^Hypertrophy  of  Left   Ventricle  and 
Auricle — Obstruction  and  Incompetency  of  Mitral  Valve — Pneumonia. 

History. — Samuel  Crawford,  tet.  42,  employed  at  Chemical  Works — admitted 
June  10th,  1850.  He  has  been  subject  to  palpitation  and  dyspnoea,  after  any  con- 
siderable exertion,  for  four  or  five  years.  Last  February  he  had  to  leave  off  work 
on  account  of  these  symptoms,  which  subsided  in  a  fortnight  under  medical  treat- 
ment. Three  days  ago  they  once  more  returned.  He  has  noticed,  during  the  last 
four  or  five  months,  swelling  of  the  feet,  legs,  and  abdomen.  He  never  had  rheuma- 
tism or  any  other  serious  complaint. 

Symptoms  on  Admission. — The  cardiac  dulness  measures  three  inches  and  a 
quarter  transversely.  The  apex  beats  between  the  sixth  and  seventh  ribs,  two 
inches  below  and  to  the  left  of  the  nipple.  The  carotid  and  subclavian  arteries  beat 
strongly.  Over  the  apex  a  bellows  murmur  is  heard,  with  both  sounds  of  the  heart. 
Over  the  base  there  is  a  loud  prolonged  blowing  murmur  with  the  second  sound, 
which  is  propagated  in  the  course  of  the  large  vessels.  The  first  sound  heard  at  the 
base  is  unusually  short  and  muffled.  The  pulse  is  regular,  strong,  and  jerking.  He 
has  cough,  and  considerable  dyspnoea.  Percussion  over  the  lungs  is  resonant,  but 
posteriorly  and  inferiorly  there  are  fine  moist  rales.  He  is  liable  to  giddiness  and  a 
feeling  of  faintness  on  sudden  exertion.  Can  only  sleep  in  a  half  sitting  posture, 
resting  somewhat  on  his  left  side.  Considerable  oedema  of  the  lower  extremities. 
Other  functions  normal. 

Progress  of  the  Case. — The  cough  and  dyspnoea  continued.  On  the  13th  of 
June  the  urine  became  scanty  and  high  coloured.  On  the  17th  there  was  diarrhoea. 
Moist  and  dry  rales  were  heard  over  a  considerable  portion  of  chest,  and  there  was 
much  cough  and  expectoration.  On  the  26th  the  urine  was  again  abundant,  but 
there  was  general  fever,  cough  suppressed,  dyspnoea,  and  expectoration  tinged  with 

*  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


VALVULAR   DISEASES   OF   THE   HEART.  535 

blood.  Pulse  108,  full  and  hard.  Crepitant  and  mucous  rales  were  heard  over  the 
lower  portion  of  the  right  side.  On  tlie  28th  all  oedema  of  the  extremities  had 
disappeared,  but  there  was  decided  pneumonia  on  right  side.  Low  delirium  during 
the  night.  Died  on  the  morning  of  tlie  29th.  On  the  first  day  §  x  of  blood  were 
drawn  from  the  arm  with  immediate  relief,  but  it  was  followed  by  sleeplessness  and 
agitation  at  night.  He  was  then  ordered  §  vj  of  wine  daily,  and  a  mixture  con- 
taining expectorants  and  diuretics,  with  tincture  of  digitalis.  Local  blood-letting, 
by  means  of  leeches,  was  also  practised  from  time  to  time.  The  scantiness  of  the 
urine  and  oedema  gave  way  under  the  use  of  cream  of  tartar  in  3  j  doses  three 
times  a  day.  "When  the  pneumonia  came  on,  local  blood-letting,  by  cupping 
to  5  xij,  and  tartrate  of  antimony  internally  were  employed,  but  without  success, 
although  the  former  relieved  the  dyspnoea. 

Sectio   Cadaveris. — Forty-eight  hours  after  death. 

Thorax. — The  pericardium  contained  four  ounces  of  straw-coloured  serum.  The 
heart  weighed  twenty-three  and  a  half  ounces.  This  increase  in  size  was  owing  to 
hypertrophy  of  the  walls  of  the  left  ventricle  and  auricle,  and  to  dilatation  of  the 
right  ventricle.  The  aortic  valves  were  fringed  with  numerous  warty  vegetations. 
One  of  the  valves  was  ruptured,  and  the  ruptured  edges  were  studded  over  with 
granules  of  recent  exudation.  In  consequence  of  these  lesions  the  valves  allowed 
water  to  rush  rapidly  through,  when  poured  on  them  from  above.  The  septal  leaf 
of  the  mitral  valve  was  perforated  in  two  places  by  orifices  of  sufficient  size  to 
admit  a  crow  quill.  These  orifices  were  surrounded  by  vegetations,  presentmg  a 
funnel-shaped  prolongation  on  the  internal  surface  of  the  valve,  through  which  the 
orifice  passes.  There  were  several  other  vegetations  on  the  opposite  leaf  of  the 
valve  and  fringing  its  margin.  One  of  the  chordae  tendinese  was  broken  across  at 
its  valvular  attachment,  the  ruptured  or  floating  end  being  thickly  covered  with 
fibrinous  vegetations.  Aorta  healthy.  The  lower,  middle,  and  a  portion  of  upper 
lobe  of  right  lung  dense,  hepatised,  presenting  a  reddish-gray  colour,  and  yielding 
sanguineous  pus  on  squeezing  the  cut  surface. 
Abdomkn'. — Abdominal  organs  healthy. 

Commentary. — Both  the  cases  now  detailed  exhibit  very  strongly 
how  the  rules  formerly  mentioned,  correctly  applied,  enable  iis  to  deter- 
mine the  nature  of  the  cardiac  lesion  present, — for  you  will  remember 
that,  in  both,  the  lesions  named  at  the  head  of  each  case  were  confidently 
stated  to  exist,  before  the  body  was  examined.  In  Case  XCIII.  "  a  bel- 
lows murmur  was  heard  with  the  second  sound,  loudest  at  the  base  of 
the  lieart,  and  propagated  in  the  cours.-  of  the  large  arteries."  Kule  5 
tells  us  that  this  indicates  aortic  insulficiency,  and  on  examination  such 
was  found  to  exist.  As  the  case  progressed,  however,  he  complained  of 
a  pulsation  in  his  throat  and  of  dysphagia ;  and  it  is  worthy  of  remark, 
that  not  onlv  had  an  incipient  aneurism  formed  in  the  arch  of  the  aorta, 
which  explained  these  symptoms,  but  that  a  tendency  to  the  formation 
of  aneurisms  existed  in  other  parts  of  the  arterial  system.  In  Case 
XCIV.  the  diao;nosis,  though  more  complicated,  and  therefore  more 
difficult,  was  also  determined  on  by  paying  attention  to  the  same  rules. 
"Over  the  apex  a  bellows  murmur  was  heard  with  both  sounds  of  the 
heart."  Now  rule  0  tells  us  that  this  indicates  mitral  obstruction  with 
insutficiency,  and  a  description  of  the  lesion  found  aflecting  this  valve 
after  death,  must  convince  us  that  whilst  the  vegetations  prevented  proper 


533  DISEASES   OF   THE   CIRCULATORY   SYSTEil. 

closure  of  the  orifice,  some  of  tliein  must  also  have  obstructed  the  flow 
of  blood  ill  its  passage  from  the  auricle  to  the  ventricle.  But  there  was 
also  a  bellows  murmur  with  tlie  second  sound,  heard  loudest  at  the  base; 
and  this,  as  in  Case  XCIII.,  is  a  sign  of  aortic  insufficiency.  A  careful 
determination  of  the  cardiac  signs,  therefore,  and  an  exact  appreciation 
of  the  facts  in  the  first  instance,  led  us,  in  accordance  with  the  laws 
previously  generalized,  to  a  correct  conclusion  as  to  the  nature  of  this 
complicated  case.  No  two  cases  could  better  convince  you  of  the  dia- 
gnostic value  of  physical  signs.  The  treatment  in  the  last  case  is  what  I 
should  now  consider  as  far  too  depletory.  On  looking  back  to  it  after 
seven  years'  additional  experience,  it  will  be  observed  that  it  confirms 
all  that  I  have  previously  stated  as  to  the  inutility  of  such  practice.  The 
hard  pulse  of  the  pneumonia  which  usliered  in  death,  was  evidently 
caused  by  the  aortic  disease,  in  the  same  manner  that  a  similar  compli- 
cation in  the  course  of  pericarditis  was  attended  with  the  same  svmptom. 
(See  Case  LXXXIX.) 


Case  XCV.* — Licompeieiicy  of  Mitral  Valve. 

History. — Agaes  ilurraj,  set.  41 — admitted  June  IGtli,  1850.  About  eighteen 
mouths  ago  she  first  experienced,  without  any  obvious  cause,  palpitations  and  pains 
in  the  cardiac  region,  which  have  continued  ever  since.  They  became  more  violent 
after  exertion,  and  were  accompanied  by  dyspnoea.  Latterly  there  has  been  an 
cedematous  swelling  of  the  legs,  abdomen,  and  face.  She  has  had  four  attacks  of 
bsemoptysis,  the  first  occurring  eighteen  months,  and  the  last  three  months,  ago. 

Symptoms  ox  Admissiox. — The  cardiac  dulness  measures  two  and  a  quarter  inches 
across.  The  apex  of  the  heart  beats  under  the  sixth  rib,  below  and  a  little  outside 
the  nipple.  Over  the  apex  there  is  heard  a  harsh  bellows  murmur,  which  diminishes 
in  intensity  towards  the  base  and  large  vessels.  Pulse  80,  weak.  Great  dyspnoea 
and  palpitation  on  exertion,  and  occasional  severe  pain  in  the  cardiac  region.  Reso- 
nance of  lungs  natural.  Posteriorly,  over  right  lung,  loud  sibilant  murmurs  are 
heard,  both  with  inspiration  and  expiration.  Expectoration  abundant.  No  anasarca 
at  present,  or  cerebral  symptoms. 

Progress  op  the  Case. — This  woman,  under  the  action  of  small  doses  of  digitalis 
and  cream  of  tartar,  and  the  occasional  application  of  a  few  leeches  to  the  cardiac 
region,  became  gradually  much  better.  The  palpitations,  dyspnoea,  and  bronchitis 
disappeared.     She  was  dismissed  greatly  relieved,  July  IGth. 


Case   XCVI.f — Incompetency   of  Mitral    Valve — Pulmonary   Eeraorrhage — Hydro- 
thorax. 

History. — Robert  Ross,  set.  30,  a  lath  splitter — admitted  June  28th,  1850.  For 
some  time  past  he  has  occasionally  experienced  pali^itation,  and  observed  now  and 
then  slight  swelling  of  the  legs.  He  first  became  severely  ill  only  seven  weeks  ago, 
when  he  was  seized  with  repeated  vomitings,  which  continued  two  days.  He  sub- 
sequently caught  cold,  to  which  he  is  very  liable,  and  since  then  has  been  labouring 
under  cough,  dyspnoea,  a  feelmg  of  tightness  across  the  upper  part  of  the  abdomen, 
and  general  weakness. 

*  Reported  by  Mr.  Edmund  S.  "U'ason,  Clinical  Clerk. 
f  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


VALVULAR   DISEASES   OF   THE   HEAET.  537 

Symptoms  on  Admission. — Cardiac  duluess  cannot  be  distinctly  defined.  Tlie 
apex  beats  feebly  between  the  fifth  and  sixth  ribs,  two  inches  below  the  nipple.  A 
bellows  murmur  is  heard  with  the  firet  sound  over  the  apex,  but  much  more  distinctly 
three  inches  to  the  right  of  it,  near  the  sternum.  It  is  almost  inaudible  over  the 
base.  The  second  sound  is  normal.  Pulse  100,  small  and  soft.  Considerable  dys- 
pnoea and  cough ;  sputa  viscid  and  tinged  with  blood.  No  dulness  on  percussion 
over  the  lungs.  Sibilant,  raucous,  and  crepitating  rales  are  heard  veiy  generally  over 
the  inferior  parts  of  chest,  both  anteriorly  and  posteriorly.  No  increase  of  vocal 
resonance.  The  general  surface  is  slightly  jaundiced.  On  careful  percussion  of  the 
liver,  its  inferior  border  presents  a  prominence,  anteriorly  the  size  of  an  egg,  over  the 
pylorus. 

Progress  of  the  Case. — Up  to  the  8d  of  July  there  was  occasional  vomiting. 
The  inferior  extremities  became  oedematous,  and  fluid  accumulated  in  the  abdomen. 
On  percussion,  the  resonance  over  the  right  lung  is  diminished  as  high  as  the  sca- 
pula ;  there  is  a  slight  increase  of  the  vocal  resonance.  On  the  8th  of  July,  the  sur- 
face generally  was  anasarcous.  From  the  10th  to  the  I5th,  the  dyspncea  greatly 
increased.  He  expectorated  on  various  occasions  mouthfuls  of  florid  blood.  Lat- 
terly, he  could  only  lie  on  the  left  side.  The  lefl  side  of  the  chest  became  completely 
dull  on  percussion,  with  absence  of  respiration.  He  was  now  removed  from  the 
Infirmary  by  his  friends.  Leeches  to  the  epigastrium,  with  naphtha  and  anodynes 
internally,  checked  the  vomiting.  The  principal  object  of  the  treatment  however, 
was,  by  means  of  diuretics,  to  increase  the  amount  of  urine,  and  thereby  diminish 
the  anasarca.  Pills  of  lead  and  opium  were  also  administered  to  check  the 
liajmoptysis. 

Commentary. — Tlie  two  last  cases  contrast  very  strongly  with  the 
two  first.  In  both,  the  bellows  murmur  was  heard  only  with  the  first 
sound,  loud  over  the  apex,  diminishing  towards  the  base;  and  rule  4 
tells  us  that  this  indicates  mitral  incompetency.  The  concomitant 
symptoms  fully  bear  out  this  diagnosis.  The  pulse  was  weak, — the 
pulmonary  organs  were  those  disturbed,  while  the  cerebral  functions 
were  unaffected.  In  Case  XC  V.  there  was  bronchitis,  which  diminished 
under  appropriate  treatment.  In  Case  XCVI.  bronchitis  also  existed, 
but  it  was  much  more  general,  and  mingled  with  a  certain  degree  of 
collapse  of  the  lung  on  the  right  side.  Extravasation  of  blood  into  the 
pulmonary  tissue  of  both  lungs  had  most  probably  also  taken  place,  as 
indicated  by  the  haemoptysis ;  and,  latterly,  the  general  dropsy  which 
prevailed  affected  the  thoracic  cavities,  causing  hyclrothorax  on  the  left 
side.  The  man  was  evidently  in  a  dying  condition  when  his  friends 
insisted  on  his  removal  ;  and  I  was  rather  surprised  to  hear  that  he 
lingered  a  fortnight  before  death  took  place.  No  examination  could  be 
obtained. 


Case    XCVIL* — Mitral    Incomjietency — Hypertrophy   of  left    Ventricle — Attack   of 
Acute  Rheumatism,  foUoxced  by  Aortic  Incompetency. 

Htstohy. — John  CoDolly,  fet.  49,  a  joiner — admitted  June  22d,  18.50.  He  has  for 
some  years  past  been  subject  to  pain  in,  and  swelling  of,  the  joints.  Eighteen 
months  ago  he  was  suddenly  seized  with  pain  in  the  cardiac  region,  unaccompanied 

*  Reported  by  Mr.  Charles  Murchisou,  Clinical  Clerk. 


538  DISEASES   OF  THE   CIRCULATORY  SYSTEM. 

by  dyspnoea,  but  followed  by  severe  cough.     He  has  been  copiously  bled,  and  under- 
gone a  lengthened  treatment. 

Symptoms  on  Admission. — The  cardiac  dulness  measures  2f  inches  across.  The 
apex  beats  in  a  hollow  between  the  xiphoid  cartilage  and  the  cartilage  of  the  seventh 
left  rib.  Heart's  impulse  strong.  A  bellows  murmur  can  be  heard  with  the  first 
sound,  synchronous  with  the  cardiac  impulse.  It  is  loudest  at  the  apex,  and  dimi- 
nishes in  intensity  towards  the  base.  Pulse  74,  full  and  strong.  No  cough,  liut  con- 
siderable dyspnoea  on  making  the  slightest  exertion.  Percussion  and  auscultation 
indicate  slight  pulmonary  emphysema  anteriorly,  but  no  bronchitis.  Slight  tinnitus 
aurium,  and  dimness  of  vision  occasionally.  There  is  a  patch  of  j^soriasis  Jigu7-aia,  an 
inch  and  a  half  in  diameter,  on  the  right  cheek  and  side  of  the  nose. 

Progress  of  the  Case. — July  1st,  he  was  attacked  with  severe  articular  rheu- 
matism in  the  hip,  knee,  and  wrist  joints,  which  had  entirely  disappeared  under 
appropriate  treatment  on  the  9th.  On  the  14th  he  had  diarrhcea,  accompanied  by 
considerable  discharge  of  blood  per  anum.  This  continued  in  smaller  quantities 
from  time  to  time.  On  the  22d,  a  careful  examination  exhibited  a  change  in  the 
cardiac  signs.  The  impulse  over  the  apex  w^as  more  prolonged,  with  a  deep  murmur 
and  jog.  The  bellows  murmur  synchronous  with  the  impulse,  was  no  longer  audible, 
but  one  can  be  heard  alternating  with  it  at  the  base, — that  is,  with  the  second 
sound.  Great  pulsation  of  the  carotid,  subclavian,  and  humeral  arteries  was  seen 
and  felt,  and  a  loud  puffing  murmur,  synchronous  with  their  dilatation,  could  be 
heard  over  them.  His  general  health,  however,  was  greatly  improved,  the  local 
and  other  symptoms  having  disappeared ;  and  he  left  the  house,  at  his  own  desire, 
July  24th. — At  first  he  took  digitalis  for  six  days,  with  a  view  of  diminishing  the 
cardiac  impulse  and  pain.  It  was  then  suspended  on  account  of  the  nausea  and 
weakness  it  apparently  occasioned.  The  rheumatic  iever  and  arteritis  were  com- 
bated by  salines,  diaphoretics,  and  venesection  to  the  extent  of  §  xij.  Afterwards 
the  local  pains  rapidly  yielded  to  small  blisters  placed  over  each  aflected  joint.  The 
diarrhoea  and  discharge  of  blood  were  checked  by  piUs  of  lead  and  opium. 

Commentary. — This  man,  after  frequent  attacks  of  Rheumatism, 
entered  the  Infirmary,  labouring  under  liypertrophy,  with  incompetency 
of  the  mitral  valve.  At  the  time  there  was  no  bronchitis,  but  he  had 
previously  suffered  from  severe  cough  and  pulmonary  derangement. 
AVhilst  in  the  house,  one  of  his  acute  rheumatic  attacks  caine  on. 
Manv  of  the  joints  were  swollen  and  exceedingly  painful ;  but  this 
aftec'tion  yielded  to  one  small  general  bleeding,  tartar  emetic  internally, 
and  blisters  locally,  in  eight  days.  The  eflect  of  this  attack  was  to  give 
rise  to  acute  endocarditis,  which,  instead  of  aftecting  the  auriculo-ven- 
tricular  orifice  formerly  diseased,  fixed  itself  upon  the  aortic  valves. 
The  lesion,  however,  must  have  been  slight — probably  limited  to  a  few 
small  vegetations  upon  the  margins  of  the  valve — because  the  murmur 
was  soft  in  character,  and  the  incompetencj'  not  of  such  amount  as  to 
occasion  either  cerebral  or  other  functional  symptoms.  The  pulsation 
in  the  large  vessels,  however,  was  greatly  augmented,  and  there  is 
every  reason  to  fear,  that  should  the  incompetency  continue  (as  is  most 
probable),  the  aorta  and  cavity  of  the  left  ventricle  will  both  become 
dilated. 


VALVULAR   DISEASES   OF   THE   HEART.  539 


Case  XCYin*—JIitral  Incompetency— Ilyperlrophy  of  Left  Ventricle— Aortic  Incom- 
petency and  Obstruction — Angina. 

History. — Edward  Monro,  iBt.  41,  a  painter — admitted  June  24,  1850.  Two 
years  ago,  witliout  any  assignable  cause,  he  was  suddenly  seized  witli  angina,  con- 
sisting of  severe  pain  in  tlie  middle  of  the  sternum,  often  running  down  the  left  arm, 
accompanied  by  violent  palpitations.  Since  then  the  paroxysms  have  been  increas- 
ing both  in  frequency  and  intensity. 

Symptoms  on  Adjiission.— The  cardiac  dulness  below  the  nipple  measures  three 
and  a  quarter  inches  transversely.  The  apex  of  the  heart  cannot  be  felt  to  beat  at 
any  particular  spot.  Heart's  action  is  regular.  A  distinct  bellows  murmur  can  be 
heard  accompanying  both  the  first  and  second  cardiac  souuds,  which  are  equally  loud 
at  the  apex  and  at  the  base.  Both  are  heard  loudest  to  the  right  of  sternum,  ojDpo- 
site  the  second,  third,  and  fourth  costal  cartilages.  A  loud  blowing  murmur  is 
heard  over  the  carotid  arteries.  Pulse  74,  regular.  Has  a  slight  cough,  with  expec- 
toration. Lungs  resonant  on  percussion,  and  on  auscultation  the  inspiratory  mur- 
murs are  louder  and  rougher  than  natural,  and  the  expiration  is  slightly  prolonged. 
He  has  frequently  expectorated  small  quantities  of  dark-coloured  blood.  There  is 
great  dyspnoea  on  making  the  slightest  exertion,  and  he  has  occasional  severe  attacks 
of  angina.  There  is  considerable  dyspepsia.  Slight  dimness  of  vision,  and  muscse 
volitantes,  but  otherwise  no  cerebral  symptoms. 

Progress  of  the  Case  —The  attacks  of  angina  returned  four  and  five  times 
a-day.  They  occasioned  great  agony,  profuse  perspiration,  and  increased  action  of 
the  heart,  during  which  the  murmurs  were  heard  louder.  There  was  also  occasional 
nau-sea  and  tendency  to  vomit.  On  the  8th  of  July  he  fainted,  being  unconscious  for 
five  minutes.  At  this  time  the  murmur  with  the  first  sound  assumed  a  whining 
character,  heard  loudest  at  the  apex.  There  was  a  double  bellows  murmur  heard 
distinct  from  this,  at  the  base.  July  IK/i.— There  was  cough  and  expectoration. 
A  fine  moist  rale  could  be  heard  over  the  lower  half  of  left  chest,  both  anteriorly 
and  posteriorly.  No  dulness  on  percussion,  or  increased  vocal  resonance.  July  lath. 
— He  has  now  only  one  attack  of  angina  in  the  day,  which  is  also  mucli  less  severe. 
The  cough  and  expectoration  are  diminished.  A  mucous  rale  still  perceptible  in  left 
lung  iuferiorly.  A  whining  murmur  with  the  first  sound  is  still  heard  at  the  apex, 
and  a  double  bellows  murmur  at  the  base,  propagated  in  the  course  of  the  great  ves- 
sels. He  left  the  house  at  his  own  desire.  The  attacks  of  angina  were  at  first 
treated  with  anodyne  and  antispasmodic  draughts,  containing  M.  v.  of  chloroform  for 
a  dose.  Afterwards  they  were  greatly  relieved  by  taking  carminatives,  such  as 
tliree  drops  of  each  of  the  oils  of  aniseed  and  cajeput  dropped  on  sugar.  Latterly 
they  greatly  diminished  after  §  vj  of  blood  were  drawn  from  the  cardiac  region  by 
cupping.     The  bronchitis  was  treated  with  anodynes  and  expectorants. 

Commentari/. — When  this  man  entered  the  Infirmary  it  was  veiy 
difficult  to  determine  at  what  point  the  two  bellows  murmurs  were 
heard  loudest.  Repeated  and  careful  examination  failed  to  discover 
whether  one  or  both  were  referable  to  the  ape.x  or  to  the  base  ;  and  in 
consequence  we  could  not,  according  to  the  rules  given,  determine 
whether  the  disease  was  aortic,  mitral,  or  both.  This  was  probably 
owino-  to  the  circumstance  of  the  abnormal  murmurs  originating  in  two 
places,  and  being  at  the  same  time  so  similar  in  tone,  that  the  ditfusion 

*  Reported  by  Mr.  Charles  Murchison,  Clinical  Clerk. 


540  DISEASES   OF   THE    CIRCULATOEY   SYSTEil. 

of  sound  was  pretty  equal  over  the  whole  cardiac  region.  But  as  the 
case  progressed  the  inurmurs  underwent  such  modifications  as  left  us  in 
no  doubt.  The  murmur  with  the  first  sound  over  the  apex  assumed  a 
whining  tone,  so  that  it  was  easily  separated  from  the  double  bellows 
murniur  which  still  remained  loud  at  the  base.  The  former,  according 
to  the  rules  given,  must  have  depended  on  mitral  incompetency;  whilst 
the  latter,  for  the  same  reason,  must  have  been  owing  both  to  incompe- 
tency and  obstruction  of  the  aortic  orifice.  The  man  laboured  under 
slight  pulmonary,  as  well  as  cerebral,  symptoms.  His  chief  complaint, 
however,  was  the  angina,  the  attacks  of  which  were  in  him  \ery  severe, 
causing  the  most  excruciating  agony,  and  bathing  the  whole  surface 
Avith  sweat.  This,  in  its  turn,  seemed  to  be  connected  with  a  state  of 
dyspepsia  which  existed.  Whenever  gas  accumulated  in  the  stomach, 
so  as  to  distend  that  organ  and  press  the  heart  upwards,  the  attacks 
were  most  severe.  The  carminatives  gave  relief  by  causing  discharge  of 
this  gas.  After  local  bleeding,  and  an  improvement  in  his  general 
health,  but  more  especially  in  the  dyspeptic  symptoms,  the  angina 
diminished  in  intensity. 

The  two  last  cases  recorded  exhibit  how  important  it  is  carefully  to 
examine  the  cardiac  signs  from  time  to  time  as  the  case  progresses,  and 
to  watch  the  modifications  they  undergo.  AVhere  doubt  and  difficulty 
prevail,  it  is  only  in  this  way  they  can  be  removed.  Under  such  circum- 
stances, never  state  an  opinion  at  all,  but  continue  to  watch  until  the 
signs  become  permanent  and  unequivocal.  This  advice  you  will  find  to 
be  even  more  useful  in  private  than  in  hospital  practice,  for  reasons 
which  I  shall  allude  to  hereafter.  But  not  only  are  frequent  examina- 
tions useful  in  clearing  up  different  points  in  diagnosis,  they  also  reveal 
to  the  pathologist  the  changes  which  take  place  in  the  affected  parts. 
Of  this  the  following  case  atibrds  us  an  instructive  example. 


Case  XCIX.* — Incompetency  of  the  Aortic   Valves  with  Musical  Murmur — Hyper- 
trophy  vjith  Dilatation  of  Left  Ventricle — Pneumonia — Pulmonary  Hemorrhage. 

History. — ^William  Caird,  set.  29,  labourer — admitted  May  30,  1S50.  Five  months 
ago  he  first  noticed  that  he  became  unusually  breathless,  and  had  palpitations  after 
exertion.  He  continued  to  work  untU  two  months  ago,  when,  being  engaged  in 
lifting  heavy  stones,  he  was  suddenly  seized  with  pain  in  the  cardiac  region,  violent 
cough  and  haemoptysis.  He  entered  the  Glasgow  Infirmary,  from  which  he  was  dis- 
charged, much  relieved,  in  a  fortnight.  Since  then  he  has  been  subject  to  giddiness, 
dyspnoea,  and  palpitation,  with  occasional  htemoptysis. 

STJiPTOiis  ox  Adiiissiox. — Cardiac  dulness  extends  three  and  three  quarter 
inches  transversely.  The  apex  beats  between  the  sixth  and  seventh  ribs,  three 
inches  below,  and  a  little  to  the  left  of  the  nipple.  A  bellows  murmur  is  lieard 
•with  the  second  sound,  loudest  at  the  base,  and  propagated  in  the  course  of  the 
large  vessels.  The  first  sound  is  normal.  Pulse  92,  strong  and  regular.  He  feels  a 
shooting  pain  in  the  cardiac  region,  extending  to  the  epigastrium.  There  is  great 
dyspnoea,  and  palpitation  on  exertion.  Sliglit  cough,  and  fine  moist  rale  in  both 
lungs,  heard  inferiorly  and  posteriorly.     Occasional  giddiness. 

Progkess  of  the  Case. — The  pain  in  the  cardiac  region  and  epigastrium  was 

*  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


YALVL'LAR   DISEASES   OF   THE    HEART.  511 

the  chief  source  of  complaint  during  the  progress  of  rhe  case.  Tlie  dvspncea  and 
palpitations  were  from  time  to  time  distressing.  There  was  occasional  vomiting. 
On  the  12th  of  July,  it  was  observed  that  the  bellows  murmur  assumed  a  whining 
character,  and  on  the  15th  it  was  distinctly  musical,  like  the  chirping  of  a  small  bird. 
On  the  ITth  the  heart's  action  was  tumultuous,  and  vomiting  was  very  distressing. 
On  the  23d  there  was  considerable  haemoptysis,  mouthfuls  of  blood  being  evacuated. 
On  the  24th,  there  was  duluess  on  percussion,  over  the  inferior  portion  of  chest, 
and  distinct  crepitation  could  be  heard  with  increased  vocal  resonance.  The  cardiac 
dulness  was  determined,  on  careful  percussion,  to  measure  five  inches  transversely. 
The  vomiting  and  haemoptysis  defied  all  remedies.  The  pulse  was  100,  soft.  He 
gradually  became  weaker.  The  urine  was  scanty,  and  oedema  of  the  legs  appeared. 
Latterly  there  was  muttering  delirium  at  night.  Died  on  the  29th.  At  first  he 
experienced  relief  from  the  cardiac  and  epigastric  pains,  after  small  local  bleedings 
by  means  of  leeches  and  cupping.  Blisters  were  also  applied.  All  kinds  of  reme- 
dies were  tried  to  check  the  vomiting,  but  with  little  effect.  Antispasmodics  were 
employed  to  relieve  the  dyspnoea ;  and  latterly,  as  the  pulse  became  weak,  wine 
and  stimulants  were  freely  administered. 

Sectio  Cadaveris. — Thirtij  hours  after  death. 

TnOR.iX — Heart  much  enlarged,  weighing  25  ounces,  owing  almost  entirely  to 
hypertrophy  with  dilatation  of  the  left  ventricle.  When  water  was  poured  upon  the 
aortic  valves  from  above,  it  passed  rapidly  tlirough  the  orifice.  The  aortic  valves 
were  thickened  throughout  and  shortened;  their  curled-in  and  dense  margins  were 
one-tenth  of  an  inch  thick.  Two  of  the  valves  were  united  at  their  neighbouring 
surfaces,  so  as  to  form  one,  the  only  vestige  of  a  septum  between  them  being  a  har- 
dened nodule  at  the  base  of  the  enlarged  valve.  On  the  edge  of  the  smaller  valve 
was  a  warty  excrescence,  the  size  of  a  coftee-bean,  soft  in  consistence,  composed  of 
recent  exudation,  and  infih  rated  with  blood,  so  as  to  present  a  purple  colour. 
There  was  red  hepatisation  of  the  posterior  and  inferior  portion  of  both  lungs,  and 
there  was  considerable  apoplectic  extravasation  in  the  substance  and  tlie  neigh- 
bourhood of  the  diseased  portions  of  the  lung.  The  bronchi  were  filled  witli  frothy 
mucus. 

ABDO-ViEy. — The  liver  presented  the  nutmeg  appearance,  being  in  the  first  stage 
of  cirrhosis.     Other  organs  healthy. 

Commentary. — ^We  had  very  little  difficulty  ia  detenuiuino-,  from  the 
cardiac  signs  in  this  case,  that,  according  to  the  rules  laid  down,  there 
was  incompetency  of  the  aortic  valves,  with  dilated  hypertrophy  of  the 
left  ventricle.  The  bellows  murmur,  which  was  at  first  sore,  gradually 
chano-ed  its  character  as  the  case  progressed,  without  altering  its  posi- 
tion. It  became  whining,  and  then  chirping,  constituting  what  is  called 
a  musical  murmur.  It  is  generally  found  in  such  cases  that  a  solid  body 
projects  into  the  current  of  the  blood  as  it  flows  through  the  valve,  so  as 
to  be  thrown  into  vibrations  ;  and  it  was  interesting  to  discover,  on  the 
examination  of  the  body,  that  the  vegetation  described  exactly  fulfilled 
these  conditions.  .From  its  softness  also  there  is  every  reason  to  suppose 
it  was  of  recent  formation,  originating  probably  about  the  time  the 
musical  murmur  was  first  observed.  From  the  great  induration  of  the 
aortic  valves,  there  can  be  very  little  doubt  that  they  had  been  atfected 
for  a  lono-  time,  at  least  many  months  ;  but  it  becomes  a  question, 
whether  the  adhesion  and  formation  of  one  valve  out  of  two  might  not 
have  been  caused  by  a  rupture  of  one  or  both  valves,  two  months  pre- 


542  DISEASES   OF   THE   CIECULATOEY   SYSTEM. 

vioiisly,  at  the  time  lie  ^Yas  lifting  heavy  stones,  and  -svas  suddenly  seized 
with  cardiac  pain  and  other  symptoms.  It  is  worthy  of  observation, 
also,  that,  although  he  had  cerebral  symptoms,  the  lungs  were  greatly 
affected,  the  bronchitis  latterly  passing  into  pneumonia  with  pulmonary 
hemorrhaoe. 


Case  C* — Mitral  Incomj^eiency — Hypertrophy  of  Left  Ventricle — Dilatation  and  Dis- 
ease of  Arch  of  Aorta — Aortic  Incompyetency. 

History. — Hugh  Devine,  set.  40,  labourer — admitted  July  17,  1850.  Dates  his 
illness  from  a  severe  strain  of  the  back,  eighteen  months  ago,  but  is  not  sure  when 
he  first  noticed  dyspnoea  and  palpitation,  which  have  prevented  him  from  working 
for  the  last  eight  months.     Never  had  rheumatism  or  haemoptysis. 

Symptojis  on  Admissiox. — Cardiac  dulness  measures  two  and  three  quarter  inches 
t^ansverseh^  The  apex  beats  between  the  fifth  and  six  ribs,  two  inches  below,  and 
a  little  to  the  right  of  the  nipple.  A  bellows  murmur  with  the  first  sound  is  heard 
at  the  apex,  decreasing  towards  the  base.  A  bellows  murmur  of  a  rougher  character 
is  also  heard  with  the  first  sound  at  the  base,  which  is  prolonged  in  the  course  of  the 
large  vessels.  The  second  sound  is  normal.  There  is  distinct  pulsation  under  the 
clavicles,  but  none  above  the  sternum.  Pulse  104,  regular,  full,  and  jerking.  No 
cough  or  pulmonary  symptoms,  with  the  exception  of  dyspnoea  on  exertion.  Has 
frequent  pain  in  the  upper  part  of  the  head  and  across  the  temples,  and  occasional 
dimness  of  vision.     The  thyroid  gland  is  somewhat  enlarged. 

Progress  of  the  Case. — Since  his  residence  in  the  Infirmary  the  symptoms  have 
been  greatly  ameliorated.  The  dyspnoea,  palpitation,  and  cephalalgia,  have  nearly 
disappeared.  The  cardiac  signs,  however,  have  undergone  considerable  change.  On 
the  16th  of  August  it  is  reported  that  there  is  still  a  bellows  murmur  with  the  first 
sound,  heard  loud  at  the  apex.  An  inch  above,  and  to  the  inside  of  the  nipple,  a 
loud,  harsh,  grating  murmur  is  heard  with  the  first  sound,  and  followed  by  a  soft 
bellows  murmur  with  the  second.  In  the  course  of  the  aorta  there  is  unusual  im- 
pulse, and  coinciding  with  it  there  is  a  bellows  murmur,  which  is  propagated  along 
the  carotids.     He  was  dismissed,  September  12th. 

Commentary . — This  man  was  examined  with  great  care,  and  cardiac 
signs  ascertained  to  exist  which  are  not  often  associated  together.  For 
instance,  there  was  a  distinct  bellows  murmur,  loud  over  the  apex  and 
diminishing  towards  the  base,  which,  according  to  the  rules  given,  we 
ascribed  to  mitral  incompetency.  Over  the  aortic  valves,  however,  and 
extending  along  the  arch  of  the  aorta,  there  was  a  bellows  murmur  of  a 
rougher  character,  and  also  occurring  with  the  first  sound.  Now  rule  7 
tells  us  that  this  may  depend  on  three  circumstances, — "  1st,  On  an 
altered  condition  of  the  blood,  as  in  anaemia;  2nd,  On  dilatation  or  dis- 
ease of  the  aorta  itself;  or,  od.  On  stricture  of  the  aortic  orifice,  in  which 
case  it  is  almost  alwavs  associated  with  insufilciency,  and  then  the  mur- 
mur is  double."  It  is  clear  that  the  first  and  third  propositions  would 
not  apply,  and  I  therefore  came  to  the  conclusion  that  in  addition  to 
mitral  regurgitation,  the  aorta  was  dilated  and  diseased,  the  former  indi- 
cated by  the  increased  impulse,  and  the  latter  by  the  roughened  murmur. 
Latterly,  when  dismissed,  the  roughened  muinuir  over  the  aorta  assumed 

*  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


VALVULAR   DISEASES   OF   THE   HEART.  543 

a  raspino-  character,  and  a  soft  bellows  murmur  was  also  heard  with  the 
second  sound, — so  that  the  dilated  and  diseased  aorta  had  at  that  time 
probably  become  associated  with  aortic  incompetency. 


Case  CL* — Constridion  of  Mttral  and   Tricuspid   Orijires — Aortic  Incompetence — 
Anasarca — Hijdrothorax, —  Collapse  of  Left  Lung — BrigMs  Disease  of  Kidney. 

History. — Elizabeth  King,  aged  26 — admitted  Jul.v  20th,  1855.  Two  years  ago 
she  entered  this  Hospital,  labouring  under  an  attack  of  acute  rheumatism  ;  was  dis- 
missed relieved  at  the  end  of  six  weeks,  but  soon  afterwards  she  was  again  laid  off 
work  by  general  anasarca;  and  in  the  November  of  the  same  year  (1853)  she  again 
returned  to  this  Infirmar3^  She  was  a  patient  in  the  CUnical  Wards ;  was  treated  for 
double  pneumonia ;  was  recognised  at  that  time  to  labour  under  mitral  insufficiency ; 
was  much  relieved  during  her  stay,  and  discharged  in  the  middle  of  February,  1854. 
But  she  has  never  recovered  her  strength.  Three  months  ago  she  became  affected 
with  swelling  of  the  legs  and  abdomen,  with  occasional  slight  lumbar  pain,  and  with 
severe  pain  in  the  hypogastric  region  attendant  upon  the  abdominal  swelling.  The 
pain  and  the  swelling  have  gradually  become  worse.  She  has  been  confined  to  bed 
for  the  last  ten  days. 

Symptoms  ox  Admission. — Impulse  weak ;  apex  beat  not  definable  ;  transverse 
duluess  three  and  a  half  inches ;  at  the  normal  site  of  apex  beat  there  is  a  double 
blowing  murmur;  the  same  is  audible  all  the  way  up  to  the  clavicle,  but  it  diminishes 
in  intensity  from  below  upwards.  Pulse  86,  small  and  weak ;  palpitation,  vertigo, 
slight  cough ;  muco-purulent  expectoration ;  dyspnoea  on  exertion,  with  occasionally 
orthopnoea  at  night ;  face  slightly  livid,  with  a  faint  tinge  of  yellow ;  is  naturally 
freckled.  Has  great  thirst  and  little  appetite ;  the  bowels  are  costive.  The  urine  is 
scanty,  of  an  orauge-j-ellow  colour;  sp.  gr.  1015;  is  not  albuminous.  The  lower 
extremities  and  the  skin  over  the  hypogastric  region  are  oedematous.  tense,  and  pain- 
ful on  pres.sure.  Yesterday  had  severe  pain  in  the  right  iliac  passing  to  the  lumbar 
region.     Does  not  sleep  well  at  night. 

Progress  of  the  Case. — The  pain  in  the  right  iliac  region  disappeared  under 
treatment  during  the  first  week.  Vomiting  occurred  at  every  meal  during  the  same 
period.  After  the  24:th  July,  the  urine  contained  a  large  quantity  of  bile,  and  the 
whole  body  became  slightly  jaundiced.  Xo  increase  in  m-ine  could  be  effected.  On 
the  9tli  August  it  is  reported  very  scanty  and  albuminous.  The  anasarca  steadily 
increased,  with  painful  tension  of  limbs  and  abdomen.  Ultimately  the  whole  trunk, 
upper  extremities,  and  fiice  became  oedematous.  Respiration  became  more  embar- 
rassed, and  over  the  upper  parts  puerile.  On  the  8th  August  there  were  signs  of 
hydrothorax  on  the  left  side.  The  dyspnoea,  cough,  sleeplessness,  and  want  of  nou- 
rishment wore  out  her  remaining  streugtli ;  and  she  died  Sept.  5th.  At  first,  leeclies 
followed  by  warm  fomentations,  were  applied  to  the  hypogastric  and  right  iliac  regions 
to  relieve  the  local  pain.  Subsequently,  diuretics  and  cathartics  were  employed  to 
relieve  the  anasarca,  combined  with  nutrients  and  latterly  stunulants. 

Sectio  Cadaveris. — Eif/hteen  hours  after  death. 

Body  extremely  anasarcous. 

Thorax. — Heart  weighed  lOi  ounces,  lay  unasually  transverse,  with  apex  point- 
ing to  left  side.  The  right  auricle  was  dilated,  especially  the  auricula  ;  the  foramen 
ovale  within  the  annulus  was  not  patent,  but  the  membrane  was  pushed  back  into 

*  Reported  by  Mr.  D.  M'Gregor,  Clinical  Clerk. 


54:4:  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

a  pouch ;  its  lining  membrane  was  much  thickened.  Tiie  tricuspid  vah-es  were 
thickened  at  their  margin,  and  so  constricted  that  tlie  first  joint  of  the  httle 
finger  up  to  the  root  of  the  nail  could  alone  pass.  The  pulmonary  valves  were  quite 
healthjr.  The  left  auricle  was  not  dilated;  the  mitral  valves  were  thickened  and 
constricted  so  as  only  to  admit  the  first  joint  of  the  little  finger  up  to  about  the  mid- 
dle of  the  nail;  the  tendinous  cords  were  so  .shortened  that  the  valves  appeared  to  be 
fixed  directly  to  the  summit  of  the  columns  carnete.  The  aortic  valves  were  also 
thickened  (more  at  the  margin  than  the  base)  so  as  to  be  inelastic  and  incompetent. 
Both  ventricles  hj^pertrophied  and  dilated.  The  left  lung  was  collapsed ;  about  one 
pint  and  a  half  of  fluid  in  the  pleural  cavity.  The  right  lung  was  adherent  through- 
out, especially  at  the  base,  to  the  diaphragm  ;  the  diaphragm  itself  was  adlierent  to 
the  costal  pleura  from  the  sixth  rib  downwards.  On  section,  the  lung  appeared  very 
(edematous  in  some  portions,  and  in  others  collapsed. 

Abdomex. — The  liver  was  fatty;  weighed  2  lb.  lOi^  oz.  The  spleen  seemed 
healthy.  The  kidneys  were  atrophied,  especially  the  right,  which  weighed  2-^ 
ounces ;  and  on  section  presented  a  good  specimen  of  the  hard,  contracted,  and 
granulated  kidney  of  Bright.  In  the  left  kidney  only  one  cone  was  disorganized. 
The  uterus  and  ovaries  were  normal,  and  the  intestines  healthy. 


Case  CII.* — Constriction  of  Mitral  and  Tricuspid  Orifices — QHdema — Htmorrliage 

into  the  Lungs. 

History. — "William  Page,  ret.  20,  ploughman — admitted  August  30th,  1852.  States 
that  nine  months  ago,  while  carrying  a  heavy  sack  of  grain  on  his  back  up  a  flight 
of  stairs,  his  foot  slipped,  and  he  fell  with  the  load  upon  him.  Asserts  tliat  he  was 
insensible  for  a  fortnight  afterwards,  and  on  recovering  was  affected  with  cough  and 
bloody  expectoration  for  a  month.  He  has  also  been  constantly  liable  to  palpitation, 
dyspnoea,  and  starting  from  sleep,  and  been  unable  to  ascend  stairs  in  consequence 
of  the  violent  palpitations  and  feeling  of  faintness  thereby  produced.  Says  he  was 
in  perfect  health  at  the  moment  of  the  accident,  and  never  had  rheumatism.  He  has 
been  subjected  to  various  kinds  of  treatment,  and  been  salivated  with  mercury  with- 
out any  benefit. 

Symptoms  on  Admission. — Apex  of  the  heart  beats  distinctly  in  the  intercostal 
space  between  the  sixth  and  seventh  ribs.  The  impulse  is  strongest  in  a  line  drawn 
vertically  from  the  nipple — is  full  and  rather  diffused.  The  pulsations  at  the  heart 
are  more  numerous  than  those  at  the  wrist.  On  percussion  the  cardiac  dulness 
measures  three  and  a  half  inches  across.  On  auscultation  a  prolonged  blowmg  mur- 
mur is  audible  with  the  first  sound  at  the  apex,  which  decreases  in  intensity  towards 
the  base  of  the  organ,  and  is  entirely  lost  at  the  commencement  of  the  great  vessels. 
Second  sound  normal.  Pulse  72,  full,  not  hard;  and  there  is  an  occa.sional  small, 
sharp  beat  occurring  after  every  five  or  six  of  the  ordinary  pulsations.  Breathing 
slightly  accelerated,  amounting  to  dyspnoea  on  the  slightest  exertion;  occasional 
cough,  followed  by  tough  mucous  expectoration,  interspersed  with  a  few  points  of  a 
dirty  rusty  colour.  Percussion  normal,  and  auscultation  over  lungs  only  elicits  a  few 
scattered  sibilant  and  sonorous  rales,  posteriorly  on  left  side.  The  appetite  has  been 
diminished,  with  occasional  vomiting  for  the  last  three  mouths.  Is  apt  to  start  hur- 
riedly from  sleep  after  lying  down,  and  is  disturbed  by  dreams.  Slight  oedema  of 
the  feet  and  ankles.     Urine  healthy.     Other  functions  normal. 

Progress  of  the  Case. — During  the  months  of  September  and  October  the  symp- 

*  Reported  by  Mr.  William  Calder  and  Mr.  David  Milroy,  Clinical  Clerks. 


TALYULAR   DISEASES   OF   THE   HEART.  545 

loms  gradually  increased.  The  dyspnoea  became  more  urgent,  and  the  paroxysms 
more  frequent.  The  cough  with  bloody  expectoration  the  oedema,  general  weakness, 
and  palpitations  were  all  augmented.  There  has  also  been  occasional  vomiting,  and 
the  skin  has  assumed  a  yellow  jaundiced  hue.  He  had  again  been  put  under  a  mer- 
curial course,  and  a  variety  of  remedies  were  employed  to  relieve  cough  and  spasm, 
all  of  which  produced  only  temporar3^  relief.  On  taking  charge  of  the  case  on  the 
1st  of  November,  I  found  a  loud  blowing  murmur  occupyhig  the  period  of  both 
sounds  at  the  apex,  the  impulse  of  which  was  felt  between  the  fifth  and  sixth  ribs 
two  inches  in  a  straight  line  below  the  nipple.  Over  the  xiphoid  cartilage  the 
second  sound  was  determined  to  be  healthy,  immediately  following  the  blowing  with 
the  first.  At  the  base  also  the  second  sound  was  heard  distinctly  normal,  and  the 
blowing  with  first  sound,  though  still  loud,  more  distant.  Sputum  was  gelatinous, 
deeply  tinged  with  fluid  blood.  Anteriorly  the  chest  was  resonant,  but  inferiorly  and 
posteriori}'  percussion  was  slightly  impaired,  with  occasional  crepitating  rale  and 
double  friction.  Pulse  120,  feeble  and  irregular ;  great  weakness.  Nutrients  with 
wine.  November  I2th.—ls  worse.  Great  lividity  of  face  and  orthopnoea.  Heart's 
action  so  tumultuous  that  no  individual  sounds  can  be  distinguished.  Extremities 
oedematous  and  cold.  Pulse  imperceptible.  In  this  condition  he  continued  until  the 
]  5th,  when  he  died. 

Sectio  Cadaveris. — Forty-four  hours  after  death. 

Body  not  emaciated ;  surface  considerably  jaundiced. 

THOR.iX. — Pericardium  contained  several  ounces  of  serum.  Heart  much  enlarged, 
especially  on  right  side.  Right  auricle  the  size  of  a  large  orange.  Left  auricle  also 
considerably  distended.  Both  ventricles  dilated,  the  walls  not  much  hypertrophied. 
Endocardium  of  left  auricle  thickened  and  opaque.  Mitral  valve  constricted,  its 
edges  rigid,  and  partly  calcareous,  so  that  it  could  only  admit  one  finger.  The  tri- 
cuspid valve  was  also  constricted,  so  as  scarcely  to  admit  two  fingers.  This  was 
owing  to  thickening  and  shortening  of  the  valvular  segments,  which  were  also  abnor- 
mally adherent  to  each  other  at  their  extremities.  At  the  edge  of  one  valve,  were 
a  few  rough  granulations  of  lymph.  Aortic  and  pulmonary  valves  healthy.  Both 
lungs  were  emphysematous  anteriorly,  but  the  dilatation  of  individual  air-cells  was 
not  extreme.  In  the  posterior  and  inferior  portions  were  irreg-ular  condensed  masses 
of  hemorrhagic  extravasation,  varying  in  size  from  a  walnut  to  a  hen's  egg.  Inter- 
spersed through  the  lungs  generally  were  several  miliary  tubercles.  The  pleurje 
were  adiierent  in  several  places,  and  also  contained  a  few  tubercles.  The  trachea 
and  bronchi  were  loaded  with  viscid  muco-purulent  matter. 

Abdomex. — Liver  congested,  presenting  to  a  certain  extent  the  nutmeg  appear- 
ance.    Kidnej's  and  other  abdominal  organs  healthy. 

Commentary. — In  both  these  cases  careful  examination  of  the  heart 
did  not  enable  me  to  form  a  conjecture  that  the  tricuspid  valve  was 
diseased.  In  the  first  case  the  continued  blowinp;  at  the  apex  completely 
masked  the  second  sound,  even  at  the  base  of  the  organ.  In  the  other 
case,  while  the  blowing  occupied  the  period  of  both  sounds  at  the  apex, 
the  second  sound  was  audible  towards  the  right,  over  the  xiphoid  carti- 
lage. In  the  case  of  King,  there  was  also  incompetency  of  the  aortic 
valves,  but  in  both  the  auriculo-ventricular  valves  were  the  chief  seat  of 
disease.  The  spnptoms  were  not  unlike,  and  were  characterized  by 
excessive  palpitation;  great  dyspnoea,  with  oedema  of  the  lungs  in  one, 
and  hemorrhage  into  the  lungs  in  the  other  case ;  vomiting,  dropsy,  and 

35 


54:6  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

jaundice.  None  of  which  symptoms,  however,  either  individually  or 
collectively,  can  be  said  to  indicate  tricuspid  as  distinguished  from  mitral 
lesion.  The  origin  of  the  two  cases  was  widely  different.  The  one 
dependent  apparently  on  rheumatic  endocarditis,  the  other  caused  by  a 
fall  and  contusion,  although  how  this  should  have  affected  both  auriculo- 
ventricular  valves  is  by  no  means  clear.  The  utility  of  mercury  was 
fairly  tested  in  Page's  case,  and  as  usual  found  to  be  of  no  benefit  what- 
ever. Theoi-etically  it  is  impossible  to  understand  how  this  drug  is  to 
diminish  thickenings  of  valves  or  contractions  of  the  chorda;  tendineffi, 
and  practical  experience  has  utterly  failed  in  demonstrating  its  advantage 
in  endocarditis  any  more  than  in  pericarditis. 


Case  CIII.* — Soft  adherent  Polypm,  caitsing  incompetency  of  the  Mitral    Orifice — 

Anasarca. 

History. — William  Taylor,  set.  50,  a  compositor, — admitterl  Dec.  20th,  1852.  The 
patient  enjoyed  good  health  till  a  year  ago,  when  he  became  subject  to  attacks  of 
vertigo.  The  first  of  these  came  on  after  a  long  race ;  they  returned  frequently, 
especially  after  meals.  Three  mouths  ago,  cough  and  dyspnoea  came  on,  which  have 
gradually  become  worse.  Two  weeks  ago  his  legs  began  to  swell,  and  five  days  ago 
the  lower  part  of  both  legs  became  of  a  purj^le  colour,  not  disappearing  on  pressure, 
the  rest  of  the  skin  of  the  body  assuming  a  yellowish  hue ;  these  discolorations  have 
since  increased.     Has  suffered  much  mental  distress  during  the  last  six  months. 

Symptoms  on  Admission. — Cardiac  apex  in  normal  condition ;  impulse  somewhat 
increased.  With  the  first  sound  there  is  a  blowing  murmur,  heard  loudest  at  the 
apex;  second  sound  normal;  transverse  dulness  normal.  Pulse  very  small  and 
weak,  120  per  minute.  Percussion  of  the  lungs  normal ;  breathing  hurried ;  respira- 
tions being  40  per  minute;  no  abnormal  sounds  audible  on  auscultation.  Sleeps 
badly  and  is  very  weak.  Tongue  slightly  furred  ;  appetite  bad ;  bowels  consti- 
pated ;  stools  dark  coloured.  Urine  in  goodly  quantity,  high  coloured,  loaded  with 
lithates ;  contains  a  slight  amount  of  albumen.  Legs  swollen.  Ordered  to  have 
3  iv  of  'Wine  and  diuretic  mixture. 

Progress  of  the  Case. — Decemher  23d!. — Crepitation  over  lower  half  of  both  lungs 
posteriorly ;  no  dulness  or  increased  vocal  resonance.  Expectoration  streaked  with 
blood.  Weakness  great ;  pulse  hardly  perceptible.  Ordered  expectorants  and  3  vj 
of  wine.  2Uh. — Urine  passed  in  very  small  quantity.  Ordered  diuretics  with  nitric 
aether  and  half  the  wine  to  be  replaced  by  an  equal  quantity  of  gin.  25th. — Was 
delirious  last  night,  and  suflered  from  dyspnoea.  Died  this  morning  at  half-past 
eleven. 

Seciio  Cadareris. — Forty-eight  hours  after  death. 

Thorax. — The  pericardium  contained  about  an  ounce  of  turbid  yellowish  serum. 
The  heart  was  slightly  enlarged  on  the  right  side.  All  the  cavities  were  full  of 
blood,  partially  coagulated,  the  coagula  being  soft  and  coloured  throughout.  In  the 
left  auricle  was  a  soft,  gelatinous,  semi-transparent  mass  the  size  of  a  pigeon's  ^^^, 
which  hung  over  the  mitral  orifice,  and  appeared  to  choke  it  up.  It  was  firmly 
attached  to  the  membrane  of  the  auricle  by  a  surface  about  half  an  inch  square,  in 
substance  resembling  colloid,  and  externally  was  not  unlike  a  soft  polypus,  or  a 
mass  of  uterine  hydatids ;  on  section,  it  was  homogeneous,  and  consisted  of  a  fibrous 
stroma,  which  could  easily  be  torn,  enclosing  between  its  meshes  a  clear  viscous 

*  Reported  by  Mr.  R.  Brown,  Clinical  Clerk. 


VALVULAR  DISEASES   OF   THE   HEART.  547 

fluid.  The  flaps  of  the  mitral  valve  were  somewhat  thickened,  without  deformity  or 
thickening  of  the  chordfe  tendiaete,  which,  with  the  coluiunse  carneas,  were  quite 
healthy.  The  other  valves  were  normal  The  lung-s  were  oedematous,  with  small 
hemorrhagic  patches  at  various  pomts. 

Abdomen'. — The  peritoneal  cavity  contained  about  half  a  gallon  of  clear  serum. 
There  was  slight  hepatic  congestion  of  the  liver,  but  the  other  abdominal  viscera 
were  unfortunately  not  examined  by  the  pathologist. 

MiCKOSCOPic  ExAJiiXATiox. — The  attached  pol3-pus  in  the  left  auricle  consisted  of 
bands  of  fibrous  tissue,  crossmg  one  another  and  forming  oval  and  circular  areolae 
containing  a  viscous  serum.  Embedded  in  these  bands  were  nucleated  cells,  round, 
oval,  and  fusiform  in  shape.  Some  of  the  latter  were  lengthened  out  into  fibres. 
They  were  fibre-ceUs  exhibiting  every  stage  of  transformation,  from  the  rounded  cell 
up  to  that  of  perfect  areolar  tissue. 

Commentary. — The  structure  and  firm  attachment  of  the  polypus  in 
this  case,  can  leave  us  in  no  doubt  that  it  must  have  existed  some  time 
before  death,  and  caused  the  symptoms  of  which  this  man  complained. 
From  its  position  it  appeared  calculated  materially  to  interfere  witli  the 
passage  of  the  blood  from  the  left  auricle  to  the  left  ventricle,  but  the 
sound,  during  life,  indicated  an  incompetency  rather  than  a  narrowing  or 
stricture  of  the  auriculo-ventricular  orifice.  To  it,  however,  the  exces- 
sive dyspnoea,  which  was  the  chief  character  of  the  case  during  life,  was 
most  probably  owing.  The  mass  itself  closely  resembled,  to  the  eye  as 
well  as  under  the  microscope,  some  kinds  of  simple  colloid  I  have  seen  ; 
whether  it  originated  in  an  exudation,  in  a  deposition  of  fibrin  from  the 
blood,  or  in  a  combination  of  the  two,  it  is  difficult  to  determine ;  the 
last  supposition  is  the  most  probable. 

That  coagula  are  formed  from  the  blood  in  the  cavities  of  the  heart 
during  life,  there  can  be  little  doubt,  although  we  are  ignorant  of  any 
means  of  detecting  them.  They  have  been  supposed  to  be  the  result  of 
endocarditis.  If  so,  we  must  suppose  that  an  exudation  thrown  out  on 
the  endocardial  lining  membrane  catises  roughness,  which,  as  the  blood 
flows  over  it,  tends  to  produce  fibrinous  deposition  from  that  fluid. 
However  formed,  two  subsequent  changes  may  occur — ]  st.  Fibre  cells 
may  be  formed  in  it,  and  the  whole  gradually  developed  into  a  fibrous 
structure,  as  in  Case  GUI.  This  is  very  rare.  More  commonly  it  softens 
in  the  centre,  and  is  gradually  reduced  to  a  fluid,  which  to  the  naked 
eye  closely  resembles  pus.  Such  collections  have  been  called  "  purulent 
cysts."  I  have  frequently  examined  the  contents  of  these  cysts,  and 
have  no  doubt  that  in  many  cases,  the  so-called  "  purulent  cvsts  "  are 
simply  formed  by  a  mechanical  disintegration  of  the  clot,  in  the  manner 
first  described  by  Mr.  Gulliver,  and  are  not  purulent  cvsts  at  all.  I  once 
found  a  pyriform  clot  in  the  right  ventricle  of  the  heart,  firmly  attached 
to  the  endocardium  by  its  smaller  extremity.  It  was  the  size  of  a  hen's 
Qggi  and  on  cutting  into  it  there  flowed  out  two  ounces  of  a  fluid  exactly 
like  good  laudable  pus.  Yet  it  did  not  contain  one  pus  corpuscle,  but 
was  wholly  made  up  of  molecular  matter,  associated  with  the  broken 
down  debris  of  a  fibrous  clot,  and  a  few  collapsed  colourless  cells  of  the 
blood.  In  this  way  a  microscope  demonstrates,  not  unfrequently,  that 
what  was  regarded  as  pus,  and  considered  a  proof  of  inflammation,  is  in 
truth  quite  unconnected  with  the  latter  process,  and  is  owing  to  alto 
o-ether  difi'ereut  causes. 


548  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 


Case  CIV.* — Enlarged  Foramen  Ovale — Phthisis. 

History.— James  M'Queenie,  fet.  27,  a  tailor — admitted  June  23d,  1853.  Has 
never  been  a  strong  man,  having  been  very  liable  to  suffer  from  colds  and  indiges- 
tion. Since  boyhood  he  has  been  liable  to  pali:)itation  and  dyspnoea  on  the  slightest 
exertion.  His  health,  however,  continued  pretty  good  till  eighteen  months  ago, 
when  he  was  admitted  into  this  Infirmary.  He  then  laboured  under  inflammatory 
fever,  with  coughs  and  pains  in  the  chest ;  there  was  evidence  of  condensation  of  the 
apex  of  the  right  lung ;  and  obscure  shifting  murmurs  were  heard  with  the  cardiac 
sounds,  which  led  to  the  belief  that  the  patient  was  suffering  from  subacute  pericar- 
ditis in  the  course  of  tubercular  disease.  He  was  treated  with  aconite,  and  after- 
wards with  mercury.  He  became  much  better,  but  did  not  entirely  regain  his 
health ;  the  physical  phenomena  remained  as  before ;  cough  and  expectoration  also 
continued.  Of  late  these  symptoms  have  become  more  troublesome,  so  as  to  induce 
him  to  re-enter  the  Hospital. 

Symptoms  on  Admission.— Apex  of  the  heart  beats  slightly  to  the  right  of  the 
usual  pcsition ;  transverse  dulness  three  inches;  sounds  feeble  and  indistinct;  with 
the  first  and  running  into  the  second,  there  is  a  pecuhar  whizzing,  neither  a  blowing 
nor  a  friction  murmur ;  it  is  heard  most  distinctly  at  the  base,  is  not  constantly 
present,  and  is  not  propagated  along  the  large  vessels.  Heart's  impulse  feeble,  and 
producing  a  zvavy  motion  under  three  intercostal  spaces.  Palpitation  on  exertion  or 
mental  excitement.  Pulse  90,  small  and  slightly  intermittent.  Under  the  right  cla- 
vicle, dulness  on  percussion,  with  increased  sense  of  resistance,  and  imperfect  cracked- 
pot  sound ;  on  auscultation  there  are  loud  moist  rales  almost  gurgling  in  character ; 
much  prolonged  expiration ;  loud  bronchophony.  Towards  the  lower  margin  of  the 
right  lung  there  is  harsh  respiration  with  sibilus.  Below  the  lefc  clavicle  for  a  hands- 
breadth  there  are  fine  moist  rales  with  prolonged  expiration  and  loud  vocal  reso- 
nance ;  sibilus  also,  as  on  the  right  side.  Posteriorly  the  signs  correspond  to  those 
in  front.  Sputum  abundant  and  muco-purulent ;  cough  frequent,  but  not  harsh ; 
breathing  easy.  Appetite  scarcely  impaired.  Occasional  diarrhoea,  now  checked 
by  astringents.  Hepatic  and  splenic  dulness  normal.  Great  sweating  at  niglit. 
Urine  of  normal  character.      Ordered  to  take  cod-liver  oil,  and  to  have  nourishing  diet. 

Progress  of  the  Case. — June  2M  to  July  13th. — Treatment  as  above ;  strength 
much  increased.  Yesterday  had  a  rigor,  followed  by  a  stitch  in  the  side ;  it  was 
relieved  after  the  application  of  leeches.  July  13th-23d. — Has  gradually  become 
much  worse.  Suffers  now  fi-om  great  dyspnoea,  frequent  cough,  copious  expectora- 
tion, night  sweats,  loss  of  appetite,  diarrhoea,  and  great  weakness.  No  great  change 
in  the  physical  signs ;  the  heart  sounds  are  much  masked  by  the  pulmonary  rales. 
Has  taken  cod-liver  oil,  with  occasional  antispasmodics  and  astringents,  and  latterly 
3  iv  of  wine  and  §  ij  of  brandy  in  the  course  of  the  day.  July  lUh. — Gradually 
sunk,  and  died  at  twelve  noon. 

Sectio  Cadaveris. —  Tioenty-five  hours  after  death. 

Body  much  emaciated ;  rigor  mortis  moderate. 

Thorax.— No  adhesions  between  the  layers  of  the  pericardium,  or  between  the 
pleura  and  that  m.embrane.  The  pericardium  contains  about  two  ounces  of  turbid 
yellowish  fluid  with  small  flocculi  of  lymph.  Surface  of  the  heart  presents  a  milky 
patch  the  size  of  a  shilling  towards  its  base  posteriorly,  and  there  are  some  smaller 
ones  over  left  auricle.     Heart  soft,  flaccid,  and  fatty;  it  weighs  twelve  ounces.     The 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


VALVULAR  DISEASES   OF   THE   HEART.  5^9 

right  ventricle  is  much  dilated  and  the  walls  are  thin ;  the  tricuspid  orifice  admits 
four  fingers  with  ease ;  mitral  valves  very  slightly  thickened  at  the  margms,  but 
otherwise  healthy ;  aortic  valves  healthy.  In  the  septum  auricularum  there  is  a  large 
opening  which  can  admit  three  fingers ;  evidently  the  foramen  ovale  much  enlarged ; 
it  is  oval  in  shape,  and  the  edges  are  smooth  and  rounded.  Pulmonary  artery 
dilated;  cahbre  of  the  aorta  diminished,  and  only  half  the  size  of  the  pulmonary 
artery.  Eight  lung  adherent  aU  over.  Adhesions  firmest  near  the  apex.  The  lung 
is  non-crepitant  throughout,  and  everywliere  infiltrated  with  tubercle,  which  Ls  most 
chronic  at  the  apex,  where  there  are  several  puckeriugs  and  dense  cicatrizations. 
The  left  lung  also  infiltrated  with  tubercle,  but  not  to  so  great  au  extent,  and 
more  recent. 

Abdomex. — The  liver  was  much  congested,  with  a  hnear  cicatrix  two  inches 
long,  situated  half  an  inch  anterior  to  its  diaphragmatic  attachment.  The  lower 
third  of  the  ileum,  with  the  coecum  and  ascending  colon,  the  seat  of  numerous 
tubercular  ulcerations.  A  few  tubercular  deposits  in  the  mesenteric  glands.  Other 
organs  normal 

Commentary. — The  peculiarity  of  the  cardiac  sounds  in  this  case, 
consisted  in  the  existence  of  a  kind  of  whizzing  murmur,  synchronous 
with  the  svstole,  and  loudest  at  the  base,  combined  with  palpitations, 
feeble  impulse,  and  a  weak  intermittent  pulse.  This  combination  of  sio-ns 
and  symptoms  forbade  the  supposition  that  the  lesion  was  aortic,  while 
the  sex,  and  absence  of  murmur  in  the  larger  vessels,  were  opposed  to 
the  notion  of  its  being  ana?mio.  After  death  a  large  opening  was  found 
between  the  auricles,  with  smooth  edges,  which  must  have  admitted  the 
ready  flow  of  blood  through  it.  Whether  the  peculiar  whizzing  sound 
— which  was  neither  loud  nor  constant — was  caused  by  this  opening,  it 
is  difficult  to  say,  but  judging  from  its  situation  and  character,  this  is 
not  improbable.  The  slight  "thickening  of  the  flaps  of  the  mitral  valve 
did  not  seem  to  interfere  with  its  competency,  and  certainly  caused  no 
murmur. 

Few  well-observed  cases  of  patent  foramen  ovale  in  the  living  subject 
have  been  recorded.  In  one  recorded  by  Dr.  Markham,*  the  open 
foramen  ovale  allowed  the  blood  to  pass  readily  from  the  right  to  the 
left  auricle,  but  not  in  the  opposite  direction,  excepting  through  two 
narrow  slits.  There  was  audible  during  life  a  loud,  rough,  and  prolonged 
svstolic  murmur  over  the  whole  pericardial  region,  over  the  upper  part 
and  alonty  the  right  border  of  the  sternum,  and  in  the  whole  of  the  upper 
half  of  the  interscapular  space.  From  an  inquiry  by  Dr.  .John  Oglef 
into  this  subject,  when  he  was  Curator  of  the  Pathological  Museuyi  at 
St.  Georo-e's  Hospital,  he  found  that  of  thirteen  cases  of  patent  foramen 
ovale,  it  was  stated  in  seven  that  no  murmur  synchronous  with  the  systole 
existed.  The  size  of  the  openings  is  not  given.  In  one  other  case,  a 
diastolic  murmur  was  present,  owing  to  undoubted  disease  of  the  aortic 
valves.  Hence,  of  the  whole  thirteen,  there  was  no  evidence  that  this 
lesion  produced  a  murmur  at  all,  Dr,  Markham's  case  being  uncompli- 
cated and  well  observed,  aftords  pretty  strong  evidence  that  a  murmur 
mav,  under  certain  conditions,  be  occasioned  by  open  foramen  ovale,  as 
does  the  one  now  recorded.     But  what  those  conditions  are,  as  well  as  a 

*  British  iledical  Journal,  April  4th,  1857.  f  Ibid.  June  13th,  1857. 


550 


DISEASES   OF   THE   CIRCULATORY   SYSTEM. 


crowd  of  int^re-sting  points  in  coBnection  witli  tliem,  can  only  be  deter- 
mined bv  future  observations. 


Patliolofjy  of  Valvular  and  Organic  Diaeascs  of  the  Heart. 

The  lesions  producing  valvular  diseases  of  the  heart  are  various,  and 
may  be  referred  to  mechanical  violence,  to  the  effects  of  exudation,  acute 
or  chronic,  to  depositions  of  fibrin,  aud  to  the  different  forms  of  degene- 
ration of  texture.  But,  however  occasioned,  they  all  tend  to  produce 
subsequent  changes  in  the  texture  and  vital  actions  of  the  heart  itself; 
above  all,  hvpertrophy  and  fatty  degeneration  of  its  muscular  walls,  with 
increased,  diminished,  or  irregular  contractions  of  its  cavities.  Although 
it  is  with  these  latter  that  the  physician  has  principally  to  do,  a  know- 
ledge of  the  former  is  essential  to  the  correct  appreciation  and  proper 
treatment  of  every  individual  case. 

Mechanical  injuries  not  unfrequently  occasion  sudden  disease  or 
rupture  of  the  valves  (Cases  XCIX.  and  CIL),  separating  their  attach- 
ments, and  causing  subsequent  adhesions  and  tibrinous  depositions. 
Great  muscular  exertion  has  also  occasioned  similar  results.  Four  cases 
of  this  are  recorded  by  Dr.  E.  Quain,*  in  one  of  which  a  smith,  when 
working  vigorously,  experienced  "  an  uneasy  shaking  of  the  heart," 
shortness  of  breath,  and  heard  a  peculiar  noise  "  up  his  chest,  neck,  and 
in  his  ears."  On  examination,  a  loud  ringing  musical  murmur  was  heard 
over  the  aortic  valves  with  the  second  sound,  and  there  was  a  softer 
blowing  with  the  first  sound.  After  suffering  two  years,  during  which 
the  sounds  underwent  different  modifications,  followed  by  cardiac  hyper- 
trophy, he  died,  and  on  dissection,  the  conjoined  attachments  of  two  of 
the  valves  to  the  aorta  were  found  to  be  separated  from  the  wall  of  that 
vessel,  so  that  they  dropped  below  the  level  of  the  third,  which  retained 
its  connections  (Fig.  415).     Cases  of  this  kind  would  perhaps  be  more 


Fig.  415.= 

frequentlv  observed,  if  the  origin  of  valvular  diseases  were  more  carefully 
looked  for. 

*  Montlilv  Journal  of  Medical  Science.     December  1846. 

Fig.  415.  Conjoined  attachment  of  two  of  the  aortic  valves  at  a,  separated  from 
the  aorta  at  b.  Here  the  wall  of  the  vessel  was  raised  into  a  superficial  elevation. 
At  c,  the  margin  of  one  valve  was  slightly  everted,  and  studded  with  small  granula- 
tions.— {R.  Quain.) 


VALVULAR   DISEASES   OF   THE   HEART. 


551 


Exiulation  into  or  on  the  surface  of  the  valves^  constituting  the  endo- 
carditis of  systematic  writers,  is  a  common  cause  of  valvular  disease.  If 
acute,  it  may  appear  in  the  form  of  minute  granulations,  or  forming  a 
layer,  varying  in  thickness  and  shape,  on  the  surfaces  or  on  the  edges  of 
the  valves.  If  chronic,  they  are  firm,  and  not  unfrequently  associated 
with  an  exudation  which  has  also  occurred  in  the  texture  of  the  valve 
itself,  causing  more  or  less  thickening  or  induration  of  its  various  parts. 
In  the  same  manner  the  chorda?  tendineas  may  become  thickened  and 
shortened  from  interstitial  exudation.  As  a  result,  the  edges  of  the 
valves  do  not  come  into  accurate  contact,  and  become  incompetent  to 
fulfil  their  functions.  After  a  time,  in  consequence  of  excess  of  exuda- 
tion and  subsequent  contraction,  the  orifices  are  narrowed,  and  me- 
chanical obstructions  offered  to  the  free  passage  of  the  blood  through 
them. 

In  tlie  aortic  valves,  in  addition  to  thickenings  and  contractions, 
adhesions  may  occur,  with  or  without  the  lacerations  of  septse  formerly 
noticed.      In  this   manner  there   may  be  two,   rarely   only  one   valve 


Fig.  416.  Fig.  41 T. 

from  laceration  of  the  attachment  to  the  aorta  and  subsequent  adhesion 


Fi-    418. 

of  the  broken   edges.     In   Fig.   416  the  union  of  all  the   valves  lias 


Fig.  416.  A,  Aortic  orifice  with  one  valve  of  a  funnel-shape,  seen  from  the  front. 
B,  The  same  valve  seen  from  above,  showing  the  original  septse  of  the  valve  united 
together. — [Peacock.) 

Fig.  417.  Two  valves  at  the  aortic  orifice,  with  a  rudimentary  one  interposed. — 
{Peacock.) 

Fig.  418.  Congenital  malformation  of  the  aortic  valves.  A,  The  aorta  slit  up 
lengthways.     B,  Transverse  section  of  the  aorta  just  above  the  valves. — {Brinton.) 


552 


DISEASES   OF   THE   CIRCULATORY   STSTEM. 


resulted  in  the  formation  of  one  valve  of  a  funnel-sbape.  In  Fig.  415, 
two  valves  have,  as  it  appears,  been  broken  into  one  another  and  united 
together,  so  as  to  form  one.  In  Fig.  418,  one  of  the  valves  seems  to 
have  been  abortive,  or  not  developed.  Again,  the  number  of  valves 
may  be  multiplied  in  consequence  of  adhesions  being  formed,  and 
extra  pouches  thereby  established.  Thus  four  valves  are  occasionally 
met  Avith,  as  in  Fig.  419.     Sometimes  these  are  of  unequal  size,  and 

are  then  most  com- 
monly the  result  of 
disease.  But  I  have 
seen  four  valves, 
all  exactly  like  one 
another,  iu  which 
case  the  malforma- 
tion appears  to  be 
congenital.  I  only 
know  of  one  instance 
Fig.  410.  in  which   five   valves 

existed  at  the  aortic  orifice,  and  that  is  given  by  Dr.  Peacock,  in 
his  recent  valu- 
able work  on 
"  Malformations 
of  the  Human 
Heart,  18o8," 
and  which  is 
copied  (Fig- 

420).  The  ex- 
cess is  owing  to 
the  division  of 
two   valves,   the  Fig.  420. 

supernumerary  segment  being  imperfect. 

The  mitral  valves,  in  addition  to  roughness  and  thickenino;s  of  the 
valves  themselves,  and  various  alterations  of  their  edges  in  consequence 
of  shortening  of  the  chordfe  tendine;e,  present  in  chronic  cases  a  oreat 
tendency  to  contraction  of  the  orifice.  On  looking  down  into  the 
auricle,  these  con.strictions  of  the  auriculo-ventricular  orifice  are  seen  to 
assimie  two  shapes,  the  one  being  only,  however,  a  greater  deo-ree  of 
contraction  than  the  other.  In  the  first  it  exhibits  a  slit,  or  button-hole 
appearance,  in  the  other  a  rounded  or  oval  aperture — both  openings 
being  at  the  base  of  a  funnel-shaped  depression,  caused  by  the  adhesion, 
thickening,  and  contraction  of  the  edges  of  the  two  valves. 

Deposition  of  fibrin  from  the  blood  may  occur  on  the  valves  in  conse- 
quence of  laceration,  or  of  exudations;  but  sometimes,  so  far  as  can  be 
ascertained,  without  oiganic  lesion.  It  has  been  experimentallv  proved, 
that  the  introduction  of  a  thread  across  the  aortic  a])erture,  will  cause 
the  precipitation  upon  it  of  the  fibrin   of  the   blood — [Simon).      Any 


Fig.  419.  Four  valves  at  the  aortic  orifice,  from  adliesion  of  one  to  the  wall  of  the 
vessel,  so  as  to  form  two  pouches. 

Fig  420.  Five  valves,  formed  from  adliesions  and  production  of  septse  in  two  valves. 
(Peacock.) 


VALVULAR   DISEASES   OF  THE   HEART.  553 

rough  surface  will  i^roduce  the  same  effect.     Indeed  there  is  every  reason 


occurs 


l"ig  421.  Fig.  422. 

to  suppose,  that  when  the  blood  abounds  in  fibrin,  as  especially 
in  acute  rheumatism,  such  deposits  may 
take  place  on  the  yalves  themselves, 
without  any  previous  lesion  of  them,  an 
occurrence  which  would  serve  to  explain 
the  relation  between  rheumatic  and  car- 
diac disorders.  Be  this  as  it  may,  there 
can  be  little  doubt  that  such  rheumatic 
constitution  of  the  blood  once  established, 
fibrinous  deposits  are  apt  to  be  thrown 
down,  which  constitute  the  vegetations 
so  frequently  found  at  the  edges  of  the 
valves,  resembling  soft  warty  tumours, 
obstructing  the  orifices,  and  occasionally 
hanging  down  by  peduncles  into  the 
ventricle  (Fig.  423). 

Degeneration  of  the  valves  may  occur 
in  various  ways,  and  in  its  nature  be 
albuminous,  fatty,  or  mineral.  Tlius 
the  thickening  and  indurations  owing  to 
chronic  exudation,  may  assume  a  density 
equal  to  ligament  or  fibro-cartilage.  Or, 
on  the  other  hand,  they  may  soften,  un- 
dergo the  fatty  degeneration,  and  at  -  — '' 
length  ulcerate,  forming  one  or  more  ^'g-  428. 
perforations  through  the  membranous  portion  of  the  valve  (Fio-.  423). 

Fig.  421.  Mitral  orifice,  constricted  so  as  to  form  an  elongated  and  rio-jd  slit  resem- 
bling a  button  hole.     Seen  from  the  auricle. 

Fig.  422.  Mitral  orifice,  greatly  constricted,  so  as  to  form  an  oval  aperture  at  the 
bottom  of  a  funnel-shaped  depression.     Seen  from  the  auricle.  ' 

Fig.  433.  Fibrinous  vegetations,  and  atheromatous  degeneration  of  an  aortic  valve 
with  rupture. 


554  DISEASES   OF   THE    CIECULATOEY   SYSTEM. 

Lastly,  it  is  by  no  means  uncommon  to  find  the  thickened  vah^es  to  have 
undergone  the  mineral  degeneration,  presenting  nodules  and  masses  of 
earthy  matter,  varying  in  size,  more  or  less  rouo;h,  resembling  concre- 
tions, and  obstructing  the  orifice  in  proportion  to  their  size. 

The  immediate  result  of  all  these  different  lesions  is,  that  the  valves 
being  incompetent,  and  not  closing  perfectly,  the  blood  regurgitates  back 
into  the  ventricles  or  auricles  at  each  systole  or  diastole,  according  to  the 
valve  affected  ;  or  if  there  be  contraction  and  obstruction  at  the  orifice, 
it  is  propelled  forwards  with  difficulty.  In  either  case,  increased  mus- 
cular eftort  is  required  to  carry  on  the  circulation,  and  the  result  is  the 
greater  or  less  enlargement  of  the  heart  or  hypertrophy. 

HypertropJoj  of  the  heart  may  arise  from  several  causes  ;  but  by  far 
the  most  common  is  disease  in  one  or  more  of  its  valves.  In  this  case, 
it  follows  the  law  of  increased  growth  formerly  referred  to  (p.  148), 
whereby  parts  subjected  to  unusual  exertion  or  increase  of  function 
augment  in  bulk.  Hence  either  disease  of  the  aortic  or  mitral  valves 
induces  hypertrophy,  with  dilatation  of  the  left  ventricle,  from  the  neces- 
sity of  increased  action.  The  same  causes  operate  on  the  other  parts 
of  the  organ.  Chronic  bronchitis  and  emphysema,  bv  impeding  the  cir- 
culation in  the  lungs,  produce  similar  enlargements  in  the  right  ventricle, 
and  so  on.  In  chronic  heart  diseases,  it  is  rare  that  the  lesion  is  confined 
to  one  cavity,  because,  as  it  advances,  it  produces  increasing  embarrass- 
ment in  the  others.  Thus  hypertrophy  of  the  left  ventricle,  in  conse- 
quence of  aortic  disease,  atfer  a  time  induces  enlarorement  of  the  left 
auricle ;  this  embarrasses  the  return  of  blood  from  the  lungs,  causing  con- 
gestions and  derangement  of  those  organs.  These  in  turn  induce 
enlargement  of  the  right  cavities  of  the  heart,  and  then  tlie  retui-n  of 
blood  from  the  systemic  circulation  is  impeded,  causing  congestions  in 
the  liver  and  other  viscera.  In  consequence  of  the  over-distension  of  the 
venous  capillaries  so  occasioned,  eft'usion  of  serum  occurs,  producing 
ffidema,  and  more  or  less  anasarca.  As  the  dropsical  fluid  so  occasioned 
angments,  the  pressure  it  produces  interferes  still  more  "nith  the  action 
of  the  kidneys,  skin,  lungs,  etc.,  until  at  length  life  can  no  lono-er  be 
maintained.  These  effects  will  follow  more  rapidly  if,  in  addition  to  the 
aortic,  the  mitral  valves  are  disordered,  or  if  further  complications  add 
to  the  gravity  of  the  case.  Thus  the  tricuspid  orifice  may  also  be 
afi'ected  (Cases  CI.  and  CII.) ;  or  there  may  be  adherent  pericardium, 
or  aneurism  of  the  large  vessels.  Again,  the  course  of  these  changes 
may  be  modified  or  inverted.  The  disease,  for  instance,  mav  commence 
in  the  lungs  or  liver,  and,  by  the  obstructions  to  the  circulation  thereby 
occasioned,  may  affect  the  heart  secondarily.  Or,  conjoined  •with 
valvular  disease  and  cardiac  hypertrophy,  there  may  be  primary  lesions 
of  the  lungs,  kidney,  or  liver.  It  is  by  pathological  knowledge  alone 
that  the  influence  and  mutual  dependence  of  these  various  derangements 
can  be  understood,  and  a  treatment  judiciously  directed  to  their  relief. 

Fatty  Derjeneration  of  the  Heart. — The  heart  mav  be  loaded  and  even 
more  or  less  infiltrated  with  adipose  tissue,  producing  one  form  of  fatty 
degeneration.  By  far  the  more  important  form,  however,  is  the  lesion, 
for  a  knowledge  of  which  we  are  indebted  to  the  recent  researches  of 
histologists,  and  more  especially  in  this  country  of  Paget,  Ormerod,  and 
Quain.     Of  its  nature  I  have  already  spoken  (p.  218).     It  may  occur  as 


YALYrLAR   DISEASES   OF   THE   HEART.  000 

a  sequela  of  everv  form  of  cardiac  disease,  but  especially  wlien  the 
aortic  valves  are  affected,  as  well  as  from  a  modification  in  the  general 
condition  of  the  system  leading  to  fatty  degeneration  of  a  number  of 
other  organs.  It  may  be  observed,  for  instance,  that  in  cases  where  the 
liver  and  kidneys  are  fatty,  the  muscular  substance  of  the  heart  is 
commonlv  fatty  also.  Indeed  there  is  no  degeneration  of  texture  more 
common  "than  that  of  fatty  heart,  which,  existing  in  various  degrees,  is 
dangerous  in  proportion  to  its  intensity,  extent,  and  complication  with 
other  diseases.  In  elderly  persons  more  especially  this  degeneration 
mav  proceed  to  a  great  extent  without  even  being  suspected,  and  then 
some  unaccustomed  exertion,  by  demanding  from  ihe  organ  more 
forcible  muscular  contractions  than  it  is  capable  of  exerting,  suddenly 
arrests  its  action,  and  fatal  syncope  is  the  resuh.  Many  cases  of  sudden 
death  formerly  ascribed  to  "apoplexy,''  or  "spasm  of  the  heart,"  may 
now  be  confidently  affirmed  lo  have  been  owing  to  this  lesion.  Its 
detection  in  the  living  body  cannot  be  made  with  confidence.  Slowness 
and  feebleness  of  thepulse  have  been  by  some  thought  diagnostic.  But 
manv  extreme  cases  of  this  degeneration  have  died  under  my  observation 
without  any  such  symptom.  It  may  cause  rupture  of  the  heart  and  fatal 
hemorrhage. 

Myocarditis,  or  true  inflammation  of  tlie  substance  of  the  heart,  is  one 
of  the  rarest  organic  diseases  known.  "Whether,  in  cases  of  pericarditis, 
the  muscular  substance  below  the  serous  membrane  is  the  seat  of  an 
exudation,  is  yet  to  be  determined  by  histological  research.  Tlie  intro- 
duction of  the  terra  "Parenchymatous  inflammation,"  employed  by 
Yirchow,  can  onlv  cause  confusion,  without  in  any  Avay  advancing  our 
knowledge,  as,  in  trutb,  it  is  no  inflammation  at  all,  but  the  fatty  degene- 
ration of  the  muscular  fasciculi  just  referred  to. 


Treatment  of  Valvular  and    Organic  Diseases  of  the  Heart. 

That  the  various  lesions  of  the  valves  are  susceptible  of  being  removed 
bv  drugs,  is  one  of  those  notions  which  the  advance  of  diagnosis  and 
pathology  has  happily  expelled,  and  which  seems  now  almost  universally 
rejected.  All  that  the  practitioner  can  hope  to  accomplish,  is  to  modify, 
and,  if  possible,  check  those  resulting  phenomena  from  which  real  danger 
is  to  be  apprehended.  But  here  much  misconception  has  prevailed  as  to 
the  real  object  to  be  kept  in  view,  or  rather  the  phenomena  themselves 
have  been  wrongly  interpreted  by  medical  men.  We  have  seen  that 
valvular  disease  leads  to  dilated  hypertrophy ;  this  is  accompanied  by 
excessive  action,  and,  especially  if  the  aortic  valves  are  diseased,  by  a 
strong,  jerking,  and  hard  pulse.  The  notion  is  very  general  that,  simply 
because  the  pulse  is  strong,  it  is  the  mission  of  the  practitioner  to  make 
it  weak ;  that,  because  the  heart  acts  violently,  it  ought  to  be  made  to 
beat  quietly  by  lowering  remedies.  But  the  strong  pulse  and  enlarged 
ventricle  in  the  one  case,  is  a  wise  provision  of  nature,  set  up  to  counter- 
balance the  otherwise  fatal  consequences  of  the  valvular  obstruction;  and 
the  violent  action  of  the  heart  in  the  other  is  a  proof  of  weakness  rather 
than  of  strength,  and,  instead  of  being  lessened  by  bleeding  and  anti- 
phlogistics,  requires  for  its  removal  tonics,  nutrients,  and  calmatives.    To 


556  DISEASES   OF   THE   CIRCULATOKY   SYSTEM. 

Fio  one  is  medicine  more  indebted  for  making-  this  proposition  intelligible 
than  to  Dr.  Corrigan,*  and  his  views  and  practice  have  been  acted  upon 
to  a  great  extent  by  those  who  have  sedulously  cultivated  the  physical 
diagnosis  of  diseases  of  the  heart.  It  is  the  attempt  to  treat  mere 
symptoms  without  a  knowledge  of  the  oi'ganic  diseases  on  which  they 
depend  that  leads  to  mistakes  among  medical  men.  But  with  that 
knowledge,  their  judicious  treatment  of  the  effects  of  valvular  disease  of 
the  heart,  forms  one  of  the  best  examples  of  a  modern  scientific  as  distin- 
guished from  a  foi'iner  empirical  practice. 

What  then  we  have  principally  to  attend  to  in  valvular  diseases  of  the 
lieart  is,  to  do  all  in  our  power  to  support  the  normal  strength  of  the 
economy,  and  avoid  agitating  the  patient,  instead  of  lowering  the  pulse, 
or  giving  mercury  under  the  idea  that  thereby  we  are  putting  down  an 
inflammation  or  causing  absorption  of  the  exudation.  In  this  way  per- 
sons aftected  with  cardiac  disease  have  continued  to  live  quite  uncon- 
scious of  it  for  many  years  in  comfort.  If,  however,  it  occasion  dyspnoaa, 
care  must  be  taken  to  avoid  sudden  or  great  exertion,  and  violent 
emotions ;  while  by  means  of  diet  properly  regulated,  and  by  gentle 
exercise,  a  due  supply  of  blood  is  maintained,  and  its  unequal  distribution 
between  the  lungs  and  liver  prevented.  Pain,  angina,  and  paroxysmal 
attacks  may  be  relieved  by  the  cautious  use  of  morphia,  digitalis, 
aconite,  and  other  sedatives,  used  as  palliatives,  and  occasionally  by  car- 
minatives. (Case  XCVIII.)  When  dropsy  appears,  we  may  delay  its 
advance,  and  often  get  rid  of  it  for  a  time,  by  means  of  diuretics, 
sudorifics,  and  even,  if  the  strength  admit  of  it,  by  drastic  purgatives. 
According  to  Stokes,  the  action  of  these  remedies  may  occasionally  be 
assisted  by  mercurials.  For  any  other  purpose  they  are  useless.  AVhen 
hypeitrophy  exists  to  any  great  extent,  and  there  is  obvious  difficulty  in 
propelling  the  blood  through  the  lungs,  as  evidenced  by  excessive 
dyspnQ?a,  lividity  of  the  face,  and  irregular  heart's  action,  the  application 
of  a  few  leeches,  or  cupping  to  the  extent  of  four  or  five  ounces  of  blood, 
frequently  gives  great  relief  for  a  time.  Eveu  dry  cupping  is  often 
beneficial.  If  there  be  a  tendency  to  faintness,  or  reason  to  suspect  fatty 
disease  of  the  heart,  in  addition  to  the  other  kinds  of  treatment  referred 
to,  a  stimulant  should  always  be  at  hand  to  be  administered  at  the  first 
approacli  of  syncope. 


FUNCTIONAL  DISORDERS  OF  THE  HEART. 

W^hat  are  called  functional  disorders  of  the  heart,  are  in  fact  only 
symptoms  of  obscure  organic  diseases,  of  indigestion,  or  of  weakness  of 
the  general  system  from  alteration  of  the  blood.  They  assume  three 
principal  forms :— 1st,  Angina  pectoris,  or  spasm  of  the  muscular  walls 
of  the  heart,  causing  excruciating  pain  and  a  feeling  of  sinking  difficult 
to  describe.  It  is  generally  induced  by  exertion.  We  have  seen  it 
accompany  organic  disease  of  the  organ  (Case  XCVHL),  and  it  has 
been  frequently  observed  in  connection  with  fatty  heart  and  calcareous 

*  Edin.  Medical  and  Surgical  Journal,  vol.  xxxvii.  1852. 


ANEURISM.  557 

deo-enoration  of  tlie  coronary  valve.  2d,  In  clilorosis,  and  the  anaemia 
of  young  women,  there  are  palpitations  with  a  tendency  to  syncope, 
accompanieJ  by  a  blowing  murmur  at  the  base,  with  the  first  sound, 
of  soft  character  and  not  permanent.  It  is  propagated  in  the  course  of 
the  laro-e  vessels,  on  placing  the  stethoscope  over  which,  a  continuous 
buzzing"  or  humraing-top  murmur  is  audible  [Bruit  de  diable  of  the 
French).  The  cause  of  this  is  very  obscure,  and  is  by  some  said  to  be 
arterial,  and  by  others  venous.  (See  Diseases  of  the  Blood.)  3d, 
Similar  palpitations,  often  with  a  small  heart,  in  young  men  who_  fol- 
low sedentary  pursuits,  especially  students  of  the  learned  professions. 
Their  appetite  is  generally  defective,  the  body  weak  and  indisposed 
to  exertion,  the  mind  and  nervous  system  irritable,  and  the  sleep  pre- 
vented by  the  excessive  action  of  and  uneasy  sensations  attributed  to 
the  heart. 

The  treatment  in  all  these  cases  is,  when  it  is  dependent  on  weak- 
ness, to  increase  the  vigour  of  the  constitution  by  nutrients,  proper 
exercise,  and  the  administration  of  chalybeates.  In  chlorosis,  more 
especially,  the  different  preparations  of  iron  are  beneficial.  In  young 
men,  regulated  exercise,  suspension  from  study,  attention  to  diet,  and 
especially  removing  the  attention  from  the  heart  at  night  by  cheerful^ 
conversation,  or  interesting  light  reading,  are  the  most  useful  means  of 
removing  the  disorder.  In  all  cases  the  concomitant  derangements 
must  bestudied,  and,  if  possible,  removed,  such  as  araenorrhoea,  hiemor- 
rhoids,  spennatorrhcea,  dyspepsia,  etc.,  etc. 


ANEURISM. 

Case  CV.*— Aneurism  of  the  Ascending  Arch  of  the  Aorta — Incompetency  of  Aortic 
Valves — Hypertrophy  of  Left  Ventricle. 

History. — Charles  Watt,  fet.  31.  groom — admitted  June  19,  1850.  During  the 
last  eight  months  has  frequently  had  occasion  to  lift  heavy  weights,  and  has  occa- 
sionally felt  slight  pain  in  the  epigastrium.  This  suddenly  became  very  violent  on 
the  8th  of  June ;  and  the  next  day,  on  walking,  he  experienced  violent  dyspnoea. 
On  the  11th  he  was  cupped,  with  considerable  relief  Has  been  aware  of  a  pulsa- 
tion in  the  neck  for  two  years,  but  never  suffered  any  inconvenience  from  it.  No 
dysphagia. 

Symptoms  os  Admission'. — The  cardiac  dulness  extends  three  inches  trans- 
versely. The  apex  beats  with  great  force  between  the  fifth  and  sixth  ribs,  two 
inches  below,  and  a  little  to  the  left  of  the  nipple.  A  bellows  murmur  is  heard 
with  the  second  sound,  loudest  at  the  base.  The  first  sound  is  normal.  In  the  right 
side  of  the  neck,  immediately  above  the  sternum  and  clavicle,  there  is  a  pulsating 
tumour  the  size  of  a  hen's  egg,  extending  laterally  two  inches.  It  communicates  a 
strong  impulse  and  a  peculiar  thrill  to  the  hand  placed  on  it,  and  over  it  there 
may  be  heard  a  loud  hoarse  bellows  murmur,  synchronous  with  the  impulse  of  the 
heart,  and  this  murmur  may  be  heard  at  the  back,  extending  down  the  course  of 
the  aorta.  Pulse  74,  regular,  hard,  and  jerking,  alternating  with  the  impulse  at  the 
apex,   stronger  in  the  right  than  the  left  wrist.      Pain  in  the  epigastrium,  and 

*  Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


558  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

dj'spnosa  oa  exertion.  No  other  pulmonary  symptoms.  Frequent  pain  in  the  left 
temple,  extending  down  that  side  of  the  nose.  Giddiness  on  rising  suddenly.  Fre- 
quent muscce  volitantes. 

Progress  of  the  Case. — Continued  to  have  pain  in  the  epigastrium,  and 
d;'spnoea  at  intervals.  He  was  treated  by  occasional  small  topical  bleedings,  which 
always  relieved  the  symptoms.  Blisters  also  were  now  and  then  applied,  and 
latterly  small  doses  of  aconite  given.  The  physical  signs  underwent  no  change, 
but  the  distre.ssing  concomitant  symptoms  nearly  disappeared,  and  he  felt  so  well 
that  he  was  dismissed,  at  his  own  desire,  July  15. 

Commentary. — In  this  case  aortic  incouipetency  was  proved  to  exist 
by  the  same  sign  as  we  have  seen  to  accompany  it  in  former  cases. 
The  visible  swelling,  diffnse  pulsation,  and  bellows  murmur,  synchronous 
with  the  dilatation  of  the  vessel,  could  leave  little  doubt  that  an 
aneurism  of  the  aorta  existed.  It  became  a  question,  however,  whether 
the  innominata  was  or  was  not  involved ;  and  I  am  inclined  to  consider 
not,  from  a  variety  of  circumstances,  but  more  especially — 1st,  Because 
the  pulse  at  the  right  wrist  was  stronger  than  at  the  left;  2d,  Because 
the  pain  in  the  head  and  face  was  on  the  left,  and  not  on  the  right 
side ;  and,  3d,  Because  the  bellows  murmur  over  the  tumour  was  super- 
ficial, anterior,  and  propagated  down  the  back  in  the  course  of  the 
aorta.  In  addition,  it  could  be  argued  that  there  was  neither  dysphagia 
nor  dyspnoea,  while  the  respiratory  murmurs  are  equally  loud  in  both 
lungs.  Now  aneurisms  of  the  transverse  arch  of  the  aorta  press  against 
the  most  convex  part  of  the  trachea,  which  is  least  liable  to  compres- 
sion, whilst  the  oesophagus  at  this  point  is  well  protected.  Hence  the 
seat  of  the  aneurism  explains  why  deglutition  and  respiration  were  not 
interfered  with. 


Case  CVI.* — Aneurism  of  Ascending  Aorta,  immediately  above  the  Aortic  Valves — 
Incompetency  of  Aortic  and  Mitral  Valves — Hypertrophy  of  left  Ventricle —  Waxy 
Kidneys — Pulmonary  Hemorrhage — ^-1  nasarca. 

History. — Kenneth  M'Kenzie,  ast.  52,  quarryman — admitted  October  31st,  18.53. 
Has  been  more  or  less  subject  to  rheumatism  during  the  last  twelve  years.  Nine 
months  ago,  after  much  exposure  to  cold  and  wet,  he  complained  of  unu.sual  palpi- 
tation and  dyspnoea,  and  has  since  been  subjected  to  paroxysms  of  breathlessness, 
suffocation,  and  a  feeling  of  extreme  anxietj-,  unattended  with  cough  or  expectora- 
tion. Three  weeks  ago  a  mass  of  earth  and  loose  stones  fell  upon  his  back  between 
the  shoulders,  and  since  then,  his  whole  body  has  been  painful  and  stiff,  and  the 
other  symptoms  much  aggravated. 

Symptoms  ox  Admissiox. — The  impulse  of  heart  is  diffuse,  raising  more  espe- 
cially the  fifth  and  sixth  intercostal  spaces.  The  apex  beats  strongly  between  the 
fifth  and  sixth  ribs,  in  a  vertical  line  below  the  left  nipple.  The  transverse  cardiac 
dulness  begins  at  the  margin  of  the  sternum,  and  extends  three  inches  and  a  quarter 
outwards.  On  auscultation  a  loud,  harsh,  but  somewhat  musical  murmur  is  heard  at 
the  apex  with  the  first  sound,  immediately  followed  by  the  second  sound,  which  is 
rather  sharp  and  rough,  but  without  murmur.  At  the  base  there  is  a  blowing  mur- 
mur with  both  sounds,  wliich  are  particularly  marked  over  the  articulation  of  the 

*  Reported  by  Mr.  AYilliam  Calder  and  Mr.  Almeric  Seymour,  Clinical  Clerks, 


ANEURISM.  559 

fourth  rib  with  the  sternum.  Over  the  great  vessels  at  the  root  of  the  neck,  a  single 
blowing  murmur  is  heard  synchronous  with  the  pulse  at  the  wrist,  and  this  is  heard 
loudest  immediately  above  the  sternal  end  of  the  clavicle.  At  this  point  a  distinct 
impulse  may  be  felt  with  the  finger,  and  even  seen  by  the  eye,  but  no  circumscribed 
swelling  can  be  made  out.  A  similar  impulse  and  murmur  exists  above  left  clavicle, 
but  not  so  distinct.  Pulse  90,  strong,  and  rather  jerking.  Has  frequent  palpitation  and 
dyspnoea,  sometimes  coming  on  when  lying  quite  still,  and  always  on  making  any 
unusual  exertion.  Percussion  over  the  lungs  everywhere  good.  On  the  right  side, 
harsh  inspiration  both  anteriorly  and  posteriorly.  Has  a  copious  expectoration  of 
frothy  mucus.  Breathing  somewhat  laboured  and  wheezing.  The  appetite  is  not 
good,  but  the  digestive  system  is  otherwise  normal.  Has  occasional  headache  and 
a  frequent  feeling  of  dizziness,  with  muscje  volitantes.  Palpitation  and  dyspncea, 
when  severe,  often  occasion  faintness.     Other  functions  normal. 

Progress  of  the  Case. — During  the  month  of  November  there  was  little  change 
in  his  condition,  although  the  symptoms  were  somewhat  alleviated  by  quietude  and 
treatment.  December  8<;i.— Last  night  was  seized  with  pains  in  the  right  chest, 
accompanied  with  great  difficulty  of  breathing.  To-day  on  auscultation,  crepitating 
rale  is  mingled  with  harsh  inspiration,  and  sibilant  and  sonorous  rhouchi  on  expiration. 
Percussion  and  vocal  resonance  good.  No  rigor  or  fever.  Dec.  22d. — Since  last 
report,  the  attacks  of  dyspnoea  have  become  more  urgent,  and  now  he  cannot  assume 
the  recumbent  posture.  Expectoration  is  copious  and  slightly  tinged  with  blood. 
On  the  13th,  oedema  of  the  ankles  made  its  appearance,  and  on  examining  the  urine, 
it  was  found  to  be  highly  albuminous.  Pulse  GO,  jerking.  Dec.  2dth.— (Edema  of 
inferior  extremities  has  now  extended  to  the  thighs  and  scrotum,  and  is  rapidly 
increasing.  Amount  of  urine  passed  daily  much  diminished  and  highly  albuminous. 
Orthopnoea  at  night,  and  great  dyspncea  at  all  times.  Sputum  largely  mixed  with 
blood.  Dulness  on  percussion  over  lower  third  of  riglit  lung  posteriorly.  January 
4th. — Since  last  report  there  has  been  general  anasarca,  with  great  distension  of  the 
inferior  extremities  and  scrotum.  Has  been  unable  to  assume  the  recumbent  pos- 
ture, and  beeu  obliged  to  pass  the  night  leaning  forward  on  a  table.  The  urine  has 
continued  very  scanty,  and  the  pulse,  though  still  jerking,  has  gradually  become 
weak.  He  gradually  became  exhausted,  and  died  Jan.  9th,  at  11  A.M.  The  treat- 
ment consisted  at  first  of  abstraction  of  small  quantities  of  blood  from  over  the  heart 
or  lungs,  by  cupping  or  leeches,  which  always  produced  temporary  relief.  Expecto- 
rants and  anodynes  to  relieve  cough,  favour  expectoration,  and  promote  sleep.  Anti- 
spasmodics to  diminish  dyspnoea.  When  the  dropsy  appeared,  diuretics  and 
afterwards  hydragogue  cathartics  caused  relief,  and  for  a  time  diminished  the  accumu- 
lation of  the  fluid. 

Sectio  Cadaveris. —  Twenty-five  hours  after  death. 

Head.— Considerable  effusion  in  subarachnoid  cavity.  Lateral  ventricles  con- 
tained 3  iij  of  clear  serum.     Brain  otherwise  healthy. 

Thorax.— Heart  much  enlarged,  weighing  28  ounces.  This  was  owing  almost 
entirely  to  hypertrophy  of  the  left  ventricle,  its  cavity  being  dilated  and  walls  much 
thickened.  The  aortic  valves  were  shortened,  thickened,  and  incompetent.  The 
margins  of  mitral  valve  were  thickened,  and  the  chordte  tendinese  shortened  and 
thickened.  The  lining  membrane  of  the  aorta  was  rough  and  irregular  from  athero- 
matous and  calcareous  degeneration.  Immediately  above  the  sigmoid  valve,  which  is 
next  the  right  ventricle,  was  an  aneurismal  pouch  the  size  of  a  walnut.  It  contained 
no  coao-ula,  was  formed  by  a  dilatation  of  all  the  aortic  coats,  and  its  internal  surface 
was  rough  from  atheromatous  degeneration.  The  entire  arch  of  the  aorta  was  also 
rough  from  a  similar  cause,  but  the  descending  aorta  was  normal.     Both  lungs  were 


560  DISEASES   OF   THE    CIRCULATORY   SYSTEM. 

oedematous.     In  the  right  lung  were  several  masses  of  coagulated  extravasated  blood , 
generally  about  the  size  of  a  walnut. 

Abdomen. — The   kidneys  presented  the  waxy  degeneration.      Other  abdominal 
organs  healthj^ 

Commentary. — This  case  is  an  example  of  a  commencing  aneurism  at 
the  root  of  the  aorta,  although  it,  like  the  last,  may  be  regarded  essen- 
tially as  a  cardiac  disease,  as  the  physical  signs  indicated  both  mitral  and 
aortic  incompetency.  It  was  the  load,  single  blowing,  synchronous  with 
the  systole,  combined  with  the  distinct  impulse  felt  and  seen  over  the 
clavicle,  which  pointed  to  an  aortic  aneurism.  The  size  of  this  aneurism 
could  not  be  large,  as  percussion  failed  to  detect  any  dulness  over  the 
chest,  and  although  he  at  first  said  that  deglutition  had  been  slightly 
impaired,  this  symptom  was  afterwards  ascertained  not  to  be  present. 
The  aneurism  may  have  assisted  in  producing  the  incompetency  of, the 
aortic  valves,  which,  with  the  aneurism  itself,  was  occasioned  by  the 
chronic  arteritis,  and  subsequent  atheromatous  degeneration  of  the  arch 
of  the  aorta.  At  what  time  the  mitral  disease  cotnmenced  was  unknown, 
but  it  was  comparatively  subordinate  to  the  aortic  disease,  and  was  fol- 
lowed by  hypertrophy  of  the  left  ventricle,  and  the  pulmonary  compli- 
cation. The  renal  lesion  came  on  when  he  was  in  the  ward,  and  we 
need  not  be  surprised  at  the  universal  and  rapid  anasarca  which,  under 
such  circumstances,  proved  fatal.  Treatment  under  such  circumstances 
could  only  be  palliative. 

Case  GVII.* — Aneurism  of  Ascending  Arch  of  Aorta — Chronic  Pericarditis — Disease 
of  Aortic  Valves — Great  Hijpertrophy  of  Heart — Anasarca. 

History. — Robert  Laing,  ajt.  .5.3,  married,  a  bookbinder — admitted  January  11th, 
1854.  States  that  he  never  had  rheumatism,  and  cannot  account  in  any  way  for  his 
illness,  which  he  dates  from  about  four  months  ago ;  previously  to  tliat  time  he  was 
in  the  enjoyment  of  excellent  health.  Palpitation  and  dyspnoea  were  the  drst 
symirtoms  he  noticed,  and  a  strong  pulsation  in  the  back  was  observed  by  his  wife. 
Qildema  of  the  lower  limbs  came  on  about  a  month  afterwards,  and  has  since 
gradually  increased  During  his  illness  he  was  treated  with  diuretic  remedies,  which 
produced  temporary  diminution  of  the  dropsy.  A  few  days  before  admission,  the 
dyspnoea  became  very  urgent,  but  was  somewhat  relieved  by  venesection  to  the 
amount  of  a  few  ounces. 

Symptoms  on  Adihssion. — The  impulse  of  the  heart  is  weak  and  diffused  over 
considerable  part  of  tlie  fifth  intercostal  space,  being  felt  most  distinctly  in  a  line 
perpendicularly  below  the  nipple.  Dulness  on  percusssion  extends  from  the  left 
nipple  across  the  chest,  nearly  as  far  as  the  right  nipple ;  upwards  on  the  left  side 
it  extends  as  far  as  to  the  third  intercostal  space,  but  above  that  line  percussion  is 
normal.  On  the  right  side,  dulness  extends  from  apex  to  base,  over  a  space 
bounded  by  the  sternum  within,  and  a  line  drawn  vertically  through  the  nipple 
externally.  The  heart  sounds  are  much  obscured  by  pulmonary  rales ;  in  the  usual 
situation  they  are  feeble,  and  their  precise  character  cannot  be  determined.  Over 
the  upper  two-thirds  of  the  right  side  of  the  chest,  as  fkr  out  as  the  nipple,  there  is 
very  loud  hoarse  double  murmur;    no  impulse  can  be  felt  in  that  region.     Pulse 

*  Reported  by  Mr.  Robert  Bird,  Clinical  Clerk. 


ANEURISM..  561 

76,  and  of  jerking  aortic  character;  regular,  and  of  equal  strength  on  both  sides. 
Posteriorly  the  chest  is  resonant  everywhere,  and  loud,  sonorous,  and  sibilant  rales 
are  heard;  exi:)iration  is  considerably  prolonged.  Dyspnoea  considerable;  there  is 
some  cough  with  frothy  mucous  expectoration.  The  inferior  extremities  and  scro- 
tum are  enormously  distended,  and  pit  on  pressure;  the  abdomen  is  swollen,  and 
fluctuation  can  be  detected;  the  face  is  pale  and  somewhat  sallow.  Appetite  much 
impaired ;  thirst  considerable.  He  can  lie  only  on  his  back  or  his  right  side.  Has 
considerable  difficulty  in  speaking.     Urine  very  scanty  and  muddy  in  appearance. 

Progress  of  the  Case. — January  11th  to  I'iih. — Was  treated  with  antispas- 
modics and  hydragogue  cathai'tics,  and  afterwards  with  leeches  to  the  praicordia, 
which  last  measure  relieved  the  dyspnoea  considerably.  On  the  morning  of  the 
13th,  on  awakening  he  called  the  nurse;  immediately  afterwards  he  fell  into  a  state 
of  stupor  from  which  he  could  not  be  roused.  His  pulse  was  120,  weak;  the  pupils 
were  strongly  contracted.  Brandy  and  carbonate  of  ammonia  were  administered, 
but  he  continued  in  the  same  state  for  two  hours,  and  then  died. 

Sectio  Cadaveris. — Twenty-seven  hours  after  death. 

Great  anasarca  of  the  body. 

Thorax. — The  veins  of  the  neck  greatly  engorged,  so  that  on  cutting  them  across, 
a  large  quantity  of  black  fluid  blood  escaped.  On  removing  the  sternum,  the  peri- 
cardium was  seen  to  extend  in  a  transverse  direction  from  nipple  to  nipple,  so  as  to 
measure  eight  inches  across.  On  being  opened,  it  was  found  to  contain  two  ounces 
of  serum.  Over  the  anterior  and  posterior  pericardial  surface  of  all  the  cavities,  but 
especially  the  anterior  surface  of  the  right  ventricle,  masses  of  old  lymph  were 
attached — in  some  places  smooth,  in  others  rough  and  shaggy.  The  heart  was 
enormously  enlarged ;  the  cavities  of  both  ventricles,  but  especially  of  the  right, 
were  increased  in  size.  Their  walls  also  and  the  septum  were  much  thicker  than 
natural.  The  aortic  valves  were  thickened,  and  could  not  be  applied  against  the 
walls  of  the  aorta  in  consequence  of  masses  of  calcareous  matter  deposited  at  their 
bases.  The  whole  internal  surface  of  the  aorta  was  rough  and  thickened  bj^  athe- 
romatous degeneration.  Immediately  above  the  semilunar  valves  was  an  aneuris- 
mal  pouch,  springing  from  the  aorta.  The  opening  into  it  was  rather  larger  than  a 
crown  piece,  and  was  perfectly  round.  Above  this  aneurism,  formed  by  a  dilatation 
of  all  the  coats  of  the  vessel,  was  another,  formed  only  of  the  middle  and  external 
coats.  Into  this  there  were  two  openings,  one  about  the  size  of  a  shilling,  the  other 
a  fourth  of  that  size.  This  second  pouch  was  parti}'  filled  by  coagulated  blood. 
Externally,  the  aneurism  was  applied  innuediately  over  the  riglit  auricle,  was  of  a 
flattened  oval  form,  and  about  the  size  of  a  cocoa  nut.  The  mitral  valve,  and  those 
on  the  right  side  of  the  heart,  were  healthy.  The  pleuras  on  the  left  side  were 
thickened  and  universally  adherent.  At  the  lower  part  of  upper  lobe  it  was  of 
cartilaginous  consistence,  over  a  space  the  size  of  a  crown-piece.  The  lung  was 
slightly  emphysematous  at  its  anterior  margin.  Bronchi  contained  muco-purulent 
matter.  The  right  lung  was  not  adherent  anywhere.  At  the  apex  were  numerous 
emphysematous  bullie  the  size  of  peas.  Inferiorly  and  posteriori}',  the  pulmonary 
tissue  was  collapsed  in  several  places. 

Abdomen. — The  liver  and  kiduej-s  were  considerably  congested;  otherwise 
healthy.     Other  organs  natural. 

Commentary. — In  this  case  the  aneurism  originating  from  the  ascend- 
ing portion  of  the  aortic  arch  was  the  size  of  a  cocoa  nut,  and  was 
formed  on  the  right  side.  During  the  hfe  of  the  patient  it  was  supposed 
to  be  much  larger  in  consequence  of  the  extended  duUiess,  which  was 

36 


562  DISEASES   OF   THE    CIRCULATORY   SYSTEM. 

afterwards  determined  to  be  partly  dependent  on  the  dilated  pericardium. 
The  chronic  pericarditis  gave  rise  to  no  symptoms,  l;>ut  probably  assisted 
in  cansing  the  heart's  sounds  to  be  obscured,  which,  however,  were  suf- 
ficiently masked  by  the  bronchitic  rales.  The  loud  double  murmur 
heard  on  the  right  of  the  sternum  was  n]ost  probably  owing  to  the  flux 
and  reflux  of  the  blood  into  the  first  aneurismal  pouch,  for  although 
similar  sounds  might  have  originated  from  the  diseased  aortic  orifice, 
they  would  be  rendered  inaudible  by  the  pericarditis  and  bronchitis. 
The  complications  here  were  formidable,  and  the  man  died  rather  from 
the  heart  disorder  than  from  the  aneurism. 


Case  CVIII.* — Large  Aneurism  of  the  Ascending  Arch  of  the  Aorta,  causing  Ah- 
sorption  of  a  portion  of  the  Third  Rib,  and  bursting  into  the  Pericardium — Chro- 
nic Pericarditis — Incompetency  of  Aortic  Valves — Hypertrophy  of  Left  Ventricle. 

History. — James  M'Killoii,  set.  24,  labourer,  of  inlemp'jrate  habits — admitted 
January  12th,  1857.  He  says  that  two  years  and  a  half  ago,  while  engaged  in 
lifting  a  heavy  weight,  he  suddenly  felt  something  give  way  in  the  region  of  the 
left  chest.  From  that  period  he  became  subject  to  a  beating  in  that  locality,  but 
suffered  no  other  inconvenience,  till  about  four  months  ago,  when  he  experienced  a 
numbness  down  the  left  arm.  For  the  last  twelve  months  he  has  observed  his  left 
chest  to  be  somewhat  swollen.  Six  weeks  ago  he  first  felt  dyspnoea,  which  was 
increased  on  exertion,  and  was  attended  with  frequent  cough.  Two  weeks  after- 
wards, he  observed  his  face  and  neck  begin  to  swell,  and  this  has  graduallj^  gone 
on  until  now.     Continued  to  work  till  six  weeks  ago. 

Symptoms  on  Admission. — Apex  of  heart  beats  between  the  fifth  and  sixth  ribs, 
internal  to  and  below  the  left  nipple.  It  is  feeble  and  diffused.  A  heaving  pulsation 
is  also  felt  over  the  upper  part  of  left  chest,  synchronous  with  the  cardiac  impulse, 
having  also  an  expansive  lateral  motion.  On  percussion,  at  a  level  with  the  nipple, 
cardiac  transverse  dulness  is  three  inches.  Above  this  tliere  is  a  dull  space, 
bounded  by  a  curved  line,  which  passes  internally  to  mid-sternum,  superiorly  to  the 
lower  border  of  the  first  rib,  and  externally  as  far  as  a  line  passing  vertically 
through  the  left  nipple.  This  space  measures  four  inclies  from  above  downwards, 
and  five  inches  transversely.  It  bulges  forwards  visibly  more  than  the  correspond- 
ing part  on  the  opposite  side,  especially  in  the  second  intercostal  space,  two  and  a 
half  inches  from  the  sternum.  On  auscultation  at  the  heart's  ajjex,  a  double  blowing 
murmur  is  audible,  which,  however,  evidently  originates  at  the  base,  where  it  is 
loudest,  the  first  murmur  being  rough,  and  the  second  comparatively  soft.  All  over 
the  region  of  the  pulsating  tumour,  there  is  a  double  murmur,  the  first  not  so  loud 
as  the  second.  They  are  most  distinct  towards  the  outer  margin  of  the  dull  space 
formerly  described,  especially  at  a  point  one  inch  above  the  left  nipple.  Over  both 
clavicles  there  is  a  single  rough  blowing  murmur.  Posteriorly,  no  comparative 
dulness  can  be  made  out  on  percussion.  On  applying  the  hand  at  the  base  of  both 
lungs,  fremitus  is  perceptible  with  the  inspiratory  acts,  most  marked  in  the  left  side. 
On  auscultation,  a  double  murmur  is  audible  all  over  the  left  back,  loudest  between 
vertebra  and  the  edge  of  scapula.  Radial  pulse  108,  small  but  strong,  without  any 
difference  in  the  two  wrists.  Both  external  jugular  veins  are  somewhat  distended, 
so  that  the  position  of  the  valves  may  be  readily  perceived.  On  auscultation  over 
both  lungs,  harsh  sonorous  rales  are  audible,  with  occasional  moist  sounds.  Expira- 
tion much  prolonged.  Has  tickling  in  the  larynx ;  occasional  cough  of  a  hard  and 
*  Reported  by  Mr.  H.  N.  Maclaurin,  Clinical  Clerk. 


ANEURISM. 


563 


somevrhat  clanging  character;  expectoration  is  mucous,  not  copious;  considerable 
d}-spnoea,  especially  on  exertion,  and  pain  in  the  left  chest  and  shoulder,  with  numb- 
ness in  left  arm ;  sleep  is  disturbed ;  irides  normal;  strength  diminished;  considera- 
ble oedema  of  face,  neck,  and  chest  only ;  eyelids  puffy;  skin  hot :  appetite  good ; 
deglutition  unaffected.  Digestive,  urinary,  and  other  functions  normal.  Eight 
Leeches  to  be  applied  over  tumour  in  left  chest,  and  to  take  a  tablespoonful  every  two 
hours  of  the  following  mixture :— If.  Sp.  JSther.  Sulph. ;  Sp.  Animon.  Aromat.  aa,  3j ; 
TV.  Card.  comp.  3iij ;  Aquoe  ad  §  iij.  M. 

Progress  of  the  Case. — January  llth.—lAtWe  benefit  followed  the  application 
of  the  leeches.  Yesterday,  ^  v  of  blood  were  removed  by  cupping,  and  caused  great 
relief.  (Edema  of  the  face  lessened.  Jan.  22d  — Complains  of  pain  passing  from 
tumour  to  middle  of  left  back.  Venesectio  ad  I  x.  Jan.  24:th.—  3  xj  of  blood  were 
taken  from  the  arm,  causing  instantaneous  relief  from  the  pain,  and  tingling  in  the 
arm.  The  relief  continued  till  to-day,  when  the  pain  has  returned.  Pulse  100, 
sharp.  Other  symptoms  the  same.  Morphia  and  JEther  draught.  Jan.  29th. — Pain 
continue.?.  Dyspnoea  and  cough  have  increased.  Face  and  neck  again  very  oede* 
matous.  To  be  cupped  over  the  lefl  chest,  and  §  vj  of  blood  taken.  Feb.  2d. — Was 
again  greatly  relieved  by  the  cupping.  Complains  of  tickling  in  the  larynx.  The 
tumour  has  extended  somewhat  upwards,  and  its  pulsation  is  distinctly  felt  at  the 
right  border  of  the  sternum  opposite  the  second  rib.  ^  Tinct.  Lobelice  In  flake  3j ; 
Sol.  Mur.  Morph.  3  j ;  Aqua  ad  I  w].  M.  One  tablespoonful  three  times  in  the 
night.  Expired  suddenly  at  7  p.m.  on  the  8th,  the  symptoms  having  undergone  little 
change. 

Sectio  Cadaveris. — Thirty-two  hours  after  death. 

Body  not  emaciated.     Left  side  of  thorax  rather  fuller  than  right. 

TiiOR.iX. — There  was  some  oedema  of  the  parietes,  greater  upon  tlie  left  than  the 
right  side.  On  reflecting  the  sofl  parts,  there  was  an  evident  prominence  in  the  left 
mammary  region,  rounded  in  form,  and  about  two  and  a  half  inches  in  diameter. 
The  pericardium  was  much  distended,  and  contained  twenty  ounces  of  blood.  An 
aneurism  arose  from  that  portion  of  the  ascending  aorta  contained  within  the  peri- 
cardium, commencing  immediately  above  the  semilunar  valves  and  the  origin  of  the 
coronary  arteries.  The  aorta  below  this  point  was  not  dilated.  The  aneurism 
anteriorly  appeared  to  be  divided  into  two  lobes;  the  left  much  larger  than  the 
right,  and  of  the  size  of  a  large  cocoa  nut,  passed  upwards  and  forwards,  its  long 
diameter  being  nearly  parallel  to  the  auterior  wall  of  the  thorax,  to  wliich  the  greater 
part  of  its  surface  was  adherent ;  the  right,  larger  than  a  turkey's  egg,  passed  back- 
wards and  a  little  downwards,  its  long  diameter  being  nearly  parallel  to  the  base  of 
the  thorax.  The  anterior  extremity  of  the  right  lobe  did  not  approach  within  two 
inches  of  the  thoracic  wall.  Posteriorly  no  such  division  into  lobes  could  be  seen, 
but  merely  a  single  large  aneurismal  sac  divided  into  two  compartments  by  the  aorta. 
The  left  pouch  was  found  adherent  to  the  posterior  surface  of  the  sternum,  between 
the  junctions  of  the  second  and  fourth  ribs,  and  to  the  cartilages  and  part  of  the 
bodies  of  second,  third,  and  fourth  ribs.  Over  this  space,  measuring  about  six  inches 
across,  and  nearly  four  vertically,  the  sac  could  not  be  separated  from  the  thoracic 
parietes;  on  the  contrary,  the  finger  introduced  into  the  sac  detected  rough  exposed 
bone  in  various  situations,  corresponding  to  the  prominence  observed.  Externally 
there  was  a  gap  in  the  thoracic  wall,  formed  by  the  absorption  of  a  considerable  por- 
tion of  the  third  rib,  external  to  its  junction  with  its  cartilage.  The  recurrent  nerves 
were  displaced  and  stretched,  especially  the  left,  in  consequence  of  the  transverse 
portion  of  the  arch  of  the  aorta  being  pushed  backwards.  A  rupture  of  the  aneurism 
into^he  pericardium  had  taken  place  at  the  most  dependent  part  of  the  larger  sac, 


564  DISEASES   OF   THE   CIRCULATOEy   SYSTEM. 

at  a  i^oint  corresponding  to  the  right  margin  of  the  sternum  between  the  junction  of 
the  fifth  and  sixth  right  costal  cartilages  with  the  sternum,  but  about  two  inches 
behind  it.  The  orifice  was  of  a  linear  form,  hah'  an  inch  in  length,  and  immediately 
overhanging  the  right  auricle.  Tlie  sac  contained  chiefly  loose  clots,  but  some 
imperfect  layers  of  decolorised  tough  fibrin  were  in  some  places  adherent  to  its 
walls.  The  heart  was  displaced  downwards  and  backwards.  The  larger  sac  inter- 
vened between  it  and  the  thoracic  walls,  so  that  its  base  was  on  a  level  with  the 
lower  margin  of  tlie  fourth  rib,  and  five  inches  behind  it.  The  heart  was  hypertro- 
phied,  but,  as  it  was  kept  attached  to  the  preparation,  it  could  not  be  weighed.  The 
liypertrophy  was  most  marked  in  the  left  ventricle.  The  surface  of  the  heart  was 
roughened  by  shaggy  growths  of  old  plastic  lymph,  most  abundant  over  the  left  ven- 
tricle. Pericardium  not  adherent.  The  aortic  valves  were  evidently  incompetent, 
being  opaque,  tliickened,  and  shortened  There  was  a  small  aneurism  of  this  portion 
of  tlie  arch,  between  the  origin  of  the  innominate  and  left  carotid  arteries,  and  par- 
tially involving  the  commencement  of  each  of  these  vessels.  It  was  about  the  size 
of  a  large  filbert.  Tlie  huing  membrane  of  the  thoracic  and  abdominal  aorta  was 
but  slightlj'  atheromatous.  The  larynx  was  quite  natural.  The  right  bronchus  was 
compressed  at  the  point  of  adhesion  between  the  lung  and  the  smaller  sac.  The  sub- 
stance of  the  lungs  was  quite  natural.  The  right  pleura  contained  a  pint  and  a  half 
of  clear  serum. 

Abdomen. — Abdominal  organs  healthy. 

Commentary. — In  this  case,  tlie  aneurisnial  tumour  developed  itself 
on  the  left  side,  and  caused  a  visible  swelling  with  protrusion  in  the  left 
chest.  It  was  of  larger  size,  and  of  older  growth  than  in  the  previous 
cases,  and  by  constant  pressure  forwards  on  the  ribs,  had  occasioned 
caries  and  interstitial  absorption  of  the  bones.  In  consequence  of  pres- 
sure posterioi'ly  on  the  bronchus  and  recurrent  nerve,  it  occasioned  harsh 
cough  and  tickling  of  the  larynx.  Although  here  also  the  aortic  valves 
were  incompetent,  the  sounds  were  marked  by  a  loud  double  blowing- 
murmur,  evidently  connected  with  the  aneurism,  because  they  were 
audible  in  the  left  back.  Only  one  sound,  however,  could  be  heard  at 
the  root  of  the  neck  above  the  clavicles,  owing  to  a  dilatation  of  the  aorta 
between  the  innominate  and  left  carotid  arteries.  In  this,  as  in  Case 
CVIL,  a  chronic  pericarditis  existed,  which  was  not  indicated  by  any 
symptoms.  The  relief  to  symptoms  by  small  abstractions  of  blood  was 
particularly  well  marked,  although  it  is  perhaps  almost  unnecessary  to 
say  that  the  real  disease  was  in  no  way  altered,  and  continued  its  march 
towards  a  fatal  termination,  (For  a  case  of  thoracic  aneurism  bursting 
into  the  pleura,  see  Case  LXXIII.) 


Case   CIX.* — Varicose  Aneurism    of    the   Ascending  Aorta    communicaiing   with 
tlie  Pulmonary  Artery — Jaundice  and  Nutmeg  Liver. 

History. — Alexander  Calder,  ajt.  33,  a  teacher — admitted  June  11th,  1855. 
He  had  always  enjoyed  good  health  until  the  beginning  of  last  February,  when  he 
felt  a  pain  under  the  ensiform  cartilage,  which  felt  like  the  pricking  of  a  pin,  and 
continued  for  a  week.  About  a  fortnight  after  this,  while  walking  hastily,  he  felt 
as  if  something  had  given  way  below  the  ensifomi  cartilage,  which  caused  him  to 

*  Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


ANEURISM.  565 

slacken  his  pace,  and  produced  a  sensation  of  weal^ness.  He  continued  to  feel  weak 
for  a  fortnight,  and  then  resumed  his  duties,  though  far  from  well.  During  tlie 
next  two  months  he  occasionally  expectorated  a  little  blood,  and  experienced  car- 
diac palpitation.  Two  months  ago  he  lost  blood  at  stool  (6  or  8  ounces  passing 
at  time  during  three  days),  which  was  regarded  as  dysenteric.  He  has  long  been 
subject  to  hemorrhoids.  Last  April  the  feet  began  to  swell,  and  the  abdomen  to 
enlarge,  symptoms  which  have  continued  more  or  less  since.  Latterly  the  palpita- 
tion has  increased,  and  tliere  has  been  considerable  dyspnoea  and  cough,  with  occa- 
sional vomiting. 

Symptoms  on  Admission. — On  percussion,  the  transverse  dulne.ss  of  tlie  heart 
measures  three  inches.  Its  impulse  is  diffused,  strong,  and  irregular.  On  auscul- 
tation, a  soft  blowing  murmur  is  heard  over  the  apex  with  the  first  sound,  and  the 
second  sound  is  distant  but  healthy.  At  the  juuction  of  the  third  costal  cartilage 
with  the  sternum,  the  first  sound  is  loud,  prolonged,  and  blowing,  the  second  is 
short,  abrupt,  and  rasping.  Over  the  manubrium  of  the  sternum  there  is  a  rough, 
continuous  blowing  murmur,  occupying  the  period  of  both  sounds.  The  same 
murmur  is  audible  under  both  clavicles  and  to  the  right  of  the  manubrium,  but  is 
softer  and  more  distant.  Pulse  90,  irregular,  but  of  natural  strength.  He  lias 
considerable  dyspnoea  on  going  up  stairs,  and  a  trifling  cough.  Over  tlie  anterior 
surfece  of  chest  tlie  respiratory  murmurs  are  harsh,  but  otherwise  percussion  and 
auscultation  furnish  no  signs  of  pulmonary  disease.  Pressure  over  the  stomach  is 
painful.  Tongue  clean;  vomits  once  or  twice  a  day  after  coughing.  Abdomen 
rather  tumid,  but  percussion  and  palpation  discover  nothing  abnoruial.  The  feet, 
legs,  and  thighs  are  oedematous,  pitting  strongly  on  pressure.  Urine  small  in 
quantity,  and  high  in  colour.  It  contains  a  superabundance  of  lithates,  but  no 
albumen.  Sp.  gr.  1025.  Tlie  other  functions  are  well  performed.  He  has  taken 
a  variety  of  remedies ;  at  one  time  drastic  purgatives,  and  at  anotlier  the  strongest 
diuretics,  all  of  which  have  only  produced  temporary  relief.  I^  Sp.  jEther.  Nit.  3  ij ; 
Tind.  ffyoscyami  3ij;  Liq.  Amman.  Acetat.  '^xy,  Aquce  §  vj.  M.  Habeat   ^j  ier  die. 

Progress  of  the  Case. — June  16ih. — The  rest  and  quietude  he  now  enjoys  have 
apparently  benefited  him,  but  he  sleeps  little.  ]J  -S/j»-.  uEtlier.  Sulph.  min.  xv.  Sol 
Mur.  Morph.  min.  xx.  Fl.  hausius.  To  he  taken  at  bedtime.  Jime  IWi. — The  breath- 
ing is  more  embarrassed,  and  the  oedema  of  the  lower  extremities  increased.  The 
cough  also  is  more  severe,  and  he  has  vomited  every  meal.  Pulse  100,  weak.  'S^ 
Sp.  Oilier.  Nit.  3j;  Sol.  Mur.  Morph.  3j;  Mist.  Campihorce  §jss.  M.  Half  to  be 
taken  at  5  p.m.  the  rest  at  bedtime.  June  2\st. — Since  last  report  the  skin  has 
gradually  become  jaundiced,  and  the  features  are  now  shrunk  and  anxious,  pulse 
128,  weak.  Vomiting  was  checked  by  the  medicine  ordered,  but  he  is  unable 
to  take  food,  or  stimulants.  5  Amman.  Carb.  gr.  v;  Tind.  Garb.  Comp.  3ij; 
Mist.  Camph.  §  iss ;  half  to  be  taken  immediately,  and  the  other  half  in  an  hour. 
June  22d. — Continues  to  sink,  notwithstanding  the  liberal  administration  of  stimu- 
lants and  nutrients.     Died  at  half-past  two  on  the  morning  of  June  23d. 

Secflo  Cadaverls. —  Thirty-four  hours  after  death. 

External  Appearances.— The  general  surface  and  conjunctivae  of  a  yellow 
tino-e — lower  extremities  oedematous.  and  several  phlj'ctenaj,  filled  with  sanguinolent 
serum,  existed  on  the  trunk  and  upper  part  of  the  thighs. 

Thorax. — The  pericardium  was  natural;  it  contained  ^  ss  dark  coloured  serum. 
On  removing  the  heart  a  bulging  was  observed  between  the  aorta  and  pulmonarj- 
artery.  Seen  externally  it  appeared  to  rise  from  the  latter  vessel.  It  was  of 
a  rounded,  rather  flattened  form,  somewhat  smaller  than  a  chestnut ;  when,  how- 
ever, the  finger  was  passed  down  the  aorta  it  entered  this  bulging,  which  proved  to 


566  DISEASES   OF   THE   CIRCULATOEY   SYSTEM. 

be  an  aneurismal  sac,  rising  from  the  root  of  the  aorta.  A  stream  of  water  passed 
down  the  aorta,  escaped  rapidly  at  first ;  but  the  latter  portion  was  retained  by  the 
semilunar  valves,  which  proved  competent.  On  laying  open  the  aorta,  the  aneurism 
was  found  to  commence  immediately  above  the  semOunar  valves.  Its  opening  into 
the  vessel  was  circular,  and  rather  smaller  than  a  florin.  The  sac  itself  was  of 
an  irregularly  rounded  form,  its  greatest  diameter  (from  above  do\^Tiwards)  being 
two  inches.  Its  capacity  about  that  of  a  large  walnut.  The  sac  was  empty  and 
contained  no  trace  of  a  clot.  At  the  apex  of  the  tumour  was  found  an  opening, 
which  passed  into  the  pulmonary  artery.  (The  sac,  as  already  mentioned,  was 
closely  applied  to  this  vessel.)  When  the  pulmonary  artery  was  cut  open  the  com- 
munication became  more  distinct.  This  opening  was  about  four  lines  in  length, 
and  the  lips  a  line  and  a  half  apart,  so  that  it  was  oval  in  form  with  its  margin 
slightly  rounded  off.  It  was  situated  transversely  to  the  length  of  the  pulmonary 
arterv.  and  was  rather  more  than  an  inch  higher  up  than  the  point  of  union  of  two 
of  the  pulmonary  semilunar  valves.  The  whole  of  the  cardiac  valves  were  natural. 
The  left  ventricle  was  rather  more  capacious  than  usual ;  its  walls  were  of  the  nor- 
mal thickness.  The  right  ventricle  was  also  a  little  dilated;  its  walls  were  more 
decidedly  hypertropbied.  The  heart  weighed  15^  ounces.  On  section  of  both 
lunss,  they  were  seen  to  contain  several  diiiused  patches  of  extravasated  blood, 
recent  and  confined  to  the  air  ceUs. 

ABDOiLEX. — In  the  cavity  of  the  abdomen  was  about  a  pint  of  turbid  serum. 
The  liver,  when  cut  into,  exliibited  congestion  of  the  portal  capillaries,  causing  the 
so-called  nutmeg  appearance.  The  spleen,  kidneys,  and  other  abdominal  organs 
were  healthy. 

Commentary. — Cases  of  aneurism  communicating  Avith  tlie  pul- 
monary arterv  are  very  rare,  and  the  physical  signs  to  which  they  give 
rise  have,  so  tar  as  I  can  discover,  only  been  recorded  in  two  instances. 
Of  five  cases  collected  by  Mr.  Thurnam,*  there  is  only  one  in  which 
the  sounds  were  accurately  observed.  It  Avas  published  by  Dr.  Hope,f 
and  was  communicated  to  him  by  Dr.  David  Monro  of  Edinburgh.  In 
that  case  the  size  of  the  aneurism  is  not  given,  it  is  vaguely  called 
"  laro-e,"  but  it  "  communicated  by  two  openings  with  the  pulmonary 
artery,  the  larger  capable  of  receiving  the  point  of  the  little  finger, 
the  smaller  of  transmitting  a  crow's  quill.  The  edges  of  both  were 
regular,  round,  and  cartilaginous.  Nearer  the  arch,  a  third  small 
opening  was  discovered,  with  thin  rugged  edges."  All  the  valves 
were  healthy,  excepting  the  semilunar  at  the  mouth  of  the  aorta,  which 
was  thickened."  We  are  not  informed  to  what  extent  the  aortic  valves 
were  thickened,  and  Avhether  such  thickening  produced  incompetence 
in  their  action.  But  we  are  told  that  "  the  first  sound  was  accompa- 
Bied  by  a  loud  blowing  murmur,  most  distinct  at  the  middle  of  the 
sternum,  but  audible  over  the  whole  fore  part  of  the  chest,  and  over  the 
back  on  both  sides  of  the  spine.  The  second  sound  was  short,  and 
much  obscured  by  the  first."  This  account  rendere  it  probable  that  the 
murmur  was  synchronous  with  the  ventricular  contraction,  Avas  caused 
bv  the  rushing  of  blood  through  the  laceration  of  the  aneurism  into 
the  pulmonary  artery,  and  Avas   not  OAving  to  the  valvular  disease.      In 

*  Medico-Chir.  Trans.,  vol.  xxiii.,  p.  349,  et  seq. 
f  Diseases  of  the  Heart,  3d  edit.,  p.  469. 


ANEURISM.  567 

a  case  of  Professor  Smith's  of  Dublin,*  tlie  pulmonary  artery  coimnu- 
nicateJ  with  the  aorta  by  a  small  opening  at  the  origin  of  the  latter 
vessel.  The  edges  of  this  opening  were  thickened  and  romided  off. 
There  was  dilatation  of  the  aorta  at  the  point  of  opening,  with  distinct 
signs  of  arteritis.  The  auiiculo-ventrienlar  openings  were  healthy. 
ATloud  blowing  murmur  accompanied  the  first  sound,  and  an  intense 
purring  ti-emor  could  be  felt  over  the  whole  cardiac  region.  AVhere 
this  blowing  murmur  was  heard  loudest  is  not  stated,  and  we  are  at  a 
loss  to  determine  whether  it  was  owing  to  the  wave  of  blood  rushing 
througli  the  dilated  and  roughened  aoita,  or  its  passing  through  the 
orifice"  into  the  pulmonary  artery.  Of  the  second  sound  nothing  is 
said.  The  purring  tremor  may  have  been  occasioned  by  the  rapid  gush 
of  blood  through  the  small  opening  of  the  aneurism,  and  a  similar  tremor 
was  observed  by  Mr.  Thurnam,  Dr.  ^Yilliams,  and  Dr.  Hope,  in  a  case 
where  an  aortic  aneurism  communicated  with  the  right  ventricle  of  the 
heart,  by  two  small  rounded  apertures.  That  such  tremor  should 
occur  where  the  opening  is  large,  appears  to  me  improbable. 

In  the  present  uncertain  state  of  our  knowledge  as  to  the  signs  which 
accompanv  an  aortic  varicose  aneurism  communicating  with  the  pulmo- 
nary artery,  the  case  of  Calder  appears  to  me  to  be  of  great  value,  as  the 
physical  signs  w-ere  examined  with  great  care,  and  recorded  at  my  dicta- 
tion by  the  clerk  at  the  bed  side.  At  the  time  they  were  exceedingly 
puzzliiiir,  because  the  idea  suggested  by  the  double  sound  heard  at  the 
base  of  "the  heart,  which,  under  ordinary  circumstances,  would  have  indi- 
cated aortic  disease  with  stricture,  was  negatived  by  the  fact  that  the 
second  sound  was  distinctly  audible  at  the  apex,  clear,  and  healthy.  At 
the  same  time,  the  manner  in  which  the  disease  occurred,  the  anasarca 
indicating  impeded  circulation,  the  dyspnoea  and  irregularity  of  pulse, 
gave  evidence  of  a  profound  lesion  of  the  heart,  although  its  nature  was 
verv  mysterious,  the  more  so  as  no  thrill  or  tremor  could  be  detected. 
The  case,  however,  was  at  once  made  clear,  and  the  nature  of  the  sounds 
explained  by  the  examination  of  the  body  after  death.  All  the  valves 
were  healthy,  and  hence  the  double  sound  must  have  been  entirely 
owing  to  the  flux  and  reflux  of  blood  through  the  communication 
between  the  aneurism  and  pulmonary  artery.  The  murmurs  were  heard 
loudest  over  the  seat  of  the  communication,  below  the  junction  of  the 
third  left  costal  cartilage  with  the  sternum ;  became  continuous  as  they 
were  propagated  upwards ;  but  interiorly  at  the  apex  of  the  heart,  only 
the  systolic  blowing  was  audible,  together  with  the  natural  sound  of  the 
semilunar  valves.  The  size  of  the  laceration  or  connecting  opening 
explains  the  absence  of  whiz  and  tremor.  These  facts  appear  to  me 
very  valuable  as  distinctive  of  such  a  lesion  when  the  valves  are  healthy. 
If,  as  frequently  happens,  they  are  diseased,  there  must  always  exist 
excessive  difliculty,  if  not  an  impossibility,  of  ever  distinguishing  such  a 
form  of  aneurism"  in  the  living  subject.  Mr.  Thurnam,  in  his  excellent 
paper,  appears  to  me  rather  too  sanguine  on  this  point. 

The  other  phenomena  presented  by  the  case  are  at  once  explained,  by 
reflecting  on  what  is  likely  to  happen  by  a  considerable  quantity  of 
blood  beino;  propelled  from  the  aorta  through  a  large  opening  into  the 

*  Dublin  Journal  of  Medical  Science,  vol.  xviii.,  p.  164,  and  Stokes  on  the  Diseases 
of  the  Heart  and  Aorta,  p.  554. 


568  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

pulmonary  artery,  and  thus  sent  to  the  lungs  again  without  liaving 
passed  through  the  systemic  circulation.  As  stated  by  Mr.  Thurnam, 
the  effects  are  referable  to  one  or  more  of  three  circumstances.  1st, 
Loss  of  blood  to  the  systemic  circulation,  and  as  a  result,  feeble,  occa- 
sionally jerking  pulse,  debility,  tendency  to  syncope,  and  diminution  to 
animal  heat.  2d,  Impediment  of  the  return  of  venous  blood  from  the 
distant  veins,  and,  as  a  result,  venous  congestion  of  the  liver,  mucous 
membrane,  and  extremities,  with  engorgement  and  dilatation  of  the 
right  side  of  the  heart,  and  as  a  result,  dropsical  effusions  and  especially 
anasarca.  3d,  Excessive  stimulation  of  the  lungs  by  the  reception  of 
arterial  instead  of  purely  venous  blood,  and  hence  dyspnoea,  cough,  pul- 
monary congestion,  and  extravasations  of  blood.  All  these  effects  wei'e 
observed  in  the  case  we  liave  had  before  us.  A  retrospective  view  of  the 
f^icts  and  phenomena  of  this  and  similar  cases  must  impress  upon  us  the 
triitli  that  drastic  purgatives  and  diuretics,  however  they  may  relieve, 
cannot  be  expected  to  produce  any  permanent  benefit.  Indeed,  when- 
ever general  anasarca  is  evidently  dependent  on  organic  disease,  it  seems 
to  us  that  the  mildest  remedies  should  be  employed,  especially  taking- 
care  by  their  use  not  to  lower  the  general  powers  of  the  constitution,  so 
that  life  may  be  prolonged  as  much  as  possible. 


Case  ex.* — Aneurism  of  the  Arteria  Innominata. 

History. — Catherine  Syme,  ret.  56,  a  seamstress — admitted  May  2,  1853.  She 
says  that  her  habits  have  always  been  temperate  and  regular.  FifTteen  years  ago  she 
had  an  attack  of  acute  articular  rheumatism,  which  afterwards  became  clironic,  and 
rendered  her  incapable  of  Avorking  for  eighteen  months.  For  six  j'cars  past  she  has 
been  subject  to  occasional  attacks  of  giddiness  and  swimming  in  the  head,  accompa- 
nied by  a  loud  noise  like  the  clanging  of  machinery.  Fourteen  months  ago,  in  the 
night,  she  was  seized  mth  a  fit  of  intense  dyspnoea,  threatening  suffocation  and 
accompanied  with  a  loud  crowing  noise  on  inspiration.  The  attack  lasted  about 
eight  minutes.  Three  months  afterwards,  she  experienced  a  somewhat  similar  but 
milder  attack,  also  in  the  night,  during  sleep.  She  now  observed  that  her  voice  was 
becoming  rough  and  hoarse;  and  a  few  months  later,  she  felt  slight  difficulty  in 
swallowing,  at  a  point  corresponding  to  the  upper  border  of  the  sternum.  In  the 
early  part  of  January  1853,  after  unusual  exposure  to  cold,  the  dyspnoea  returned 
ever}'  morning,  gradually  became  urgent,  and  generally  terminated  in  the  expectora- 
tion of  a  small  quantit}'^  of  mucus.  There  were  also  palpitations,  and  she  became 
subject  to  sudden  startings  from  sleep.  A  week  ago,  all  these  symptoms  became  so 
mucli  aggravated,  that  she  was  unable  to  leave  her  bed. 

Symptoms  on  Admission. — The  cardiac  dulness  measures  two  inches  across. 
The  apex  beats  between  the  fifth  and  sixth  ribs,  a  little  to  the  inside  of  the  nipple- 
Heart's  impulse  is  somewhat  diffused,  rhythmical,  and  of  good  strength.  A  blowing 
murmur  accompanies  both  cardiac  sounds,  that  with  tlie  first  sound  being  loudest  at 
the  apex,  and  that  with  the  second  being  loudest  at  the  base.  Immediate!}'  above 
and  towards  the  outer  side  of  the  right  sterno-clavicular  articulation,  a  pulsating 
tumour,  about  the  size  of  a  hen's  egg,  is  visible  to  the  eye.  It  is  felt  beneath  the 
sternal  and  inner  portion  of  the  clavicular  origins  of  the  sterno-mastoid  muscle,  pre- 
sents a  distinctly  rounded  outline,  and  anteriorly  slightly  overlaps  the  trachea  imme- 

*  Reported  by  Mr.  Robert  Brown,  Clinical  Clerk. 


ANEURISM.  569 

diately  above  the  upper  border  of  the  sternum.  The  impulse  is  strong  and  diffused, 
and  a  loud,  clear,  abrupt  murmur  is  heard  over  it,  synchronous  witli  the  second 
sound  of  the  heart.  The  pulse  is  regular,  106,  of  good  strength,  equal  at  both  wrists. 
There  is  a  paroxysmal  cough,  harsh,  prolonged,  and  of  a  clanging  metallic  character, 
always  worst  in  the  morning,  when  it  is  accompanied  by  urgent  dyspnoea,  and  a  loud 
crowing  inspiration.  Sputum  scanty  and  gelatinous,  containing  a  few  flocculi  of  pus. 
Yoice  hoarse  and  weak.  Chest  everywhere  resonant  on  percussion,  but  not  unusually 
arched.  Respiratory  murmurs  very  faint,  but  normal  in  character.  Expiration 
much  prolonged.  Appetite  impaired.  When  swallowing  solid  food,  she  says  the 
bolus  seems  to  meet  some  obstruction  at  a  point  corresponding  with  the  upper  border 
of  the  manubrium  of  the  sternum.  The  countenance  is  anxious,  face  livid,  and  the 
superficial  veins  of  the  chest  and  lower  part  of  the  neck  are  very  large  and  turgid. 
Sleep  restless  and  easily  disturbed.     Other  functions  normal. 

Progress  of  the  Case. — The  .symptoms  previously  noticed  continued,  with  occa- 
sional remissions,  until  the  20ih  of  June.  On  that  day,  it  was  observed  that  the 
blowing  murmur  synchronous  with  the  second  sound  at  the  base  of  the  heart,  was 
much  less  distinct,  and  that  the  murmur  with  the  first  sound  at  the  apex  was 
replaced  by  one  with  the  second.  The  veins  over  the  upper  part  of  the  chest  have 
been  gradually  enlarging.  On  the  6th  of  July,  a  careful  examination  elicited  the  fol- 
lowing results :— Pulse  88,  soft,  equal  in  both  wrists.  The  impulse  is  very  strong  over 
the  tumour,  and  on  auscultation  there  are  now  heard  two  sounds,  the  second  being 
loud,  abrupt,  and  exceedingly  clear — no  blowing  audible.  Tliese  sounds  diminish 
gradually  in  intensity  as  the  stethoscope  approaches  the  left  edge  of  the  manulirium 
of  the  sternum,  where  the  two  cardiac  sounds  are  heard  quite  normal.  As  the  instru- 
ment descends  towards  the  heart's  apex,  the  second  sound  gradually  assumes  a  soft 
blowing  character,  which  at  the  apex  is  loud  and  distinct.  The  first  sound  is  quite 
normal.  Posteriorly  above  the  right  scapula,  tlie  sounds  of  the  tumour  are  heard  at 
a  distance,  but  disappear  towards  the  centre  of  the  back,  and  are  inaudible  along  the 
vertebral  column.  July  8ih.—For  the  last  few  days  the  dyspnoea  in  the  morning  has 
been  verj^  urgent,  and  the  cough  coarser,  and  of  a  metallic  clanging  sound.  To-day 
the  paroxysm  continued  15  minutes,  and  even  now  at  the  visit,  the  breathing  is  noisy, 
laboured,  and  hurried,  the  dyspnoea  urgent,  and  the  paroxysm  of  cough  severe  and 
at  short  intervals.  She  cannot  expectorate  easily.  The  voice  is  feeble,  and  the 
countenance  expressive  of  great  anxiety.  To  relieve  these  symptoms  tracheotomy 
was  attempted  by  Mr.  Syme ;  but,  having  made  two  incisions,  and  cut  through  the 
integument  and  subcutaneous  fat,  such  an  amount  of  venous  hemorrhage  occurred 
that  he  desisted,  applied  a  ligature  to  the  large  veins,  and  declined  to  perform 
laryngotomy.  July  9th. — The  loss  of  blood  caused  considerable  relief,  and  she  passed 
a  tolerable  night.  A  double  blowing  murmur  is  now  audible  both  at  the  apex  and 
base  of  the  heart.  That  accompanying  the  second  sound  is  loudest  over  the  apex, 
while  the  one  accompanying  the  first  is  heard  loudest  over  the  ensiform  cartilage. 
July  I2th. — Last  night,  about  half-past  eleven,  p.m.,  a  severe  paroxysm  of  dyspnoea, 
threatening  suffocation,  came  on.  The  house-surgeon.  Dr.  Dobie,  enlarged  the  inci- 
sion made  by  Mr.  Syme,  upwards,  and  inserted  a  common-sized  tube  into  the  trachea 
and  larynx,  after  dividing  the  cricoid  cartilage.  To-day  she  is  again  better,  the  opera- 
tion having  been  followed  with  immediate  relief.  She  still  breathes,  liowever,  with 
difficulty  througli  the  tube.  The  countenance  is  livid  and  anxious,  extremities  cold, 
pulse  feeble  and  fluttering,  surface  bedewed  with  a  clammy  sweat.  She  now 
gradually  sank,  and  died  at  half-past  eleven,  p.m.,  on  the  14th,  the  embarrassment  of 
the  respiration  being  apparently  increased  by  the  difficulty  of  expectoration.  Imme- 
diately before  expiring,  she  ejected  through  the  tube  about  ^j.  of  dark  gre^'-coloured 
foetid  pus,  of  the  consistence  of  thick  cream. 


570  DISEASES   OF   THE   CIRCULATORy   SYSTEM, 

The  treatment  throughout  the  progress  of  the  case  was  directed  to  alleviating  tlie 
cougli  and  expectoration,  by  means  of  anodj'ues  and  expectorants,  and  diminishing 
the  paroxysms  of  dyspnoea  by  means  of  diffusible  stimuli.  Cupping  over  the  sternum, 
and  the  occasional  application  of  leeches,  were  employed,  and  for  some  time  tliese 
remedies  undoubtedly  caused  great  relief.  The  surgeons  of  the  Infirmarj-  were 
unanimously  of  opinion  that  the  aneurism  did  not  admit  of  relief  from  any  operation. 
Latterly  the  propriety  of  tracheotomy  or  laryngotomy  was  discussed  as  a  palliative, 
and  ultimately  tried  with  the  eflect  already  described. 

Sectio  Cadaveris. —  Thirteen  hours  after  death. 

The  edges  of  the  wound  through  which  the  larynx  had  been  opened  were  thick- 
ened, the  surrounding  muscles  discoloured  and  infiltrated  with  pus. 

Thorax. — The  heart,  aorta,  and  parts  connected  with  the  aneurism,  were  removed 
en  masse,  and  carefully  dissected,  with  the  following  results: — the  heart  and  its 
valves  quite  healthy,  with  the  exception  of  slight  thickening  of  the  margin  of  one 
aortic  valve.  The  arch  of  the  aorta  immediately  above  the  valves  considerably 
dilated,  and  tlie  whole  of  its  internal  surface  thickly  studded  with  atheromatous  and 
calcareous  plates.  The  whole  arteria  innominata  dilated  into  an  aneurismal  swelling 
of  a  round  and  somewhat  flattened  form,  having  a  diameter  of  fully  three  inches. 
The  tracliea  is  pushed  by  it  towards  the  left  side,  as  represented  in  the  accompany- 
ing figure,  in  consequence  of  which  the  incision  that  was  made  in  the  median  line 
during  the  operation,  was  witliin  one-eighth  of  an  inch  of  the  aneurism.  Tlie  tumour, 
by  pressing  on  the  right  side  of  the  trachea,  caused  much  bulging  into  and  diminu- 
tion of  its  calibre.  The  left  innominate  vein  was  nearly  obliterated.  The  remains 
of  its  interior  contained  a  softened  clot  resembling  pus,  which  communicated  by  a 
small  opening  through  the  aneurismal  sac  witli  a  portion  of  the  laminated  clot,  which 
occupied  about  three-fourths  of  its  internal  cavity.  The  opening  into  tiie  sac  from 
the  aorta  was  about  the  size  of  lialf-a-cro\vn,  and  presented  a  sharp  circular  margin. 
Posteriorly  the  nerves  were  reddened,  and  for  the  most  part  enlarged,  and  firmly 
united  to  the  posterior  waU  of  the  tumour.  The  superior  lar^'ugeal  nerve  was 
healthy,  being  above  the  tumour ;  but  the  inferior  was  compressed  and  imbedded 
in  thickened  cellular  tissue.  The  posterior  half  of  right  lung  was  partially  covered 
with  recent  Ij^mph,  not  adherent,  and  the  pleural  sac  contained  two  or  three  ounces 
of  sero-purulent  fluid.  The  lower  lobe  of  the  right  lung  was  hepatized ;  and  on  cut- 
ting into  it,  several  abscesses  up  to  the  size  of  a  cherry  were  found.  The  left  lung- 
was  oedematous,  and  its  bronchi  were  filled  with  muco-purulent  matter — otherwise 
healthy. 

Abdomen. — The  liver  presented  the  incipient  waxy  appearance.  The  .spleen  was 
dark  in  colour  and  pulpy,  almost  diffluent  in  consistence.  The  kidnej's  were 
crowded  with  minute  cysts,  and  the  cortical  substance  considerably  atrophied. 

Commentary. — This  case  terminated  in  the  usual  way,  by  pressure 
on  the  nerves  of  respiration,  causing  Jyspncea,  and  at  length  partial 
latent  pneumonia. 

The  double  clear  sound  over  the  aneurismal  tumour  I  have  been  in 
the  habit  of  attributing  to  the  flux  and  reflux  of  the  blood  over  a  sharp 
vibrating  opening  into  the  tumour.  In  few  aneurisms  were  these  sounds 
more  decidedly  present  than  in  the  case  under  consideration,  and  few 
after  death  presented  an  opening  having  the  margin  in  question 
better  formed.  In  another  case  of  aneurism  of  the  innominate  artery 
(that  of  John  Hunter),  examined  at  the  commencement  of  the  winter 


AXEURIS3I. 


571 


/ 


session  1856-7,  the  tumour  was  very  distinct  in  tlie  neck  above  the 
claviclr",  but  -svitliout  sound  of 
any  kind.  It  was  determined  after 
death  that  the  arteria  innominata 
was  dilated  to  the  size  of  a  thumb, 
and  gave  origin  to  the  aneurism, 
which  was  globular,  and  four  in- 
ches in  diameter,  without  any 
circular  margin,  but  rather  by  ^ 
means  of  a  narrow  neck,  as  in 
Fig.  425. 

The  sounds  heard  over  tlie  ^ 
heart,  however,  in  the  case  of 
Catherine  Syme,  changed  their 
character  as  "the  disease  advanced. 
At  first,  double  valvular  disease 
was  suspected,  but  latterly,  when 
the  murmurs  became  reversed,  and 
it  was  most  carefully  determined, 
by  repeated  examinations,  that  the 
niurmur  at  the  apex  was  with  the 
second,  and  that  at  the  base  was 
with  the  first,  sound,  they  were 
attributed  to  propagation  down- 
wards from  the  aneurismal  tumour. 
I  am  by  no  means  satisfied,  how- 
e^■er,  that  this  theory  is  correct 
with  regard  to  cardiac  murmurs 
so  distinct  as  those  in  the  present 
case,  associated  with  aneurismal  tumours  and  a  healthy  heart.  I  con- 
tent myself,  therefore,  for  the  present,  with  placing  the  facts  on  record, 
as  their  accuracy  is  undoubted,  and  they  were  con- 
firmed not  only  by  my  own  repeated  examinations, 
but  by  those  of  tlie  clinical  class  and  of  the  clerks, 
all  of"  whom  took  great  interest  in  the  case. 

The  question  of  putting  a  ligature  on  the  vessel 
having  been  decided  by  the  Infirmary  surgeons  in 
the  negative,  the  only  other  question  of  treatment 
Avas  the  prolongation  of  life.  The  source  of  danger 
was  evidently  the  dyspnoea,  and  the  frequent  attacks 
of  spasmodic  laryngeal  obstruction,  so  common 
in  aneui-ismal  cases  from  pressure  of  the  tumour  on  the  recurrent 
nerve.     The  trachea  was  also  considerably  pressed  upon  and   pushed 


Fig.  424 


Fis.  425. 


Fio-.  424.  Rough  sketch  of  the  aneurism  aud  adjoming  parts ;  a,  opening  into  the 
larynx :  Z>,  hne  of  original  incision  which  inferiorlv  came  close  upon  the  tumour ; 
c,  aneurismal  tumour ;  d,  point  where  the  obstructed  vena  innominata  had  ulcerated 
into  the  tumour ;  e,  right  carotid ;  /  right  jugular  vein ;  g,  left  carotid ;  h,  left 
subclavian. 

Fio-.  425.  Diagram  of  an  aneurism  of  the  arteria  innominata,  in  which  the  tumour 
sprung  from  the  dilated  vessel  with  a  narrow  neck,  and  in  which  no  sounds  were 
audible. 


572  DISEASES   OF   THE    CIRCULATOBY   SYSTEil. 

aside ;  but  this  could  not  liave  accounted  for  the  paroxysms  of  suffocat- 
ing dyspnoea,  for  although  diminished  in  calibre,  it  was  still  largely 
open  for  the  admission  of  air.  On  the  other  hand,  the  recurrent 
nerve  was  found  after  death  thickened,  and  embedded  in  dense  cellular 
tissue  immediately  behmd  the  tumour.  Under  such  circumstances,  it 
has  been  proposed,  by  passing  a  tube  into  the  larynx  or  trachea,  to  avert 
the  effects  of  these  spasms.  In  the  present  case,  tracheotomy  could  not 
be  peifornied ;  and  whenever  the  deep-seated  venous  obstruction  is  of 
such  a  character  as  to  cause  enlargement  of  the  supei-ficial  veins,  laryngo- 
tomy  is  the  operation  that  should  be  attempted.  This  at  length  was 
accomplished  with  momentary  relief ;  but  I  have  no  hesitationin  say- 
ing that  the  difficulty  of  expectoration,  and  the  consequent  clogging  of 
the  air  tubes,  led  to  results  equally  distressing  and  fatal  as  the  spasmodic 
attacks.  It  has,  indeed,  been  said,  that  in  these  cases  the  operation  is 
generally  delayed  too  long,  and  that  by  waiting  until  there  is  much 
secretion  of  mucus  and  diminution  of  strength,  no  very  good  effects  can 
be  reasonably  expected.  But  in  cases  of  aneurism,  it  is  at  best  only  to 
be  considered  as  a  palliative ;  and  considering  how  very  difficult  expec- 
toration must  always  be  under  such  circumstances,  I  consider  it  very 
doubtful  whether  it  is  ever  justifiable  except  as  a  dernier  ressort.  Cer- 
tainly the  case  now  recorded  is  anything  but  favourable  to  the  practice. 

In  this  case,  it  was  observable  that  after  the  incisions  in  the  integu- 
ment weie  made,  without  tracheotomy  having  been  performed,  great 
relief  was  occasioned,  which  continued  upwards  of  two  days,  "Was  this 
owing  to  the  few  ounces  of  blood  lost  during  the  operation,  or  to  the 
idea  which  she  had  adopted  that  the  operation  would  cause  relief? 
However  it  may  be  explained,  there  can  be  no  doubt  that  the  excessive 
dyspnoea  and  other  urgent  symptoms  were  alleviated  as  if  by  a  charm, 
in  consequence  of  the  unsuccessful  attempts  to  open  the  trachea. 


Case  CXI.* — Aneurism  of  Transverse  Ao'rtic  Arch — Chronic  Pericarditis  v;ith  Effu- 
sion— Tubercular  Lungs — Anasarca — Former  Popliteal  Aneurism  cured  by  com- 
pression. 

HiSTORT. — George  Fairweather,  set.  32,  a  labourer — admitted  January  20th,  1854. 
Originallj-  a  farrier,  he  entered  the  army  in  1839,  and  served  twelve  years.  In  1842. 
while  in  India,  he  was  laid  up  with  rheumatic  pains.  A  year  ago,  while  employed 
in  the  Edinburgh  police  force,  he  wa.s  obliged  to  run  a  great  distance  in  the  dis- 
charge of  his  dut}-.  Shortly  afterwards,  an  aneurism  made  its  appearance  in  the 
right  popliteal  space.  Of  this  he  was  cured  in  the  Glasgow  Infirmary  by  means  of 
compression.  He  has  since  been  troubled  with  cough  and  pain  in  the  breast,  and 
between  the  shoulders.  Last  August  he  became  very  hoarse,  and  entered  the  Glas- 
gow Infirmary,  where  he  remained  for  two  months.  Towards  the  close  of  that  period 
he  noticed  that  his  feet  were  swollen,  and  began  to  sufler  fi-om  palpitation,  with  pain 
in  the  prtecordial  region.  He  was  dismissed  from  the  Hospital  as  incurable.  The 
swelling  in  the  ankles  now  increased,  and  passed  up  the  legs  to  tlie  abdomen.  On 
the  1st  December  last  he  returned  to  the  Glasgow  Infirmary,  and  left  it  three  days 
ago.  without  having  experienced  any  rehef.  Since  then  his  urine  has  become  much 
diminished,  and  yesterday  it  was  entirely  suppressed. 

*  Reported  by  ilr.  Almeric  Seymour,  Clinical  Clerk. 


ANEURISM.  573 

Symptoms  on  Admission. — The  point  where  the  apex  of  the  heart  beats  cannot 
be  made  out ;  the  cardiac  impulse  is  not  felt  in  its  usual  position ;  and  the  cardiac 
sounds  are  inaudible  over  the  region  of  the  apex.  At  the  base  of  the  heart  the 
sounds  are  quite  healthy,  and  also  over  the  centre  of  the  sternum.  The  transverse 
cardiac  duluess  is  fully  four  inches.  There  is  an  unusual  dulness  above  the  left 
nifyple,  extending  over  a  space  about  the  size  of  the  palm  of  the  hand;  here  the  nor- 
mal cardiac  sounds  are  heard.  They  are  also  heard,  unaltered  in  character,  all  over 
the  manubrium  of  the  sternum  as  high  as  the  first  intercostal  space.  Pulse  G6,  very 
weak  and  irregular,  and  somewhat  stronger  in  the  right  wrist  than  in  the  left.  Over 
the  right  lung  percussion  is  normal ;  posteriorly  there  is  dulness  at  the  lower  two- 
thirds  of  the  left  side.  Loud,  sonorous,  and  sibilating  rales  audible  over  most  of  the 
chest  on  inspiration  and  expiration:  the  latter  movement  being  much  prolonged. 
Cough  troublesome,  and  accompanied  with  a  peculiar  crowing  sound.  Sputum 
froth}-,  gelatinous,  and  tinged  with  blood.  When  the  cough  comes  on  he  has  great 
dyspnoea,  and  respiration  is  accompanied  by  a  wheezing  laryngeal  sound.  He  can- 
not lie  upon  his  right  side,  from  a  sensation  of  choking  that  comes  on ;  he  feels 
easier  when  in  a  semi-erect  position,  or  on  the  left  side ;  dyspnoea  is  most  trouble- 
some at  night.  Tongue  moist  and  furred ;  appetite  good ;  has  a  feeling  of  oppressive 
tightness  in  the  epigastrium  after  taking  food ;  hepatic  duluess  four  inches ;  bowels 
rather  loose.  A  small  quantity  of  urine  has  been  passed  since  last  night ;  it  deposits 
a  pink  sediment,  which  clears  up  on  being  heated ;  sp.  gr.  1022.  The  whole  surface 
of  the  body  is  oedematous ;  abdomen  and  scrotum  much  distended ;  face  and  hands 
livid,  and  cold  to  the  touch ;  feels  cold  all  over  the  surface  of  the  body.  5  Infus. 
Digitalis  %  iss ;  Sp.  uEtlier.  Nitric.  3  iij ;  Acd.  Potassce.  3  iss ;  Aquoi  %  iv.  M.  One 
ounce  to  he  taken  three  times  a  day. 

Progress  of  the  Case. — January  'list  to  26lh. — Has  continued  the  above  mix- 
ture, and  was  ordered  to  apply  very  strong  infusion  of  digitalis  over  the  abdomen. 
The  anasarca  is  much  diminished,  fifty  ounces  of  urine  having  been  passed  within  the 
last  twenty-four  hours.  Hands  rather  cold.  Physical  signs  as  before  Pulse  120, 
of  better  strength.  No  diflerence  in  the  pulse  of  either  wrist.  The  cough  being 
very  troublesome,  last  night  he  was  ordered  a  mixture  containing  ^S^j.  JSther.  Xitric. 
and  Sul.  Mur.  Morphice.  Considerable  dyspnoea  after  taking  solid  food.  A  bed-sore 
has  formed  on  the  left  gluteal  region,  from  his  always  lying  on  that  side.  J^  Potassce 
Bitart.  3  j  quater  in  die.  Jan.  26ih  to  Feb.  1st. — The  dropsy  has  become  much  less, 
having  entirely  left  the  legs ;  the  size  of  the  abdomen  is  also  diminished ;  there  is 
more  anasarca  on  the  right  side  of  the  chest,  on  which  he  generally  lies,  than  on  the 
left.  On  one  occasion,  the  amount  of  urine  passed  amounted  to  150  ounces  in  the 
twenty-four  hours.  On  the  31st  he  had  great  pain  under  the  left  clavicle,  with  fric- 
tion at  the  base  of  right  lung ;  six  leeches  icere  ajyplied  over  the  painfid  sjmL  As  the 
cough  is  very  troublesome,  let  him  take  a  drachm  of  Tr.  Opii  Cam2}h.  at  bed-time. 
Continue  the  digitalis  internally,  but  stop  the  external  application.  Feb.  1st  to  &th. — 
Cough  has  been  very  troublesome,  but  has  been  relieved  by  opium,  Sp.  ^Ether.  Mt. 
and  chloroform  internally.  Gth. — The  cardiac  sounds  may  be  heard,  normal  in  cha- 
racter, over  the  right  side,  commencing  from  the  third  rib ;  the  impulse  may  also  be 
seen  and  felt  in  that  locality.  There  is  also  dulness,  which  may  be  observed  as 
high  as  the  top  of  the  sternum,  extends  in  a  sloping  direction  to  the  third  rib,  and 
can  be  elicited  down  the  whole  right  side.  Feb.  I5ih. — Almost  total  dulness  and 
want  of  expansion  over  the  left  side  before  and  behind ;  nor  is  any  respiration  heard 
except  at  the  apex.  Apply  a  blister  (6  by  5)  to  the  middle  and  inferior  part  of  the 
left  side.  Feb.  IGth  to  25fh. — On  the  16th  had  a  violent  paroxysm  of  coughing,  last- 
ing for  ten  minutes,  and  attended  with  profuse  purulent  expectoration.  Ordered  the 
following :—  1^  Misturoi  Scilke  §  v ;    Tr.  Opii  Camph.  3  j.     A  tabh-spoonful  to  be  taken 


57-1  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

vjhen  the  cough  is  urgent.  A  morphia  draught  at  bed-tirae.  These  remedies  relieved 
the  cough.  The  sputum  became  more  frothy  and  gelatinous.  He  also  slept  better. 
On  the  25th,  there  is  ahiiost  total  dulness  over  a  space  nearly  three  inches  in  dia- 
meter, in  the  left  sterno-clavicular  angle,  with  gradually  increasing  clearness  towards 
the  outer  subclavian  space.  There  is  no  respiration  in  the  former  region,  and  mode- 
rate natural  respiration  in  the  latter.  Over  the  rest  of  the  left  side,  in  front  and 
laterally,  percussion  is  very  dull,  and  respiration  all  but  absent.  There  is  general 
dulness,  and  very  feeble  respu-ation  in  the  upper  half  of  the  left  back,  with  prolonged 
sibilation  after  coughing ;  respiration  is  bronchial  and  feeble  in  the  lower  half  On 
the  right  side,  percussion  is  clear,  with  puerile  respiration,  both  before  and  behind, 
except  for  about  three  inches  to  the  right  of  the  upper  sternum,  where  percussion  is 
somewhat  dull  He  has  still  occasionally  a  difficult  and  copious  expectoration  of  a 
tough  mucous  matter.  Cardiac  sounds  natural,  except  a  very  slight  tendency  to 
reduplication  of  the  second.  Feb.  2oth  to  March  Ath  —Continued  in  much  the  same 
state  till  the  evening  of  March  3d,  when  another  fit  of  coughing  and  dyspnoea  came 
on.  Sulphuric  tether,  and  others  of  the  medicines  mentioned  above,  were  adminis- 
tered.    He  sunk,  however,  and  died  at  half-past  11  a.m.,  March  4th. 

Sectio  Cadaveris. — Forty-eiyht  hours  after  death. 

Thorax. — The  pericardium  was  much  distended,  and  contained  12  oz.  of  clear 
serum.  Its  lining  membrane  was  very  hard  in  soaie  places,  from  the  presence  of 
chronic  lymph.  The  heart  and  its  valves  were  health3^  Between  the  arteria  inno- 
minata  and  the  left  carotid  was  a  small  dilatation  of  the  arch.  Immediately  below 
the  origin  of  the  left  subclavian,  an  aneurism,  the  size  of  a  large  orange,  of  rounded 
form,  and  three  inches  in  diameter,  originated  from  the  aorta  by  a  thick  neck.  It 
pressed  forward  and  to  the  left  side,  immediately  above  the  pericardium,  slightly 
compressing  the  trachea  and  left  bronchus.  The  recurrent  nerve  was  seen  to  pass  in 
front  of  the  aneurism  uninjured.  On  examination  of  the  aneurism,  it  was  found  that 
the  internal  and  middle  coats  of  the  aorta  had  given  way,  the  pouch  being  formed  of 
the  outer  coat,  and  of  condensed  areolar  tissue.  Above  the  aortic  valves,  and  over 
the  arch,  the  inner  layers  of  the  vessel  were  atheromatous.  In  the  cavity  of  the 
left  pleura  were  two  pints  of  serum  and  some  chronic  bands  of  lymph.  The  left  lung 
was  universally  condensed,  and  on  section  was  seen  to  contain  a  large  quantity  of 
tubercle,  generally  in  masses  the  size  of  a  pea  and  larger.  Some  of  these  had  sof- 
tened, but  there  was  no  cavity.  The  intervening  pulmonary  tissue  was  condensed 
and  hepatised.  Rigiit  lung  was  voluminous,  with  a  few  miliary  tubercles  scattered 
through  it. 

Abdomex. — Abdominal  organs  healthy. 

Commentary. — In  this  case  during-  life  it  was  carefully  determined 
that  the  cardiac  sounds  were  healthy,  that  the  cardiac  dulness  was  in- 
creased to  twice  its  normal  extent,  and  that  there  was  unusual  dulness 
above  the  left  iiipi)le  in  the  sterno-clavicular  region.  These  facts  were 
subsequently  explained  by  the  demonstration,  on  dissection,  of  a  healthy 
heart,  of  chronic  pericarditis  with  effusion,  and  of  a  large  aneurism 
springing  from  the  transverse  aortic  arch,  stretching  towards  the  left 
side.  Over  the  aneurism  in  this  case  no  sounds  were  audible,  a  circum- 
stance probably  attributable  to  the  thick  neck,  by  which  it  came  oif  fi'om 
the  main  vessel,  as  explained  in  the  last  commentary.  The  limb,  whicli 
was  the  seat  of  the  popliteal  aneurism  cured  by  compression,  was  sub- 
sequently injected  and  dissected  with  care,  and  may  be  now  seen 
forming  a  very  tine  preparation  in  the  surgical  collection  of  Mr.  Spence 


ANEURISM.  575 


of  this  citv.     The  popliteal  artery  is  completely  occluded,  the  circula- 
tion having  been  maintained  through  the  enlarged  anastomosing  vessels. 


Case  CXII.* — Aneurism  of  Loiver  Portion  of  the  Thoracic  Aorta,  pressing  on  the 
Thoracic  Duct — Aneurism  of  Abdominal  Aorta — Chronic  Ulcer  of  Stomach — 
Chronic  Tubercular  Abscesses  of  Liver  and  Riijht  Kidney — Liver  and  Left,  Kidney 
Waxy — Leucocythemia. 

History. — Janet  Young,  act.  50 — admitted  June  16lh,  1854.  States  that  her 
appetite  has  been  impaired  for  the  last  three  years,  that  she  has  been  subject  to 
chronic  rlieumatism,  and  last  September  had  a  severe  bowel  complaint,  which  lasted 
fourteen  weeks.  For  the  last  ten  years  has  suffered  from  vomiting,  which  has  been 
more  or  less  constant,  and  the  matters  ejected  have  occasionally  been  of  a  dark  cop- 
per colour.     Since  the  occurrence  of  the  diarrhoea  she  has  become  very  emaciated. 

Symptoms  on  Admission. — The  whole  body  is  extremely  emaciated,  and  she  is 
very  weak.  Tongue  moist  and  clean.  Appetite  pretty  good.  No  vomiting  at 
present.  Complains  of  pain  and  tenderness  in  the  epigastrium,  and  on  palpation 
a  distinct  tumour  can  be  felt,  with  a  strong  impulse,  a  little  to  the  right  of  the 
mesian  line  in  the  position  of  the  pylorus.  It .  is  apparently  solid,  of  uneven  shape, 
about  the  size  of  a  hen's  egg ;  but  its  limits  cannot  be  accurately  determined.  On 
auscultation  over  the  tumour  a  loud  blowing  sound,  synchronous  with  the  aortic 
pulse,  is  audible.  Bowels  regular.  Apex  of  heart  beats  between  sixth  and  seventh 
ribs.  Its  size  and  sounds  are  normal.  Pulse  88,  of  good  strength.  Urine  pale,  sp. 
gr.  1010,  slightly  coagulable  on  the  addition  of  heat  and  nitric  acid.  Respiration 
and  other  s3'mptoms  normal.     Ilabeat  Tr.  lodid.  Ferri  min.  x.  ter  indies. 

Progress  of  the  Case. — On  the  19th  of  June  she  commenced  vomiting,  a  symp- 
tom which  continued,  with  slight  intermissions,  during  the  rest  of  the  month,  gene- 
rally coming  on  four  hours  after  taking  a  meal.  There  was  also  considerable  pain 
in  the  region  of  the  tumour,  which  was  relieved  by  the  occasional  application  of  two 
leeches,  followed  by  warm  fomentations.  Various  remedies  were  given  with  a  view 
of  checking  the  vomiting,  of  which  small  pieces  of  ice  allowed  to  dissolve  in  tlie 
mouth  appeared  most  effectual.  Nourishment  was  frequently  given  in  small  quan- 
tities. During  the  months  of  August  and  September,  the  vomiting  became  far  less 
frequent,  although  occasionally  still  distressing.  All  this  time  nutrients  were  con- 
stantly administered  with  wine,  and  although  these  were  frequently  retained,  and 
even  taken  with  appetite,  the  emaciation  progressively  increased.  On  examining 
the  blood,  it  was  found  to  possess  an  increased  number  of  colourless  corpuscles.  A 
series  of  observations  also  was  made  to  determine  whether  fat  was  passed  in  the 
foeces,  but  they  were  quite  healthy,  and  the  bowels  on  the  whole  were  regular. 
She  also  slept  well.  During  the  months  of  September,  October,  and  November,  she 
remained  much  in  the  same  condition,  occasionally  complaining  of  a  little  more  local 
pain  in  the  epigastric  tumour  and  abdomen,  and  latterly  of  cough  and  palpitation. 
For  the  next  three  months,  there  was  at  times  severe  vomiting,  but  otherwise  no 
marked  change.  The  urine  remained  coagulable  and  of  low  specific  gravity,  occa- 
sionally presenting  under  the  microscope  a  few  waxy  casts  and  pus  corpuscles. 
During  March  the  emaciation  was  apparently  extreme,  the  pulse  weak,  and  nutritive 
injections  by  the  rectum  were  added  to  the  nutrients  and  wine  given  by  the  mouth. 
The  vomiting  was  greatly  diminished,  but  for  some  days  she  suffered  from  conjunc- 
tivitis.    There   was   also   restlessness   at  night,  which  was    relieved  by  morphia 

*  Reported  by  Mr.  T.  Walker,  Clinical  Clerk. 


576  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

draughts.     Her  weakness  very  gradually  increased,  and  without  any  other  symptom 
she  expired,  April  16th,  1855. 

Sectio  Cadaveris. — Forty  hours  after  death. 

Thorax. — Both  lungs  had  some  puckerings  near  the  apex,  and  contained  some 
old  tubercular  matter.  The  heart  was  healthy.  Near  the  lower  part  of  the  thoracic 
aorta  was  an  aneurismal  dilatation,  about  the  size  of  a  walnut,  which  projected  to 
the  left  of  the  vertelDral  column,  directly  over  the  thoracic  duct,  which  it  appeared 
to  compress. 

Abdomen. — Arising  from  the  anterior  part  of  the  abdominal  aorta,  at  the  root  of 
the  coeliac  axis  and  superior  mesenteric  artery,  was  an  aneurism  of  a  rounded  form, 
about  two  inches  in  diameter,  which  projected  forwards,  and  was  nearly  filled  with 
firm  layers  of  fibrin.  Both  the  vessels  named  were  thrust  forward,  separated  to  the 
extent  of  an  incii,  but  were  in  themselves  healthy.  (University  Museum,  Prep. 
2333,  a.)  The  stomach  was  of  natural  size;  on  its  lesser  curvature,  about  halfway 
between  the  cardiac  and  pyloric  orifices,  but  rather  nearer  the  latter,  there  was  an 
ulcer  of  an  oval  form  with  depressed  surface,  callous  margin  and  base,  and  about  the 
size  of  a  filbert.  The  edges  were  smooth,  as  dense  as  ligament,  presented  on 
section  a  white  glistening  appearance,  and  in  some  places  were  a  quarter  of  an  inch 
thick.  The  fiver  weighed  2  lbs.  On  section  it  contained  a  number  of  masses  of 
tubercular  matter.  Some  of  them  had  softened  and  given  rise  to  abscesses.  The 
hepatic  tissue  itself  was  waxy.  The  right  kidney  was  very  small,  being  2^  inches 
long  and  IJ  inch  broad.  On  section  there  escaped  a  yellowish  white  fluid  and 
some  cheesy  matter.  The  tissue  of  the  kidney  was  quite  gone,  and  its  place  sup- 
plied by  the  cavities,  which  presented  the  usual  appearance  of  scrofulous  abscesses. 
This  kidney  weighed  one  ounce.  The  left  kidney  was  of  large  size  and  waxy.  The 
spleen  was  natural. 

Commentary. — On  the  admission  of  this  woman  it  became  a  question 
whether  the  tumour  in  the  pyloric  region  was  an  aneurism  or  a  can- 
cerous mass  lying  over  the  aorta.  The  symptoms  were  those  of  organic 
disease  of  the  stomach.  As  the  disease  progressed  and  the  emaciation 
became  more  urgent,  the  tumour  could  be  more  easily  handled,  and  its 
rounded  form  and  marked  impulse  favoured  the  opinion  of  its  being 
aneurismal.  The  frequent  vomiting,  however,  still  pointed  to  disease  of 
the  stomach,  and  served  to  explain  much  of  the  emaciation  which 
existed,  but  not  altogether,  as  it  was  observed,  that  she  still  retained  a 
considerable  amount  of  nourishment,  especially  at  some  lengthened 
periods  when  the  stomach  was  quiescent.  The  idea  was  then  formed 
that  there  might  be  some  disease  at  the  head  of  the  pancreas  ;  but, 
after  careful  examination,  no  unusual  amount  of  fat  could  be  detected  in 
the  stools.  Latterly  the  vomiting  was  comparatively  trifling,  but  still 
the  emaciation  was  progressive,  and  became  at  length  extreme.  On 
dissection  after  death,  these  facts  were  explained  by  the  discovery  of  a 
small  thoracic  aneurism  pressing  upon  the  thoracic  duct  in  addition  to 
the  abdominal  one,  which  had  become  rounder  and  harder  than  when 
first  discovered.  The  lungs  and  liver  exhibited  well-marked  examples 
of  tubercular  and  scrofulous  deposits  which  had  been  arrested  in  their 
progress.  The  diminution  of  the  stomachic  symptoms  also  Avas 
accounted  for  by  the  gradual  healing  and  cicatrization  of  the  gastric 
ulcer.  It  might  have  been  supposed  that  the  abdominal  aneurism  was 
progressing  towards   a   spontaneous  cure,   as   it  was  nearly   filled  with 


ANEURISM.  577 

dense  coagulated  fibrin.  The  commencement  of  a  tlioracic  aneurism 
above,  however,  sufficiently  accounts  for  this,  as  will  be  explained  more 
particularly  in  the  commentary  on  the  next  case. 


Case  CXII.*— Aneurism  of  the  Superior  Mesenteric  Artery  and  Aorta — Obscure 
Aneurism  of  Descending  Thoracic  Aorta — Treatment  hy  the  Method  of  Valsalva — 
Pleuritis — Caries  of  the  Vertebrce,  Softening  of  the  Spinal  Cord  and  ParapUgia — 
SvAden  Death  hy  Poisoning  with  TiiKture  of  Aconite. 

History. — Henry  Smith,  eet.  3.5,  sailor — admitted  December  19th,  1849.  States 
that,  about  twelve  months  ago,  while  at  sea,  he  received  a  severe  blow  on  the  back 
from  the  tiUer  of  the  vessel  He  was  knocked  down,  and  lay  insensible  for  a  short 
time.  Since  then  he  has  experienced  pain  in  the  abdomen  and  back,  and  latterly 
pulsation  in  the  abdomen,  and  a  sensation  of  tingling  and  numbness  in  the  thighs, 
legs,  and  feet,  especially  on  the  left  side.  States  that  about  three  weeks  aftpr  the 
accident,  he  was  admitted  into  tlie  Liverpool  Inlirmary,  where  he  remained  for  about 
eleven  months.  He  was  treated  by  opiates  and  other  anodynes,  and  latterly  also  by 
leeching  and  cupping  over  the  pained  part  of  the  abdomen.  From  this  treatment  he 
did  not  receive  much  benefit. 

Symptoms  ox  Admission. — On  admission,  he  is  of  a  dark  complexion ;  appearance 
strong  and  robust.  A  tumour  is  distinctly  seen  pulsatmg  in  the  left  hypochondriac 
region.  It  is  of  an  oval  form,  and  measures  about  three  inches  transversely ;  its 
long  diameter  cannot  be  ascertained,  as  its  superior  portion  ascends  below  the  ribs ; 
but  the  inferior  and  lateral  margins  can  be  distinctly  felt.  He  complains  of  great 
pain  and  tenderness  in  the  region  of  the  tumour,  and  of  a  beating  wliich  is  increased 
on  exertion,  and  also  upon  assuming  the  erect  posture.  He  feels  easiest  when  lying 
doubled  up,  resting  on  his  elbows  and  knees,  and  in  this  position  he  is  generally 
seen  durmg  the  day.  The  pulsation  of  the  tumour  is  forcible,  synchronous  with,  or 
immediately  succeeding,  the  heart's  impulse.  On  auscultation,  a  soft  bellows  mur- 
mur is  distinctly  heard  over  the  tumour,  and  is  loudest  at  the  lower  part.  The  apex 
of  the  heart  beats  about  an  inch  below  the  nipple.  Impulse  tolerably  strong.  On 
percussion,  the  cardiac  dulness  extends  transversely  about  two  and  a  half  inches. 
On  auscultation,  the  sounds  are  normal  in  character ;  the  first  is  heard  loudest  over 
the  apex,  just  below  the  nipple ;  and  the  second  is  most  distinct  at  least  three  inches 
above  and  to  the  inside.  He  has  no  cough  or  expectoration.  The  right  side  of  the 
chest  is  more  resonant  on  percxission  than  the  left,  both  in  front  and  behind.  On 
auscultation,  the  respiratory  murmurs  are  normal  Appetite  tolerably  good.  Bowels 
regular.  Urine  natural  in  quantity;  sp.  gr.  1-025,  not  coagulable;  presents  a 
deposit  of  Uthate  of  ammonia.      Ordered  a  morphia  draught  at  night. 

Progress  of  the  Case. — December  23d. — Has  never  slept  properly  since  his 
admission.  States  that  it  requires  a  very  large  opiate  to  produce  any  efiect  upon 
him.  Ordered  to  be  bled  to  syncope,  and  his  diet  to  be  as  follows : — Breakfast,  Bread, 
four  ounces ;  milk,  eight  ounces.  Dinner,  Steak,  two  ounces ;  bread,  two  ounces. 
Supper,  Bread,  two  ounces ;  tea,  eight  ounces.  24tt. — He  was  bled  to  thirty  ounces, 
without  syncope  or  nausea  being  induced.  The  blood  drawn  exhibits  a  distinct 
buffy  coat.  Pulse  88,  weak  and  soft.  Pain  easier,  and  sleeps  better  at  night. 
2Mh. — Dislikes  beef  for  dinner,  and  would  prefer  a  little  rice  pudding  with  the 
oread  at  dinner.  To  have  one  ounce  of  mutton,  and  three  ounces  of  rice  pudding  for 
dinner.     Twelve  leeches  to  be  applied  over  the  tumour.     26th. — Leeches  bled  freely, 

*  Reported  by  Messrs.  H.  M.  Balfour.  TV.  Clark,  and  A.  Dewar,  CHnical  Clerks. 

37 


578  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

and  he  is  now  easier.  Urine  still  presents  a  deposit  of  lithates.  30^^.— Complains 
of  constipation ;  pain  in  abdomen  rather  increased.  To  have  Elect  Senna,  3  j  daily. 
Ten  leeches  to  be  applied  to  tJie  region  of  the  tumour.  3lst. — Leeches  did  not  bleed  so 
well     Paul  stQl  severe.     Applicet.  Emplast.  Cantharid.  (3x3)  2Mrii  dolenti. 

1850,  January  2d. — Blister  gave  some  relief  Pulse  stronger.  Ordered  to  he  hied 
to  §  xij.  3d — The  blood  exhibited  the  Ijuffy  coat,  but  in  a  less  marked  degree  than 
formerly.  No  faintness  or  nausea  was  induced.  Tivo  ounces  of  bread  to  be  taken  off 
his  breakfast  and  half  an  ounce  off  his  supper.  To  be  allowed  a  bottle  of  lemonade  daily. 
1th. — Sleeps  very  badly.  5  Sol.  Mur.Morph.;  Tinct.  Eyoscyam.  a.a.,  3ss;  Aqua 
3ss.  M.,  to  he  taken  every  evening,  dth. — Sleeps  rather  better.  Pain  in  tumour 
somewhat  increased.  Eight  leeches  to  be  applied.  lOth. — Leeches  gave  relief  13th. — 
Still  complains  of  constipation,  lb  have  a  cohcynth  and  hyoscyamus  pill  daily. 
IQth. — States,  that  for  the  last  three  or  four  days  he  has  felt  much  stronger,  and  the 
pain  and  pulsation  in  the  tumour  have  increased  proportionally.  Ten  leeches  to  be 
applied.  I'tth. — Leeches  gave  relief,  but  stUl  he  does  not  sleep  weU.  21s/. — Pulse 
tolerably  strong.  Ordered  to  be  bled  to  syncope.  22d. — He  was  bled  yesterday  to 
twenty-six  ounces,  without  mducing  faintness  or  nausea.  To-day  his  pulse  is  weak 
and  soft,  and  he  expresses  himself  much  easier.  The  blood  exhibited  a  distmct 
buflfy  coat.  Urine  loaded  with  lithates  2bth. — Yesterday  he  was  ordered  to  be 
bled  until  some  faintness  was  induced,  and  28  oz.  were  abstracted  before  that  effect 
was  occasioned.  To-day  the  blood  is  cupped,  the  pulse  weak,  and  the  urine  loaded 
with  lithates.  A  chloroform  draught  at  night.  2dth.— Again  bled  to  10  oz.  Feb. 
Sth. — Great  pain  in  the  tumour  at  night,  preventing  sleep,  for  which  sedative 
draughts  and  enemas  afford  little  reUef.  20  oz.  of  blood  were  in  consequence  taken  from 
the  arm  to-day,  which  produced  faintness,  and  at  once  removed  the  pain.  \^th. — 
Size  and  unpulse  of  tumour  evidently  dimmished.  Does  not  think  he  is  much 
weaker  since  admission,  but  is  unable  to  sit  up  so  long.  Pulse  small.  To-day  pain 
returned  in  tumour.  12  leeches  to  he  applied.  March  2d. — Bled  yesterday  to  14  oz., 
without  inducing  syncope.  Blood  not  buffed.  IQth. — Pam  returned  with  violence. 
Again  bled  to  23  oz.  I9th. — Again  bled  to  8  oz.  He  has  continued  on  the  low  diet, 
which  was  altered  to-day  as  foUows: — Breakfast,  1  biscuit  (1^  oz.),  tea,  half  a  pint; 
Dinner,  2  biscuits  (2^  oz.),  eggs  2;  Supper,  1  biscuit  (IJ  oz.),  tea,  half  a  pint.  The 
analysis  of  the  blood  drawn  on  the  19th  is  as  follows: — 

Specific  gravity  of  serum        .         .         .         .         .  1028 

SoUds  in  1000  parts :— 

Fibrin 4-6 

Globules 42-7 

Serous  solids 88-2 

Water 864-5 

1000 

Ajwil  Gth.—Bled  again  to  13  oz.  loth. — Was  strong  enough  to  walk  in  the  back- 
green,  but  felt  exhausted  after  it.  21s^ — Bled  yesterday  to  34  oz.,  at  his  urgent 
request,  insisting  that  he  felt  nothmg,  until  he  fell  back  in  a  state  of  syncope,  from 
which  he  slowly  recovered.  To-day  appearance  anemic,  pulse  feeble,  feels  weak. 
May  5th. — Has  been  suffering  from  constipation,  which  has  been  relieved  by  colo- 
cynth  and  henbane  pills.  Pulsation  in  the  tumour  evidently  diminishing.  To-day, 
complains  of  shooting  pains  in  the  back,  between  the  shoulders,  and  do-mi  the  arms. 
As  he  dislikes  the  eggs,  4  oz.  of  calves'-foot  jelly  were  ordered  instead,  the  other 
articles  of  diet  remaining  the  same.  June  1st. — Considerable  pain,  and  no  sleep  for 
three  days.     8  leeches  to  he  applied.     11  ih. — 2  oz.  of  meat  instead  of  the  calves'-foot 


ANEURISM.  579 

jelly.  July  \1tli. — Has  occasionally  been  walking  a  little  in  the  open  air,  which, 
however,  causes  some  pain.  Apply  12  leeches.  Aug.  dih. — Pain  on  walking,  caused 
by  hemorrhoids,  for  wluch  injections  of  cold  water  have  been  ordered  with  benefit. 
IGlh. — Pain  in  tumour  returned.  Apply  12  leeches^  which  caused  fahitness,  for 
which  3  ij  of  ivine  were  given.  30th. — Went  out  of  the  house  yesterday  by  per- 
mission. Oct.  20th. — Has  been  allowed  to  go  out  of  the  house  once  a-week  for 
exercise.  To-day  pain  in  tumour  severe.  Apply  8  leeches.  2oih. — The  tumour  was 
observed  to  be  movable  to-day.  "When  he  lies  on  his  left  side,  the  prominence  is 
concealed  below  the  cartilages  of  the  ribs,  but  when  he  turns  on  his  back,  it  moves 
three  or  four  inches  towards  the  right  side.  He  says  he  has  only  noticed  this  mobility 
during  the  last  week.  A'ov.  20th. — Complains  of  a  sharp  pain  under  the  left  clavicle, 
and  six  leeches  were  applied  there  in  consequence.  2Gih. — Pain  under  clavicle  con- 
tinues, but  was  removed  by  cupping  on  the  22d  and  to-day.  Dec.  2~tth. — Bled  to  z viij, 
to  remove  pain  in  tumour. 

1851,  February  nth. — Since  last  report,  has  continued  to  feel  pain  in  the  tumour. 
Again  bled  to  3  viij.  20</t.— Present  diet :  Breakfast,  one  roll  and  tea ;  Dinner,  part 
of  a  fowl  and  two  potatoes;  SupjJer,  one  roil  and  tea,  wine  |iv.  The  tumour  now 
feels  hard  and  solid,  is  the  size  of  a  pigeon's  egg.  March  30th. — Bled  to  §  vj. 
Aj)ril  2d.— Bled  to  3  xij.  The  bleeding  generally  relieved  the  severity  of  the  pain, 
but  on  this  occasion  failed  to  do  so,  and  a  blister  ivas  applied.  May  2d. — Bled  to  3  x, 
with  relief  30^*. — 17  leeches  were  applied.  June  Ist.—l^o  relief  followed  the  appli- 
cation of  leeches.  To  be  cupped  on  the  back  to  §  vj.  June  Sth. — Pain  not  diminished, 
and  he  was,  bled  to  §  xij,  which  caused  great  relief.  24:ih. —  Cupped  to  3  viij.  20ih. 
— Bled  to  5  xij.  Oct.  29</i.— Bleeding  has  been  occasionally  resorted  to,  to  relieve 
pain ;  otherwise  he  has  remained  the  same.  Diet  at  present  is :  Breakfast,  one  roll 
and  a  pint  of  tea ;  Dinner,  one  flounder  and  two  potatoes ;  Supper,  one  roll  and  a 
pint  of  tea,  brandy  §  iij.  Dec.  \2tli — Since  last  report  has  been  comparatively  easy, 
getting  up  daily,  and  feeling  pain  only  for  about  two  hours  after  rising  in  the  morn- 
ing.    To-day,  the  pain  having  increased,  12  leeches  were  applied. 

1852,  January  lOih. — Complains  of  weakness,  so  that  he  is  obliged  to  use  a  stick 
in  walking.  15th. — Tumour  fully  the  size  of  a  walnut.  Aueurismal  murmur  greatly 
diminished.  Complains  of  numbness  in  left  side,  and  pain  in  right  leg.  Walking  is 
more  difficult.  Bled  to  §  viij.  23d. — Weakness  in  lower  extremities  during  walking 
increased.  On  the  29th,  was  seized  with  general  coldness,  without  distinct  rigor. 
He  had  also  severe  pain  in  the  left  side  of  the  chest,  increased  on  inspiration.  SOth. 
— There  is  frequent  cough,  and  copious  expectoration  not  tinged  with  blood.  The 
left  shoulder  is  also  very  painful.  Skin  hot,  total  loss  of  appetite,  great  thirst,  pulse 
feeble,  great  prostration.  On  percussion,  the  whole  of  the  left  side  of  the  chest  is 
dull  throughout.  On  auscultation,  the  respiration  is  feeble  superiorly,  and  inaudible 
inferiorly.  A  friction  noise  is  heard  external  to  the  nipple.  No  crepitation  can  be 
discovered  anteriorly  or  posteriorly.  Mi.ciure  of  ipecacuanha  and  morpthia  ordered. 
31s<.— Cough  and  pain  diminished.  Feb.  2d— Sputum  slightly  tinged  with  blood. 
4,i]i_ — Cough  and  expectoration  diminished.  Sputum  consistent,  free  from  blood. 
Friction  still  present  anteriorly,  oegophony  posteriori}-.  Mi. — Return  of  pain  in  chest 
and  shoulder.  Physical  signs  the  same.  Blister  to  left  side.  \Qth. — Dulness  less 
below  left  clavicle,  and  slight  motion  of  ribs  observed  there  during  respiration. 
March  Ist. — Friction  now  audible  over  the  whole  of  left  side  of  chest  posteriori}', 
and  over  apex  of  lung  anteriorly.  Percussion  clear  over  upper  third  of  lung,  but 
still  completely  dull  inferiorly.  Pain,  cough,  and  febrile  symptoms  have  now  disap- 
peared. A  bed  sore  has  formed  in  the  sacral  region,  which  has  been  poulticed,  and 
now  exhibits  a  disposition  to  slough.  The  abdominal  aneurism  has  undergone  no 
change.     Decided  paralysis  of  motion  in  the  inferior  extremities,  but  their  sensibility 


580 


DISEASES   OF   THE   CIRCULATORY   SYSTEM. 


is  unaffected.  2IaTch  8ih. — Slough  has  separated  from  sacrum.  Ajml  8rt.— Since 
last  report,  paralysis  in  inferior  extremities  has  become  complete.  He  has  lost  all 
voluntary  power  over  them,  and  when  they  are  pinched  or  pricked,  no  sensation  is 
produced.  He  experiences,  however,  twitchings  and  startings  in  the  paralysed 
limbs,  but  no  pain.  His  evacuations  are  passed  in  bed,  and  the  sore  on  the  sacrum 
continues  to  discharge.  In  this  state  he  continued  until  May  31st. — the  lower  limbs 
paralysed,  but,  with  the  exception  of  increasing  weakness,  much  the  same  as  at  last 
report.  To-day  he  swallowed  a  considerable  portion  of  a  liniment,  containing  one- 
fourth  its  volume  of  tincture  of  aconite.  He  rapidly  became  pulseless.  The  intelli- 
gence, for  three  or  four  minutes,  was  unaffected.  The  respiration  was  embarrassed, 
and  he  was  dead  in  a  period  variously  estimated  at  from  five  to  seven  minutes. 

Sectio   Cadaveris. —  Twenty-Jive  hours  after  death. 

Thorax.— General  firm  adhesions  between  pleurae  on  the  left  side;  on  the  right 
side,  slight  adhesions  between  pleurae  at  the  apex.  The  pericardium  contained  three 
and  a  half  ounces  of  straw-coloured  serum ;  the  blood  everywhere  fluid ;  heart 
healthy;  right  lung  mostly  crepitant,  with  considerable  induration  and  puckering  at 
the  apex.  On  section,  several  cretaceous  encysted  concretions  existed  in  the  pul- 
monary tissue  at  the  apex,  surrounded  by  considerable  carbonaceous  deposit.     Here 

and  there  also  small  portions  of  the  lungs 
were  collapsed.  The  left  lung  somewhat 
compressed  posteriorly,  but  otherwise  cre- 
pitant, and  apparently  normal.  It  is  at- 
tached at  the  posterior  part  of  lower  lobe 
to  a  sacculated  tumour,  the  size  of  a  foetal 
head,  in  front  of  the  dorsal  vertebrae,  evi- 
dently arising  from  the  descending  aorta. 
The  tumour  is  situated  more  to  the  left 
than  to  the  right  side,  and,  on  being  cut 
into,  is  found  to  be  only  partially  filled  Avith 
recently  coagulated  blood.  At  that  part  of 
the  sac  which  is  adherent  to  the  lungs,  its 
wall  is  strengthened  by  the  deposition  of 
fibrin  in  laminae,  the  whole  at  its  thickest 
part  being  an  inch  thick.  The  bodies  of 
the  5th,  6th,  7th,  and  8th  dorsal  vertebrte 
were  to  a  great  extent  absorbed,  being  ap- 
parently scooped  out,  leaving  the  interver- 
tebral cartilages  prominent  between  them. 
The  caries  had  also  affected  the  heads  of  the 
corresponding  ribs  on  the  left  side.  Pos- 
teriorly the  tumour  had  projected  about  an 
inch,  presenting  an  oval,  rounded  surface, 
which  had  compressed  the  spinal  cord 
for  about  an  inch  and  a  half  of  its  length 
opposite  the  8th  and  9th  dorsal  vertebrae. 
On  removing  and  bisecting  the  cord,  its 
medullary  substance  at  the  compressed  portion  was  somewhat  softened,  an  alteration 
much  more  marked  for  two  inches  both  above  and  below,  where  it  was  pultaceous, 


Fig.  4-26. 


F\<y.  426.  Yiew  of  the  thoracic  and  abdominal  aneurisms,  the  cai'ious  vertebrte,  etc. 


aneurism:.  581 

gradually  passing  into  the  spinal  medullaiy  matter  of  normal  consistence.  The 
softening  was  white  tliroughout,  with  no  red  spots. 

ABDOiiEX. — The  pancreas  is  stretched  over  an  abdominal  tumour,  the  size  of  a 
small  cocoa-nut,  in  front  of  the  aorta,  which  is  moveable,  and  tolerably  resistent  and 
firm.  The  stomach  was  healthy,  and  about  a  third  full  of  pultaceous  lumpy  matter 
smelling  strongly  of  linimentum  saponis.  The  other  abdominal  organs  were  healthy. 
On  dissecting  the  tumour,  it  was  ascertained  to  be  an  aneurism  formed  at  tue  root 
of  the  superior  mesenteric  artery,  and  partly  involving  the  anterior  wall  of  the 
descending  aorta.  It  was  of  an  oval  shape,  with  one  extremity  resting  on  the 
vertebrae,  the  other  lying  immediately  below  the  integuments.  Its  long  diameter 
measured  four,  and  its  transverse  three  inches.  On  taking  off  a  thin  slice  on 
the  left  of  the  tumour,  so  as  not  to  interfere  with  the  exit  of  the  mesenteric  artery, 
it  was  seen  to  be  almost  whoDy  occupied  by  concentric  layers  of  fibrin,  except 
where  a  channel,  larger  near  the  aorta,  but  becoming  smaller  at  its  distal  extremity, 
allowed  a  free  communication  of  blood  with  the  efferent  vessel,  Fig.  423.  (University 
Museum,  Prep  2229.) 

Microscopic  Examixatign'. — Portions  of  the  spinal  cord  when  examined  under 
the  microscope,  with  a  power  of  250  diameters  linear,  were  everywhere  ascertained 
to  consist  of  broken-up  medullary  tubes.  Many  of  the  varicosities  liad  enlarged 
and  separated,  forming  round,  oval,  and  variously-shaped  transparent  corpuscles, 
with  double  lines,  mixed  with  fragments  of  the  tubes,  and  numerous  molecules, 
granules,  oil  globules,  and  broken-down  ganglionic  cells.  Xo  granular  corpuscles 
were  anywhere  visible. 

Commentary. — Tins  ca>e  was  in  the  Infirmary  two  years  and  a  half, 
and  during  the  whole  of  that  time  its  progress  excited  unusual  interest. 
We  had  to  do  with, — Is/,  A  thoracic  aneurism  ;  2d,  An  aneurism  of  the 
superior  mesenteric  artery  ;*  3tZ,  The  treatment  of  aneurism  by  Val- 
salva's method ;  4/^,  Acute  passing  into  chronic  pleurisy  ;  5 /A,  Gradually 
increasing,  and  at  length  complete  paraplegia;  and  6//i,  Poisoning  by 
aconite,  and  the  most  rapid  death  by  that  drug  on  record.  I  shall  notice 
the  principal  facts  of  his  case  in  succession,  point  out  the  difficulties  of 
the  diao-nosis,  the  effects  of  the  treatment  employed,  and  state  what 
occurs  to  me  with  regard  to  the  mode  of  his  death. 

The  Thoracic  Aneurism. — The  thoracic  aneurism  in  Smith's  case  was 
not  suspected  during  life.  On  looking  back  upon  the  facts  observed 
when  he  was  admitted,  I  find  that,  after  receiving  the  injury  which  pro- 
duced the  disease,  he  complained  of  pain  in  the  back,  as  well  as  the 
abdomen.  It  is  also  stated  that,  when  admitted  into  the  Infirmary,  "the 
right  side  of  the  chest  is  more  resonant  on  percussion  than  the  left,  both 
in" front  and  behind."  These  facts  were  too  vague  at  the  time  to  enable 
me  to  distinguish  a  thoracic  aneurism  in  addition  to  the  abdominal  one, 
more  especially  as  the  respiratory  murmurs  were  normal ;  there  was  no 
cough,  expectoration,  or  other  pulmonary  lesion.  The  idea,  therefore, 
of  a  thoracic  aneurism  never  occurred  to  me,  nor  if  it  had  is  it  likely 

*  For  other  cases  of  aneurism  of  the  superior  mesenteric  artery,  see  case  by  Dr. 
Donald  Monro,  in  "  Observations  on  Aneurism."  by  the  Sydenham  Society,  p.  130 :  by 
Dr.  EUiotson,  in  Lancet,  August  29,  183.5;  by  Dr.  Arthur  Wilson,  Medico-Chir. 
Transactions,  vol.  24 ;  by  Mr.  James  Douglas,  in  Medical  Gazette,  February  25.  1842  : 
by  Dr.  "W  Gairdner.  inMonihly  Journal  of  Med.  Science,  January.  1850;  by  Dr. 
John  Ogle,  in  Trans,  of  Patholog.  Soc,  vol.  8 ;  and  by  Dr.  Haldane,  in  Edinb.  Med. 
Journal,  October,  1858. 


582  DISEASES   OF  THE   CIKCULATOEY  SYSTEM. 

that  it  conld  have  been  confirmed,  altliough  now,  on  looking  back,  tbe 
importance  of  tlie  facts  above  stated  is  apparent,  and  they  prove  that  such 
aneurism  really  existed  when  he  first  came  into  the  house.  On  going 
over  the  reports  which  were  kept  of  his  progress  during  the  two  years 
and  a  half  he  was  in  the  infii-mary,  I  find  it  stated  that,  on  the  6th  of 
April,  when  under  the  care  of  Dr.  Christison,  he  "complained  of  shoot- 
ino-  pains  in  the  back,  between  the  shoulders,  and  down  the  arms."  On 
the  20th  of  November,  in  the  same  year,  when  under  Dr.  Alison's  care, 
he  "complained  of  a  sharp  pain  under  the  left  clavicle."  On  both  occa- 
sions the  pain  was  of  short  duration.  I  can  find  no  other  symptoms 
which  could  be  attributed  to  the  thoracic  aneurism  until  the  29th  of 
January,  1852,  when  he  was  seized  with  all  the  symptoms  of  acute 
pleurisy.  For  a  long  time  previously  his  chest  had  not  been  examined, 
but  when,  on  this  occasion,  it  was  percussed,  the  whole  of  the  left  side 
was  found  to  be  dull,  both  anteriorly  and  posteriorly.  This,  as  well  as 
all  the  other  symptoms  noticed  at  that  time,  was  ascribed  to  pleurisy 
witli  a  large  amount  of  exudation,  and  on  carefully  weighing  these  symp- 
toms and  physical  signs,  I  do  not  see  how  we  could  have  arrived  at  any 
other  conclusion  ;  for  a  pleurisy  did  certainly  exist,  as  proved  by  the  fric- 
tion during  life,  and  by  the  dense  chronic  adhesions  found  after  death, 
althoucli  now  we  can  have  little  doubt  that  the  dulness,  increased  vocal 
resonance,  and  other  signs,  were  for  the  most  part  dependent  on  the 
aneurismal  tumour.  Another  symptom  usually  present  in  thoracic 
aneurism  Avas  absent,  viz.,  hannoptysis,  or  bloody  sputum.  On  one  occa- 
sion only  was  this  observed,  viz.,  on  February  2d,  four  days  after  the 
pleurisy  was  established.  I  remember  that  it  induced  me  to  examine 
Lis  chest  with  the  utmost  care,  with  a  view  of  discovering  if  pneumonia 
also  existed ;  but,  as  stated  in  the  report,  no  crepitation  could  anywhere 
be  discovered.  I  am  satisfied,  from  the  careful  examination  at  that  time, 
as  well  as  when  he  first  came  into  the  house,  that  there  was  no  blowing 
or  other  abnormal  sound  in  the  chest  caused  by  the  aneurism.  It  is  not 
to  be  wondered  at,  therefore,  that  from  this  period  the  dulness  on  the 
left  side  of  the  thorax,  unaccompanied  with  other  symptoms,  should  be 
referred  to  chronic  pleurisy,  rather  than  to  a  thoracic  aneurism.  It  so 
happened,  also,  that  there  was  a  man  in  the  ward  labouriiig  under  chronic 
pleurisy  on  one  side,  who  presented  all  the  thoracic  symptoms  and  signs 
which  existed  in  Smith.  It  appears,  therefore,  that  the  detection  of  the 
aneurism  was  almost  impossible;  for,  supposing  even  that  it  had  been 
suspected  and  that  attention  had  been  directed  to  confirm  such  a  theory, 
I  am  not  aware  of  any  arguments  by  which  it  could  be  supported.  An 
idea,  bowever,  that  it  would  be  impossible  at  any  time  to  discover  such 
an  aneurism,  would  be  erroneous,  and  would  do  discredit  to  physical  dia- 
gnosis ;  for  there  can  be  little  doubt  that  had  the  chest  been  carefully 
re-examined — say  a  short  period  before  the  attack  of  pleurisy — I  think 
it  would  then  have  been  apparent  that  a  tumour  existed  in  the  chest, 
and  if  so,  that  tumour,  fi-om  its  seat  and  concomitant  circumstances,  would 
have  been  declared  to  be  aneurism  low  down  in  the  thorax.  It  was  sim- 
ply because  no  suspicion  of  its  existence  occurred  to  us,  and  because  no 
physical  examination  of  the  chest  was  made  at  that  time,  that  the  tumour 
was  not  detected  during  life. 

The  Abdominal  Aneurism. — "When    Smith    entered   the   house   the 


ANEURISM.  583 

abdominal  aneurism  was  of  considerable  size.  It  measured  three  inches 
across.  Its  inferior  and  lateral  margins  only  could  be  felt,  the  superior 
portions  being  covered  by  the  ribs.  The  impression  conveyed  to  me  by 
examining  the  tumour,  however,  was  that  it  was  about  the  size  of  a 
cocoa-nut.  It  was  prominent,  especially  when  he  stood  up,  and  pulsated 
strongly.  There  can  be  no  doubt  that  its  volume  must  have  undergone 
considerable  diminution;  for,  previous  to  his  death,  it  felt  through  the 
integuments  about  the  size  of  a  small  hen's  egg  ; — in  some  of  the  reports, 
it  is  said  of  a  pigeon's  egg,  and  of  a  walnut.  Yet,  as  you  see,  it  is  the 
size  of  a  laro;e  oranue,  elongated.  Its  form  is  a  long  oval,  one  extremitv 
of  its  long  axis  resting  deep  upon  the  vertebra?,  the  other  directed 
towards  the  skin.  Hence,  during  life,  we  could  only  feel  one  of  its 
rounded  ends.  You  observe,  however,  that  the  whole  tumour  is  dense 
and  resistant, — and  on  section  it  presents  numerous  concentric  laminte 
of  coagulated  fibrin,  with  a  small  canal  running  through  the  centre, 
keeping  up  the  communication  between  the  aorta  and  the  superior 
mesenteric  artery.  The  man  presented  habitually  a  jaundiced  skin, 
which  was  doubtless  owing  to  the  pressure  of  the  tumour  on  the  duode- 
num and  biliary  ducts. 

The  Paraplegia  and  Spinal  Softeninr/. — He  first  complained  of 
weakness  in  the  lower  extremities  early  in  January  1852  ;  at  the  end  of 
tiuit  month  my  period  of  attendance  on  the  wards  ceased.  In  the  report 
of  March  1st,  I  find  it  stated  that  there  was  decided  paralysis  of  motion 
in  the  inferior  extremities,  while  sensation  still  resulted  when  they  were 
touched.  On  April  8th,  the  paralysis  was  complete, — that  is,  volition 
failed  to  cause  movement  in  the  lower  extremities,  and  stimuli  applied  to 
them  failed  to  induce  sensation.  Involuntary  movements,  however, 
occurred,  consisting  of  twitchings  and  startings,  but  he  never  had  pain 
in  the  limbs.  In  cases  of  myelitis  the  usual  symptoms  are,  pricking  and 
tino-jing  in  the  soles  of  the  feet.  These  symptoms  were  absent,  and  the 
reason  of  this  may,  I  think,  be  found  in  the  nature  of  the  softening  in  the 
spinal  cord.  It  contained  no  granular  cells,  the  result  of  exudation,  and 
its  transformation  into  fatty  granules ;  but  the  tubular  substance  of  the 
cord  was  broken  down,  forming  round  and  oval  fragments  of  the  tubes. 
Hence  it  was  a  mechanical  softening,  the  result  of  gradual  pressure 
merely.  These  distinctions  have  not  been  hitherto  suflSciently  attended 
to  in  pathology.  (See  p.  310.)  You  will  observe  that  the  aneurismal 
tumour  commenced  pressing  on  the  left  side,  and  fi-om  before  backwards, 
and  the  symptoms  indicate  that  weakness  was  felt  in  the  left  inferior 
extremity  before  the  right  one  was  afi'ected, — and  that  motion  was 
paralysed  first,  sensation  last. 

Treatment  h[/  Valsalva's  Method. — A  short  tinie  previous  to  the 
admission  of  Smith,  I  treated  another  case  of  abdominal  aneurism  by 
the  method  of  Valsalva,  for  a  period  of  foity  days, — at  the  expiration  of 
which  time,  he  walked  out  of  the  house,  with  little  assistance,  to  the 
nearest  cab-stand,  a  distance  of  nearly  250  yards,  and  left  the  city.* 
In  the  case  of  Smith,  therefore,  the  bleedings  were  more  frequently 
repeated,  and  greater  in  amount,  while  the  diet  w-as  even  more  dimi- 
nished ;  and  yet,  after  nearly  a  month's  treatment,  the  pulse  was  of  such 

*  See  Monthly  Journal,  February  1850,  p.  169. 


584  DISEASES   OF   THE    CIRCULATORY   SYSTEM. 

good  strength,  tliat  I  ordered  venesection  to  syncope — an  etFect  tliat  was 
not  pioduced  after  the  loss  of  twenty-six  ounces  of  blood — so  that  the 
clerk,  afraid  to  proceed  farther,  bound  up  the  arm.  Three  days  after- 
wards, twenty-eight  ounces  of  blood  were  removed,  with  the  effect  of 
only  producing  a  feeling  of  faintness.  Similar  bleedings  were  practised 
at  no  distant  intervals,  besides  numerous  applications  of  leeches,  and  the 
restricted  diet;  and  yet  the  report  of  21st  April  1850  is,  "that  he  was 
bled  to  thirty-four  ounces,  at  his  urgent  request,  insisting  that  he  felt 
nothing,  until  he  fell  back  in  a  state  of  syncope."  I  am  induced  to  sup- 
pose, therefore,  that  in  this  case,  as  in  the  preceding  one,  the  treatment 
had  not  been  carried  out  to  its  full  extent.  The  nurse,  indeed,  now 
informs  me,  that  perhaps  during  the  first  two  months  his  diet  was  really 
limited ;  but  she  thinks  so  simply  because,  at  that  period,  he  sufi^"erecl 
great  pain  and  seemed  very  anxious  to  follow  the  advice  given  to  him. 
Subsequently,  there  is  every  reason  to  suppose  that  he  obtained  food  from 
his  companions,  or  from  some  other  source.  I  find  from  the  reports, 
indeed,  that  whilst  his  diet  was  still  nominally  at  a  verv  reduced  amount,^ 
up  to  July,  he  was  at  the  same  time  walking  about  with  considerable 
vigour.  Fi'om  my  attempts  at  carrying  out  Valsalva's  treatment  in  these 
two  cases,  I  conclude  that  it  is  impossible  to  practise  it  on  patients  in  an 
open  ward,  or  indeed  under  anv  circumstances,  without  a  degree  of  sur- 
veiUance  that  it  would  be  very  difficult  to  obtain. 

The  good  effects  of  the  treatment,  notwithstanding  its  imperfect 
nature,  were  so  evident  as  to  strike  all  who  witnessed  it,  and  to  cause  the 
patient  continually  to  request  that  he  might  be  bled.  In  fact,  after 
every  general  bleeding,  the  dragging  pains,  and  other  uneasv  sensations, 
he  experienced  in  the  abdomen,  invariably  left  him,  and  he  enjoyed 
longer  or  shorter  periods  of  perfect  ease ;  then,  as  the  pain  giadually 
returned,  and  it  became  unbearable,  he  was  again  relieved  by  bleeding ; 
and  so  on.  During  the  progress  of  his  case,  also,  it  was  observed  that 
the  abdominal  tumour  gradually  diminished  in  size,  and  became  hai'der. 
In  October,  the  tumour  was  ascertained  by  Dr.'Christison  to  be  some- 
what movable ;  but  in  the  following  December,  when  I  examined  it,  it 
was  again  stationary.  During  the  whole  of  1851  he  enjoyed  comparative 
comfort, — occasionally,  however,  feeling  abdominal  pain,  which  was 
relieved  by  leeches  or  bleeding.  At  the  beginning  of  1852,  the  general 
opinion  of  all  who  examined  him  was,  that,  on  the  whole,  this  case  was 
a  remarkable  example  of  the  good  eftects  of  Valsalva's  treatment.  Then, 
however,  the  paraplegia  came  on,  indicating  that  the  disease  was  really 
not  conquered,  but,  by  its  pressure  backwards,  was  affecting  the  spinal 
cord.  Then  came  the  attack  of  pleurisy  and  the  paraplegia ;  and  from 
this  period  it  was  evident  the  disease  would  terminate  fatally. 

The  examination  of  the  body  after  death  was,  in  this  case,  not  only 
important,  as  determining  the  nature  of  the  aneurism,  and  in  a  diagnostic 
point  of  view;  but  it  served,  in  ray  opinion,  to  point  out  what  value 
ought  to  be  attributed  to  Valsalva's  treatment.  It  aftords  an  example 
of  a  wide  generalisation  to  which  the  cultivators  of  rational  medicine 
have  been  gradually  tending, — viz.,  that  not  only  is  the  examination  of 
the  body  after  death  necessary  for  diagnosis  and  pathology,  but  that  it  is 
essential,  in  order  that  we  may  properly  appreciate  therapeutics,  and  the 
utility  of  different  plans  of  treatment.     Let  us  suppose,  for  instance,  that 


ANEUEISil.  585 

this  man  had  died  at  the  commencement  of  1852  from  the  attack  of 
pleurisy,  and  that,  as  so  often  happens,  we  liad  been  refused  permission 
to  open  the  bodv,  my  conviction  is,  that  under  such  circumstances  this 
case  would  have  "been  recorded  in  the  annals  of  medicine  as  a  successful 
instance  of  cure  by  the  method  of  Valsalva.  But  now,  when  all  the 
facts  are  before  us,  it  is  evident  that  the  diminution  of  the  abdominal 
swellino;  was  owing  to  the  increase  of  the  thoracic  one ;  and  that,  as  the 
force  of  the  current  of  blood  became  lessened  by  the  enlargement  of  the 
aneurismal  dilatation  above,  so  the  flow  of  blood  was  retarded  in  the 
tumour  below.  In  consecpience,  the  concentric  depositions  of  fibrin,  the 
lessened  size  of  the  abdominal  swelling,  and  the  more  permanent  relief 
of  pain,  instead  of  being  attributable  to  the  treatment  as  we  had  supposed, 
must  now  be  more  rationally  ascribed  to  the  increase  of  a  thoracic 
aneui-ism,  not  detected  during  life,  which  had  produced  these  results 
mechanicallv,  and  altogether  independently  of  art. 

The  treatment  of  internal  aneurisms  by  the  method  of  Valsalva,  has 
for  some  time  been  discouraged  in  this  country,  on  the  ground  tliat  it 
gives  rise  to  a  general  irritability,  and  to  symptoms  of  a  distressing  nature, 
which  are  often  intolerable;  whilst,  on  the  other  hand,  it  is  seldom 
attended  by  a  permanently  good  efl'ect.  In  the  case  before  us,  as  well  as 
in  that  I  formerlv  treated,  no  unpleasant  symptoms  could  fairly  be 
ascribed  to  the  practice ;  but,  on  the  contrary,  it  produced  (especially 
the  bleedings)  well-marked  relief.  The  question  of  the  permanency  of 
these  good  effects  is,  I  admit,  in  no  way  supported  by  my  experience. 
But  another  important  practical  point,  namely,  the  temporary  relief 
which  bleeding  causes,  without  arresting  the  progress  of  organic  maladies, 
here  meets  with  an  excellent  illustration. 

Poi-'<onin(/  hy  Aconite. — The  facts  which  I  have  been  able  to  make  out 
reo-arding  the  poisoning  of  this  man  are  as  follows : — On  Monday,  May 
31st,  about  11  o'clock  in  the  morning,  the  attention  of  Mr.  Broadbent 
(non-resident  clerk)  and  of  Dr.  Murchison  (resident  clerk),  both  of  whom 
were  at  the  time  in  the  ward,  was  directed  to  Smith  by  a  groan  or  cry. 
He  was  then  observed  to  be  sitting  up  in  bed,  leaning  forward,  and 
groaning  like  a  man  laboui'ing  under  colic  pains.  Mr.  Broadbent,  who 
was  nearest  at  the  time,  went  to  his  bedside,  and  asked,  "  What  is  the 
matter  V  Smith  made  no  immediate  reply,  but  continued  to  groan, 
and  moved  his  arms  in  a  feeble  manner,  and  it  was  noticed  by  Mr.  B. 
that  his  hands  dropped  considerably  when  the  arms  were  raised.  He 
then  tried  to  reach  the  spit-box,  but  not  being  able  to  do  so,  it  was  given 
to  him,  and  he  seized  it,  raised  it  to  his  mouth,  and  spat  into  it.  He 
then  said,  with  short  pauses  between  his  words,  "Is  there  anything 
wrong  with  mr  face  ? — it  is  very  painful ;  what  medicine  have  I  been 
taking  V  On  being  asked  to  point  out  the  bottle  on  the  shelf,  he  did  so, 
saying,  "  That  little  bottle  there."  On  looking  at  it,  Mr.  Broadbent  saw 
by  the  label  that  it  was  a  liniment,  composed  of  Tr.  Aconiti,  3  ss. ;  Lin. 
Saponis  c.  Opio,  fjss.  Dr.  Murchison,  on  being  informed  what  had 
happened,  also  went  to  Smith,  found  him  pulseless,  and  on  letting  go 
his  arm  observed  that  it  fell  down  powerless  at  his  side.  Smith  then 
repeated  more  than  once,  "  Can  nothing  be  done  for  me  ? — What  can 
vou  do  for  me  ? — Can  you  get  me  a  vomit  V  etc.  An  emetic  of  sulphate 
of  zinc  was  immediately  sent  for,  and  it  was  further  observed  that  the 


586  DISEASES   OF  THE   CIRCULATORT  SYSTEM. 

pupils  had  undergone  no  marked  change,  that  there  was  no  lividity  of 
the  lips  or  other  part  of  the  countenance,  that  no  impulse  could  be  felt 
in  the  cardiac  region,  and  that  the  respiration  was  more  slow  and 
laborious  than  usual.  Dr.  Murchison  now  left  the  patient  to  get  a 
stomach-pump,  and  Mr.  Broadbent  saw  Smith  retch  twice,  as  if  endea- 
vouring voluntarily  to  vomit.  He  therefore  went  into  the  side-room  to 
get  a  feather,  or  some  object  to  tickle  his  fauces  with,  but  was  inuuediately 
summoned  back  by  tbe  intelligence  that  Smith  was  worse.  On  return- 
ing to  the  bed-side  he  found  tliat  the  patient  had  fallen  on  his  bed,  the 
head  thrown  back,  face  and  lips  remarkably  pale,  a  little  saliva  running 
from  the  corner  of  the  mouth,  the  respirations  occurring  at  long  intervals 
with  gasping,  the  pupils  neither  dilated  nor  contracted,  and  the  evelids 
paralysed,  when  opened  remaining  fixed,  and  not  contracting  on  blowing 
into  the  eye.  He  was  now  insensible,  and  consequently  the  emetic, 
which  at  this  time  arrived,  could  not  be  given.  About  a  minute  after, 
Dr.  Murchison,  on  hurrying  back  with  the  stomach-pump,  found  iiira 
dead.  Notwithstanding,  more  than  a  pint  of  semi-pultaceous  luatter 
was  immediately  di'awn  off  from  the  stomach,  smelling  stronglv  of  the 
liniment,  and  artificial  respiration  was  kept  up  in  vain  for  five  minutes. 

The  period  that  elapsed  from  first  noticing  Smith's  cry  or  groan  until 
Dr.  ^lurchison's  return,  when  he  was  dead,  is  differently  estimated  by  the 
gentlemen  concerned  at  five  and  seven  minutes.  The  liniment  consisted 
originally  of  Liniment.  Sapon.  c.  Opio,  3Jss,  Tr.  Aconiti,  3  ss,  and  it 
is  believed  that  the  whole  of  this  quantity  (viz.  two  fluid  ounces)  was  in 
the  bottle  when  Smith  began  to  drink  it.  There  were  found  in  the 
bottle  afterwards  five  drachms  remaining,  so  that  the  presumption  is, 
that  he  swallowed  three  drachms  of  laudanum,  and  upwards  of  two 
drachms  of  tincture  of  aconite. 

AVhether  Smith's  death  arose  from  accident,  or  whether  he  committed 
suicide,  is  not  likely  ever  to  be  known.  Those  who  knew  him  best  in 
the  ward,  as  well  as  the  nurse,  are  of  the  latter  opinion,  based  principally 
on  the  character  of  the  man,  which  was  such  as  to  prevent  his  mistaking 
a  liniment  for  a  di'aught.  It  seems,  also,  that  no  one  was  more  habitually 
careful  as  to  the  medicines  he  took, — that  the  liniment  was  not  ordered 
for  him  ;  that  he  took  it  from  a  patient  in  a  neighbouring  ward,  and 
kept  it  on  his  shelf  for  some  days ;  and  lastly,  that  since  the  paraplegia 
had  become  complete,  he  had  been  unusually  despondent  and  morose. 
"With  regard  to  the  phenomena  produced,  it  is  most  likelv  that,  imme- 
diately after  swallowing  the  poison,  he  experienced  those  violent  tingling 
and  stinging  sensations  in  the  mouth  and  fauces  which  aconite  produces, 
and  hence  the  pain  complained  of  in  his  face.  Being  alreadv  paraplegic, 
nothing  is  known  as  to  how  far  the  poison  affected  the  muscles  of  the 
lower  extremities;  but  it  is  evident  that,  whilst  the  intelligence  remained 
perfect,  the  arms  became  weak,  then  powerless.  Subsequently,  he  could 
not  support  himself  in  the  sitting  posture ;  and,  on  his  falling  back,  the 
muscles  of  the  face  and  of  respiration  were  paralysed,  and  he  died 
aspliyxiated.  Previous  to  this,  however,  a  powerful  sedative  effect  had 
been  produced  on  the  heart,  for  when  first  noticed  he  was  pulseless,  and 
shortly  after,  no  impulse  could  be  felt  in  the  cardiac  region. 

According  to  Dr.  Christison,  the  least  variable  symptoms  of  poisoning 
by  aconite  in  the  human  subject  are,  "first,  numbness,  prickling,  and 


ANEURISM.  587 

impaired  sensibility  of  the  skin,  impaired  or  annihilated  vision,  deafness, 
and  vertigo — also,  frothing  of  the  mouth,  constriction  at  the  throat,  false 
sensations  of  weight  or  enlargement  in  various  parts  of  the  body, — 
great  muscular  feebleness  and  tremor,  loss  of  voice,  and  laborious  breath- 
ing,— distressing  sense  of  sinking,  and  impending  death, — a  small,  feeble, 
irreji'ular,  and  gradually-vanishing  pulse, — cold  clamm}'  sweat,  and  pale 
bloodless  features, — together  with  perfect  possession  of  the  mental  facul- 
ties, and  no  tendency  to  stupor  or  drowsiness  ; — finally,  sudden  death  at 
last,  as  from  hiBiiiorrhage,  and  generally  in  a  period  varying  from  an 
Lour  and  a  half  to  eight  hours,"*  Although  in  this  case  many  of  the 
symptoms  just  mentioned  were  not  noticed,  it  must  be  evident  that  the 
leading  ones,  indicative  of  the  physiological  action  of  the  drug,  were 
observed.  When  the  large  dose  of  the  poison  is  considered,  and  the 
great  rapidity  of  its  effects,  it  may  be  easily  understood  how  the  minor 
symptoms,  and  especially  those  having  reference  to  the  sensations  of  the 
patient,  were  not  ascertained,  if  indeed  they  really  existed. 

Dr.  Fleming  considers  that  aconite  may  cause  death,  "first,  by  pro- 
ducing a  powerful  sedative  impression  on  the  nervous  system  ;  second, 
by  paralysing  the  muscles  of  respiration  ;  and  third,  by  producing 
syncope."  He  observes,  "that  the  second  mode  of  death  has  never 
been  recognised  in  man;  the  qnantity  of  the  poison  taken  in  no  case 
having  been  sufficient  to  exert  such  an  efl^ect  on  the  nervous  and 
muscular  systems,  as  is  necessary  to  induce  it."f  The  case  of  Smith, 
indeed,  is  the  only  one  of  this  description,  so  far  as  I  am  aware,  that  has 
ever  occurred,  in  which  the  dose  of  poison  was  so  large,  and  the  death 
so  rapid.  It  is  difficult  to  separate  the  effects  of  syncope  from  those  of 
asphyxia  in  such  a  case,  as  the  first  condition  must  induce  the  other. 
Both  were  apparently  combined.  It  is  also  difficult  to  determine  how 
far  the  effects  on  respiration  Avere  occasioned  by  paralysis,  creeping  from 
below  upwards,  as  in  the  case  of  Gow,  formerly  given  (CaseXLIV.,  p.413). 
There  are  some  facts,  liowever,  noticed  by  Dr.  Christison,  which  lend 
support  to  such  a  doctrine ;  and  it  will  be  observed  that  paralysis  of  the 
hands  and  arms  preceded  that  of  the  muscles  of  the  back  and  face  in  the 
case  of  Smith. 

The  general  diagnosis  of  thoracic  anearisins  has  always  been  con- 
sidered a  matter  of  great  difficulty.  When,  indeed,  a  tumour  with  a 
distinct  impulse  is  perceptible,  we,  in  the  majority  of  cases,  know  with 
what  disease  we  have  to  do.  But  even  here  occasional  errors  by  men 
of  the  greatest  experience  have  sufficiently  proved  that  the  art  of 
detecting  these  tumours  with  exactitude  is  imperfect.  Again,  when 
aneurismal  tumours  are  seated  at  the  upper  part  of  the  thorax,  it  is 
important  to  determine  whether  they  arise  from  the  aorta,  or  from  the 
large  vessels  coming  from  it,  and  if  the  latter,  which  vessel  is  aff"ected. 
Then  aneurisms  originating  from  the  upper  part  of  the  descending  aorta 
press  upon  neighbouring  nerves,  as  the  superior  and  inferior  laryngeal 
and  pharyngeal  branches  of  the  pneumo-gastric,  giving  rise  to  various 
symptoms;  or  they  comprc'^s  the  larynx,  trachea,  bronchus,  oesophagus, 
or  the  lung  itself^  and  so  occasion  laryngeal,  oesophageal,  or  pulmonary 

*  Oil  Poisons.     Fourth  edition.     P.  871. 

f  An  Inquiry  into  the  Physiological  and  Medicinal  Properties  of  the  Acouitum 
Napellus.     Edinburgh,  18i5.     P.  42. 


588  DISEASES   OF   THE   CIRCULATORY   SYSTEM, 

symptoms.  Lastly,  wlien  deep  in  tlie  thorax,  their  proo;ress  is  often 
latent.  Hence  the  signs  and  symptoms  of  thoracic  aneurisms  var}', — 
1st,  According  to  their  seat ;  2dly,  x\ccording  to  the  size  of  the  tumour 
and  its  pressure  upon  neighbouring  parts;  3dly,  On  the  character  of  the 
aneurism,  its  formation,  and  state  of  the  vessel. 

The  means  at  our  disposal  for  detecting  these  aneurisms  are, — 1st, 
Percussion;  2d,  Auscultation;  3d,  Palpation ;  4th,  Symptoms. 

1.  Percussion. — That  the  situation  and  size  of  the  aorta  can  be  accu- 
rately determined  by  percussion,  was  first  proved  by  Piorry.*  I  have 
frequently  succeeded,  in  favourable  cases,  in  marking  out  on  the  chest 
the  size  of  this  vessel.  To  do  so  with  accuracy,  it  is  first  necessary  to 
limit  the  margins  of  the  heart  in  the  manner  previously  explained  (see 
p.  40),  and  then  carrying  the  pleximeter  upwards  in  the  course  of  the 
aorta,  and  over  the  sternum,  the  dulness  of  the  vessel  when  compared 
with  the  resonance  of  the  lung  on  both  sides,  mav  be  made  very  appa- 
rent. In  the  same  manner  the  extent  of  saccular,  or  simple  aneuiisms 
by  dilatation,  may  frequently  be  determined  with  accuracy  when  seated 
in  the  ascending  or  transverse  arch.  In  such  cases,  however,  the  exist- 
ence of  pain  often  renders  percussion  impossible,  and  at  all  times  it 
should  be  conducted  with  great  gentleness.  "When  an  aneurism  is  seated 
in  the  descending  thoracic  aorta,  its  limitation  is  more  difficult,  as  we 
have  then  to  percuss  through  the  lung  anteriorlv.  But  careful  manipu- 
lation, and  varying  the  force  of  the  blow,  together  with  percussion  pos- 
teriorly, will  frequently  enable  us  to  determine  the  position  and  size  of 
the  swelling.  If,  on  the  other  hand,  the  aneurism  be  small  and  deep- 
seated,  while  the  lungs  are  healthy,  and  if,  at  the  same  time,  no  suspi- 
cion of  the  disease  be  entertained  by  the  practitioner,  he  is  very  likely 
to  overlook  the  importance  of  slight  dulness  on  one  side  of  the  chest, 

2.  Auscultation. — There  may  be  no  sounds  heard  over  an  aneurism, 
and  when  present  they  may  be  either  single  or  double.  Considerable 
discussion  has  taken  place,  whether,  in  the  latter  case,  the  second  sound 
originates  in  the  tumour,  or  is  propagated  along  the  vessel  from  tlie 
heart.  This  is  a  theoretical  point  which  is  not  yet  decided.  AYhether 
single  or  double,  they  must  be  judged  of  according  to  their  character 
and  seat,  AVith  regard  to  their  character,  they  may  be, — 1st,  Soft  and 
blowing;  2d,  Harsh  and  rough  (in  the  latter  case  the  vessel  is  generally 
diseased,  and  its  lining  membrane  more  or  less  atheromatous  or  calca- 
reous) ;  3d,  There  may  be  a  peculiar  clink,  or  abrupt  harsh  resonance, 
approaching  towards,  but  never  reaching,  a  metallic  sound.  It  is  gene- 
rally heard  when  a  sacculai'  aneurism,  free  from  coagula,  is  present,  with 
a  small  opening,  having  thin  and  elastic  margins.  With  respect  to  the 
seat  of  these  sounds,  when  near  the  heart,  they  are  generally  synchro- 
nous with  those  of  that  organ,  and  their  discrimination  is  very  difficult. 
When  situated  in  the  arch  of  the  aorta,  there  is  a  distinct  separate 
source  of  sound.  This  latter  can  only  be  successfully  studied  by  care- 
fully comparing  the  moment  of  impulse  of  the  heart  Avith  that  of  the 
tumour,  as  well  as  the  character  and  intensity  of  the  cardiac  and  aneu- 
rismal  sounds.  You  should  carry  the  stethoscope  carefully  from  one  to 
the  other,  and  observe  the  diminution  and  increase  of  the  murmurs,  as 

*  De  I'Exameu  Plessimetrique  de  1' Aorta,  etc.     1840. 


ANEURISM.  589 

you  lengthen  or  shorten  the  distance  from  the  origin  of  the  sounds.  It 
is  necessary  also  to  study  the  direction  in  which  the  sounds  are  propa- 
gated, those  of  a  blowing  or  rasping  character  having  a  tendency  to  pass 
in  the  direction  of  the  current  of  blood.  Hence  in  aneurisms  of  the 
innominata,  the  murmur  is  prolonged  in  the  course  of  the  rio-ht  carotid 
and  axillary  arteries,  while  those  of  the  aortic  arch,  and  especially  its 
descending  portion,  may  be  heard  in  the  aorta,  on  applying  the  ear  to 
the  back.  In  this  manner  careful  and  repented  auscultation,  conjoined 
with  percussion,  will  enable  you,  in  the  majority  of  cases,  to  determine 
exactly,  not  only  the  existence  and  seat  of  the  aneurisn],  but  in  many 
cases  its  form  and  structure. 

3.  Palpation. — When  an  aneurism  points  externally,  a  tumour  and 
an  expansive  impulse  can  be  felt  by  the  hand. 

The  position  of  the  tumour  varies  according  to  the  part  of  the  aorta, 
or  the  large  vessel  from  which  it  originates.  Thus,  saccular  aneurisms 
immediately  above  the  aortic  valves  pass  downwards.  When  situated 
in  the  innominata,  they  manifest  themselves  above  the  clavicle  on  the 
right  side.  If  originating  in  the  transverse  portion  of  the  arch,  there  is 
often  no  external  tumour;  and  when  it  does  occur,  it  generally  appears 
on  the  left  side  of  the  sternum,  above  or  below  the  sterno-clavicular  arti- 
culation. Aneurisms  lower  down  in  the  arch  are  most  common  in  the 
left  thoracic  cavity.  These  rules  are  by  no  means  absolute  ;  for,  although 
an  aneurismal  tumour  for  the  most  part  tends  to  enlarge  in  the  direction 
in  which  the  impulse,  from  the  course  of  blood,  is  applied — this,  in  seve- 
ral cases,  cannot  be  determined  in  the  living  body. 

The  impulse  of  the  tumour  is  synchronous  with,  or  follows  the 
systole  of  the  heart.  Occasionally  there  is  no  impulse,  a  circumstance 
most  frequently  observed  when  the  tumour  does  not  present  externally, 
and  is  only  determined  by  percussion.  The  pulse  of  arteries  connected 
with  the  aneurism  may  be  weakened  or  retarded.  The  pulse  at  both 
wrists  should  be  always  carefully  studied ;  for  if  one  be  weaker  than 
the  other,  it  is  clear  that  an  interruption  exists  in  the  current  of  the 
blood  in  the  axillary  artery.  This  may  arise  from  two  causes — 1st, 
From  the  vessel  being  involved  in  the  tumour;  2d,  From  its  beino- 
compressed  by  it  externally.  The  former  condition  exists  most  con> 
monly  when  there  is  aneurism  of  the  innominata,  when  the  weaker 
pulse  will  be  on  the  right  side.  In  aneurisms  of  the  arch,  on  the  other 
hand,  the  feebler  pulse  is  usually  on  the  left  side.  The  retardation  of 
the  pulse,  when  it  occurs,  is  owing  to  causes  very  similar  to  those  which 
affect  its  strength. 

4.  The  symptoms,  which  are  present  in  cases  of  thoracic  aneurism, 
vary  according  to  the  size  of  the  tumour,  and  the  parts  on  which  it 
presses.  When  seated  at  the  upper  part  of  the  chest,  it  may,  by 
pressure  on  the  larynx,  produce  alteration  of  the  voice,  more  or  less 
cough,  and  stridulous  respiration ;  by  affecting  the  branches  of  the 
eighth  pair,  occasion  increase  or  diminution  of  their  special  functions; 
impede  deglutition  by  constricting  the  oesophagus;  or  modify  the 
respiratory  murmur  by  pressing  on  the  trachea  or  larger  bronchi. 
Occasionally  there  is  a  crepitating  murmur  in  the  lung,  with  many  of 
the  signs  and  symptoms  of  pneumonia,  for  which  it  has  often  been 
mistaken,  including   rusty  sputum,  dulness,  and  increased  vocal  reso- 


590  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

nance.  Pressure  of  the  tumour  on  the  axillary  vessels  and  nerves  may 
induce  more  or  less  oedema  of  the  extremities,  and  paralysis  more  or 
less  complete.  Sometimes  there  are  dull,  gnawing,  or  lancinating  pains 
in  various  parts  of  the  chest ;  but  nothing  is  more  remarkable  than 
the  size  and  formidable  nature  of  some  aneurisms  which  have  caused 
little  pain.  Occasionally  there  is  a  feeling  of  oppression  and  constric- 
tion— dyspna-a  with  or  without  exertion,  and  haemoptysis  to  a  greater 
or  less  extent. 

The  combination  of  the  results  obtained  by  percussion,  auscultation, 
palpation,  and  vascular  impulse,  and  the  functional  symptoms,  vary 
infinitely  in  different  cases,  and  their  careful  detection,  combined  with 
a  knowledge  of  physiology,  Avill  in  the  majority  of  cases  enable  us  to 
form  a  correct  opinion  as  to  the  nature  of  the  disease,  vlt  must  not  be 
forgotten,  however,  that  there  are  some  cases  which  have  been  so 
obscure  as  to  baffle  the  efforts  of  the  most  able  physicians ;  and  that, 
generally  speaking,  the  deeper  the  aneurism  the  greater  the  difticulty 
of  detecting  its  exact  nature,  and  the  complications  connected  with  it. 
It  is  also  well  ascertained  that  the  symptoms  may  be  simulated  by  a 
tumour  situated  outside  and  upon  the  vessel ;  and  occasional  mistakes, 
made  bv  the  most  experienced  surgeons — men  who,  during  their  profes- 
sional lives,  have  carefully  examined  a  large  number  of  these  tumours — 
prove  the  excessive  difficulty  of  detecting  aneurisms,  even  when  situated 
in  the  limbs  or  in  the  neck.  How  much  more  difficult  must  be  the 
appreciation  of  these  symptoms,  when  the  aneurisms  are  below  the 
sternum  or  clavicles,  not  to  speak  of  their  occurrence  deep  in  the 
thorax.  Yet  these  very  symptoms,  tor/ether  u<itk  the  results  obtained 
bv  percussion  and  auscultation,  enable  the  physician  frequently  to  over- 
come the  greatest  difficulties,  and  to  demonstrate  what  may  properly 
be  called  the  greatest  triumph  of  his  art. 

The  physical  phenomena  most  distinctive  of  an  abdominal  aneurism 
are  a  swelling  more  or  less  defined,  an  expansive  impulse  on  applying 
the  hand,  and  a  bellows  murmur  synchronous  with,  or  immediately 
following,  the  heart's  systole  on  applying  the  stethoscope.  This  bel- 
lows murmur  is  generally  loudest  over  the  tumour,  and  is  propagated 
down  the  aorta — although,  when  immediately  below  the  diaphragm,  it 
may  be  confounded  with  the  first  sound  of  the  heart.  The  symptoms 
are  very  various,  consisting  of  dragging,  or  other  pain,  more  or  less 
acute  and  prolonged,  owing  to  pressure  and  stretching  of  the  neigh- 
bouring nerves,  together  with  functional  disturbance  of  one  or  more 
of  the  abdominal  viscera.  Various  cases  on  record,  therefore,  have 
presented  a  train  of  very  anomalous  symptoms,  and  at  various  times 
been  considered  as  different  diseases  by  medical  practitioners.  A  com- 
plete re-investigation  of  the  symptoms  and  signs  of  abdominal  aneurisms 
is  much  required.  This  is  a  task,  however,  which  will  require  a 
thorough  knowledge  of  all  that  is  now  known  of  physical  diagnosis 
and  morbid  anatomy,  combined  with  great  powers  of  observation,  and 
such  opportunities  as  fall  to  the  lot  of  few  individual  members  of  the 
profession. 

The  jicttholo^/y  of  anejirisms  is  sufficiently  treated  of  under  the  heads 
of  "Vascular  Growths,"  p.  181,  and  of  "Fatty  Degeneration  of  Blood- 


ANEURISM.  591 

vessels,"  p.  220.  The  latter,  by  inducing  -weakness  or  want  of  elasticity 
in  the  vascular  wall,  permits  of  its  dilatation  by  the  successive  impulses 
of  the  blood  on  the  enfeebled  tissue.  Occasionally  the  inner  coat  of 
the  vessel  is  lacerated  by  external  violence,  or  by  sudden  exertions, 
when  a  similar  morbid  condition  gives  rise  to  like  results.  As  the 
anemnsmal  tumour  enlarges,  it  presses  more  and  more  upon  neighbour- 
ing parts,  giving  rise  to  atrophy,  ulceration,  and  interstitial  absorption 
of  parts,  and  occasioning  a  great  variety  of  symptoms,  according  to 
the  situation  of  the  tumour,  the  organs  and  tissues  influenced  by  it,  and 
the  amount  and  kind  of  pressure  exerted  on  the  textures  concerned  iu 
the  functions  of  nutrition  and  innervation. 

The  treatment  of  aneurisms  may  be  curative  or  palliative.  The  for- 
mer is  carried  out  by  the  surgeon.  The  general  treatment  by  Valsalva's 
method  has  already  been  alluded  to  (p.  583),  and  is  now  seldom  prac- 
tised. All  the  physician  can  do  is  to  palliate  symptoms,  diminish  the 
chances  of  rupture,  and  favour  the  obliteration  of  the  enlarged  vessel ; 
to  this  end  enjoining  quietude,  especially  avoidance  of  sudden  or  long- 
sustained  exertion.  Occasional  local  and  even  general  bleeding,  topical 
applications  of  ice  or  warmth  as  may  be  found  most  useful,  and  seda- 
tives, tend  to  diminish  pain.  Constipation  should  be  carefully  guarded 
against,  and  healthy  nutrition  secured  by  attention  to  the  various  animal 
functions,  gentle  exercise,  etc.,  etc. 


SECTION  TIL . 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Ix  tliis,  as  in  the  precedino;  section,  it  will  be  well  to  introduce  the 
study  of  individual  diseases  by  a  short  enumeration  of  the  genei'al  rules 
established  for  the  diagnosis  of  lesions  of  the  Respiratory  System. 
They  are — 

1.  A  friction  murmur  heard  over  the  pulmonary  organs  indicates 
pleuritic  exudation. 

2.  Moist  or  dry  rales,  without  dulness  on  percussion,  or  increased 
vocal  resonance,  indicate  bronchitis,  with  or  without  fluid  in  the  bronchi. 

3.  Dry  rales  accompanying  prolonged  expiration,  with  unusual  reso- 
nance on  percussion,  indicate  emphysema. 

4.  A  moist  rale  at  the  base  of  the  lung,  with  dulness  on  percussion 
and  increased  vocal  resonance,  indicates  pneumonia. 

5.  Harshness  of  the  inspiratory  murmur,  prolonged  expiration,  and 
increased  vocal  resonance  confined  to  the  apex  of  the  lung,  indicate 
incipient  phthisis. 

6.  Moist  rales,  with  dulness  on  percussion,  and  increased  vocal  reso- 
nance at  the  apex  of  the  lung,  indicate  either  advanced  phthisis  or 
pneumonia.  The  latter  lesion  commencing  at  or  confined  to  the  apex 
is  rare,  and  hence  these  signs  are  diagnostic  of  phthisis. 

Y.  Circumscribed  bronchophony  or  pectoriloquy,  with  cavernous  dry 
or  moist  rale,  indicates  a  cavity.  This  may  be  dependent  on  tubei'cular 
ulceration,  a  gangrenous  abscess,  or  a  bronchial  dilatation.  The  first  is 
generally  at  the  apex,  and  the  two  last  about  the  centre  of  the  lung. 

8.  Total  absence  of  respiration  indicates  a  collection  of  fluid  or  of 
air  in  the  pleural  cavity.  In  the  former  case  there  is  diftused  dulness, 
and  in  the  latter  diffused  resonance  on  percussion. 

9.  Marked  permanent  dulness,  with  increased  vocal  resonance,  and 
diminution  or  absence  of  respiration,  may  depend  on  chronic  pleui'isy, 
on  thoracic  aneurism,  or  on  a  cancerous  tumour  of  the  lung.  The 
diagnosis  between  these  lesions  must  be  determined  by  a  careful  con- 
sideration of  the  concomitant  signs  and  symptoms. 

The  general  diagnostic  indications,  now  noticed  as  being  derivable 


LARYNGITIS.  593 

from  physical  signs,  admit  of  several  exceptions,  which,  however,  it 
would  be  difficult  to  systematize,  and  which  can  only  be  known  from  a 
careful  study  of  individual  cases.  It  is  important  also  to  remember 
that  these  signs  should  never  be  relied  on  alone,  but  be  invariably 
combined  wit1i  a  minute  observation  of  all  the  concomitant  symptoms. 
Thus  the  signs  indicative  of  incipient  phthisis  may  be  induced  by  a 
chronic  pleurisy  confined  to  the  apex,  or  by  retrograde  tubercle.  In 
either  case,  the"^previous  history,  age,  etc.,  may  enable  you  to  determine 
the  nature  of  the  lesion.  Again,  it  may  be  impossible  at  the  moment 
of  examination  to  distinguish  between  two  diseases.  For  instance, 
there  may  be  general  fever,  more  or  less  embarrassment  of  the  respira- 
tion, and  pain  in  the  side,  accompanied  with  no  dulness  on  percussion, 
but  with  a  decided  abnormal  murmur,  difficult  to  characterise,  as 
being  a  fine  moist  rattle,  or  a  gentle  friction  sound.  Under  such 
circumstances,  the  progress  of  the  case  will  soon  relieve  you  from  any 
doubt  as  to  whether  a  pleurisy  or  a  pneumonia  be  present.  The  altera- 
tions which  occur  in  the  physical  signs  during  the  progress  of  the  case 
also  Avill  indicate  to  the  pathologist  the  changes  which  occur  in  the 
physical  conditions  and  morbid  lesions  of  the  lungs.  Thus  the  fugi- 
tive dry  or  mucous  rales  heard  during  a  bronchitis,  point  out  the 
occasional  constrictions  and  obstructions  in  the  bronchial  tubes.  The 
fine  crepitation  of  incipient  pneumonia,  passing  into  absence  of  respira- 
tion, and  this  again  into  crepitation,  will  satisfy  him  as  to  effusion, 
solid  coagulation,  and  subsequent  softening  of  the  exudation.  In  the 
same  way,  by  an  accurate  appreciation  of  physical  signs,  and  a  thorough 
knowledge  of  morbid  anatomy,  the  practised  physician  can  tell  the 
abnormal  conditions  produced  by  phthisis,  pleurisy,  etc.,  and  judge 
from  the  symptoms  the  effect  of  these  upon  the  constitution,  with  a 
degree  of  accuracy  that  to  the  tyro  must  appear  to  be  marvellous.  All 
such  knowledge  can  only  be  acquired  by  constant  examination  of  the 
patient  on  the  one  hand,  and  by  a  careful  study  of  morbid  anatomy  in 
the  pathological  theatre  on  the  other. 


LARYNGITIS. 

Case  CX.1Y .*— Acute  Laryngitis — Treated  by  Topical  Applications — Recovery. 

History. — Alexander  Flint,  ast.  27,  a  salesman— admitted  February  IT,  1851, 
suffered  from  extensive  lupus  of  the  fece,  severe  diarrhoea,  Bright's  disease,  and  scro- 
fulous caries  of  the  left  knee-joint.  Under  appropriate  treatment  the  diarrhoea 
ceased,  the  lupus  was  cured,  and  the  disease  of  the  kidney  much  alleviated. 

Symptoms  of  the  Attack. — On  the  24th  of  May,  about  three  months  after 
admission,  he  first  complained  of  dry  cough  and  slight  pain  in  the  throat,  with  diffi- 
culty of  deglutition.  These  symptoms  were  increased  on  the  following  day ;  and  on 
examination,  the  mouth  and  fauces  were  unusually  red,  with  minute  florid  eleva- 
tions scattered  over  the  mucous  surfl^ce.  Notwithstanding  the  application  of  leeches, 
and  sponging  the  fauces  with  a  solution  of  the  nitrate  of  silver,  the  laryngitis  pro- 
gressed. 

*  Reported  by  Mr.  W.  M.  Calder,   Chnical  Clerk. 
38 


59-4  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

Progress  of  the  Case.— On  the  14th  of  June  the  pain  and  difScult_y  of  deglu- 
tition had  increased,  and  his  voice  had  become  indistinct  and  lioarse.  The  cougli 
also  continued,  but  was  now  attended  with  a  difficult  expectoration  of  muco- 
purulent matter.  On  the  30th  of  June,  notwithstanding  the  assiduous  use  ot 
astringent  gargles,  occasional  sponging  of  the  fauces  with  solution  of  nitrate  of 
silver,  and  the  application  of  leeches,  he  was  evidently  worse,  and  he  could  only 
speak  in  a  whisper.  July  Gih. — To  day  Dr.  Horace  Green,  of  New  York,  who  went 
round  the  wards  with  Dr.  Bennett,  stated  that  this  was  a  remarkably  good  example 
of  what  he  had  named  follicular  disease,  affecting  the  larynx.  He  passed  the  sponge, 
saturated  with  a  solution  of  nitrate  of  silver  (3ij  to  §  i  of  water),  through  the  larynx 
into  the  trachea.  The  patient  could  not  take  a  breath  for  some  seconds  afterwards, 
and  described  the  sensation  as  like  that  produced  by  a  piece  of  food  "passing  down 
the  wrong  wa}',  and  causing  choking  "  The  immediate  effect  of  the  operation  was 
decided  improvement  of  the  voice,  and  more  ease  in  deglutition.  From  this  time 
his  symptoms  gradually  left  him.  On  the  10th,  the  sponge  was  again  passed  into 
the  larynx  by  Dr.  Bennett,  and  produced  the  same  sense  of  temporary  suftbcation  ; 
but  immediately  afterwards  he  spoke  with  perfect  clearness  of  voice.  The  applica- 
tion was  made  every  second  day  until  the  16th,  when  all  the  laryngeal  symptoms 
had  disappeared,  the  voice  was  normal,  and  there  was  no  cough,  expectoration,  pain, 
or  difficulty  of  deglutition.  He  now  left  the  house;  the  disease  in  the  joint  had 
made  considerable  progress,  but  the  renal  disorder  was  much  alleviated. 


Case  CXY.* — Chronic  Lanjngiiis — Topical  Ai^iMcaiions — Recovery. 

History. — Helen  Guthrie,  ret.  24,  married,  a  fisherwoman — admitted  July  4th, 
1851.  Four  months  ago  was  seized  with  a  cough,  attended  with  hoarseness  of  the 
voice,  dryness  of  the  throat,  painful  deglutition,  and  pain  in  the  larynx,  which 
symptoms  have  continued  with  greater  or  less  intensity  up  to  the  period  of  admis- 
sion. Latterly,  there  has  been  considerable  expectoration  of  purulent  matter,  often 
tinged  with  blood. 

Symptoms  on  Admissiox. — On  admission,  she  coniplams  of  cough  coming  on  in 
paroxysms,  dryness  in  the  throat,  and  pain  in  the  larynx,  voice  cracked  and  occa- 
sionally absent.  There  is  no  difficulty  in  swallowing,  but  copious  expectoration  of 
froth}'  mucus.  Can  inspire  without  difficulty.  Percussion  over  chest  elicits  nothing- 
abnormal.  On  auscultation,  the  inspiratory  murnmr  is  harsh  over  superior  third  o^ 
chest  on  both  sides.  Over  larynx  and  trachea  there  is  heard  a  dry  snoring  sound. 
On  examining  the  fauces,  red  patches  were  observable  here  and  there,  with  slight 
erosion  on  the  left  side.  The  fauces  and  epiglottis  were  sponged  with  a  solution  of 
nitrate  of  silver  ( 9 j  to  3  j  of  water). 

Progress  of  the  Case. — The  application  was  repeated  on  the  following  day,  and 
the  voice  was  evidently  improved.  On  the  6th,  the  sponge,  saturated  with  the 
solution,  was  passed  into  the  larynx  by  Dr.  Horace  Green,  of  New  York,  and  pro- 
duced no  feehng  of  suftbcation  whatever.  It  was  passed  afterwards  every  day  by 
Dr.  Bennett  till  the  14th,  when  she  left  the  house,  all  the  laryngeal  symptoms  having 
disappeared,  and  the  voice  nearly  restored  to  its  proper  tone. 

Commentary.— ^\\G.  two  cases  above  recorded  point  out  to  yon  in  a 
very  marked  manner  the  great  advantage  to  be  derived  from  the  method 
of  local  application  to  the  larynx,  introduced  by  Dr.  Horace  Green,  of 
New  York.     This  practice  consists  in  the  direct  application  of  a  sohition 

*  Reported  by  Mr.  D.  0.  Hoile,  Clinical  Clerk. 


LARYXGITIS.  595 

of  nitrate  of  silver  to  the  interior  of  the  larynx  and  trachea,  by  means 
of  a  bent  whalebone  probe,  with  a  piece  of  sponge  fastened  to  its  extre- 
mity. Xunieroas  attempts  had  been  made,  with  more  or  less  success,  by 
Sir"C.  Bell,  Mr.  Vance,  Mr.  Cvisack,  and  MM.  Trousseau  and  Belloc,  to 
carry  this  practice  into  effect,  and  the  results  obtained,  even  by  their 
imperfect  etforts,  exhibited  the  great  advantages  which  were  to  be 
derived  from  it  in  the  treatment  of  laryngeal  diseases.  Xow,  thanks  to 
Dr.  Green,  we  can  with  safety  apply  various  solutions  directly  to  the 
parts  affected,  and  the  two  cases  you  have  observed  must  convince  you 
of  the  benefit  which  patients  so  treated  may  obtain.  In  Case  CXIY. 
you  have  observed  the  progress  of  a  tolerably  acute  case  of  laryngitis 
from  its  commencement  to  its  termination, — the  distressing  symptoms 
produced,  and  the  loss  of  voice  occasioned.  You  have  remarked,  I 
trust,  the  gradual  increase  of  the  disorder,  from  its  commencement  on 
the  24th  of  May  until  the  6th  of  July,  when  you  saw  Dr.  Green  himself 
pass  the  sponge  into  the  larynx,  and  the  immediate  effect  it  occasioned. 
Lastly,  from  that  moment  you  saw  the  case  get  better,  and  terminate  in 
perfect  cure  eight  days  afterwards.  Xo  stronger  evidence  could  be 
offered  you  in  any  single  case  of  the  benefit  to  be  derived  ii-om  a  local 
application,  especially  when  it  is  considered  that  the  usual  treatment  had 
been  actively  employed,  consisting  of  leeches  externally,  gargles,  and  the 
application  of  a  strong  solution  of  nitrate  of  silver  to  the  fauces,  pharynx, 
and  epiglottis  without  any  benefit.  It  was  only  when  the  application 
Avas  maxle  directly  to  the  part  affected  that  good  was  obtained.  The 
second  case,  though  more  chronic,  and  though  she  went  out  before  a 
perfect  cure  was  obtained,  is  also  calculated  to  impress  upon  you  the 
value  of  this  treatment. 

The  instruments  to  be  employed  are,  first,  a  tongue  depressor,  with  a 
bent  handle,  such  as  I  now  show  you,  by  means  of  which  the  tongue 
can  be  firmly  pressed  down,  so  as  to  expose  the  whole  of  the  fauces,  and 
the  upper  edge  of  the  epiglottis.  In  doing  this,  some  patients  experience 
no  inconvenience,  whilst  in  others  there  is  such  excessive  irritability,  that 
spasmodic  cough  or  even  vomiting  is  occasioned,  which  prevents  the  pos- 
sibility of  seeing  the  epiglottis.  "Secondly,  a  whalebone  probang,  about 
ten  inches  longjiaving  at  its  extremity  a  round  piece  of  the  finest  sponge, 
about  the  size  of  a  gun^  or  pistol  bullet.  The  probang,  towards  the 
extremity,  must  be  bent  in  a  curve,  which,  according  to  Dr.  Green, 
ought  to' form  the  arc  of  one  quarter  of  a  circle  whose  diameter  is  four 
inches.  Sometimes  the  curve  must  be  altered  to  suit  particular  cases ; 
and  when  it  is  thought  necessary  to  pass  it  into  the  trachea,  the  curve 
must  be  considerably  less.  It  is  important  that  the  sponge  be  fine,  and 
capable  of  imbibing  a  considerable  quantity  of  fluid  ;  that  it  be  sev:n 
firmly  to  the  extremity  of  the  whalebone,  and  that  this  last  should  not 
be  cut  in  the  form  of  a  bulb,  but  tapered  as  much  as  is  consistent  with 
firmness. 

The  solutions  of  the  nitrate  of  silver  which  will  be  found  most  useful 
are  of  two  strengths.  One  is  formed  of  3ij  and  the  other  3j  of  the 
crystallised  salt  to  an  ounce  of  distilled  water.  On  some  occasions  a 
solution  of  the  sulphate  of  copper  has  been  found  beneficial,  and  it  is 
very  possible  that  as  our  experience  of  this  kind  of  treatment  extends,^ 
the  application  of  other  substances  in  solution  may  be  found  capable  of 


596  DISEASES   OF   THE   EESPIEATORY   SYSTEM. 

meeting  particular  indications.  Some  have  used  Tr.  of  Iodine,  others, 
sohitions  of  various  salts,  and  Dr.  Scott  Alison,  in  cases  of  great  irrita- 
bility, has  recommended  olive  oil. 

The  method  of  introducing  the  sponge  which  I  have  found  most  suc- 
cessful, is  as  follows : — The  patient  being  seated  in  a  chair  and  exposed 
to  a  good  light,  you  should  stand  on  his  right  side,  and  depress  the 
tongue  with  the  depressor  held  in  the  left  hand.  Holding  the  probang 
in  the  right  hand,  the  sponge  having  been  saturated  in  the  solution,  you 
pass  it  carefully  over  the  upper  surface  of  the  instrument,  exactly  in  the 
median  ^^fone,  until  it  is  above  or  immediately  behind  the  epiglottis. 
You  now  tell  the  patient  to  inspire,  and  as  he  does  so,  you  drag  the 
tongue  slightly  forwards  with  the  depressor,  and  thrust  the  probang 
downwards  and  forwards  by  a  movement  which  causes  you  to  elevate  the 
right  arm,  and  brings  your  hand  almost  in  contact  with  the  patient's 
face.  This  operation  requires  more  dexterity  than  may  at  first  be  sup- 
posed. The  rima  glottidis  is  narrow,  and  unless  the  sponge  come  fairly 
down  upon  it,  it  readily  slips  into  the  oesophagus.  Its  passage  into  the 
proper  channel  may  be  determined  by  the  sensation  of  overcoming 
a  constriction,  which  you  yourself  experience  when  the  sponge  is 
momentarily  embraced  by  the  rima,  as  well  as  by  tlie  momentary  spasm 
it  occasions  in  the  patient,  or  the  harsh  expiration  which  follows, — 
symptoms  which  arc  more  marked  according  to  the  sensibility  of  the 
parts. 

If  the  probang  be  properly  prepared,  and  the  operation  well  per- 
formed, the  actions  which  take  place  are  as  follows : — 1st,  Tlie  sponge, 
saturated  with  the  solution,  is  rapidly  thrust  through  the  rima  into  the 
larynx,  and  frequently  into  the  trachea  ;  for  if  the  distance  of  the  pro- 
bang  be  measured  from  that  portion  of  it  which  comes  in  contact  with 
the  lips,  the  extent  it  has  been  thrust  downwards  can  be  pretty  accu- 
rately determined.  I  am  persuaded  that  on  many  occasions  I  have 
passed  it  pretty  deep  into  the  trachea,  not  only  from  the  length  of  the 
probang  which  has  disappeai'ed,  but  also  from  the  sensations  of  the 
patient,  although  this  may  be  thought  by  some  a  fallacious  method  of 
determining  the  point.  In  this  first  part  of  the  operation,  the  rima  glot- 
tidis is,  as  it  were,  taken  by  surprise,  and  the  sponge  enters,  if  the  right 
direction  be  given  to  it,  without  dilficulty.  But  2d,  the  rima  glottidis 
immediately  contracts  by  reflex  action,  so  that  on  withdrawing  the 
instrument  you  feel  the  constriction.  This  also  squeezes  out  the  solution, 
which  is  diffused  over  the  laryngeal  and  tracheal  mucous  membrane. 
Xow,  if  the  sponge  be  a  fine  one,  it  will  be  found  capable  of  holding 
about  3  ss  of  fluid,  the  effect  of  which  upon  the  secretions  and  mucous 
surface  almost  always  produces  temporary  relief  to  the  symptoms,  and 
strengthens  the  tone  of  the  voice, — results  at  once  apparent  after  the 
momentary  spasm  has  abated.  3d,  The  action  of  the  nitrate  of  silver 
solution  is  not  that  of  a  stimulant,  but  rather  that  of  a  calmative  or 
sedative.  It  acts  chemically  on  the  mucus,  pus,  or  other  albuminous 
fluids  it  comes  in  contact  with,  throws  down  a  copious  white  precipitate, 
in  the  form  of  a  molecular  membrane,  which  defends  for  a  time  the 
tender  mucous  surface  or  irritable  ulcer,  and  leaves  the  passage  free  for 
the  acts  of  respiration.  Hence  arises  the  feeling  of  relief  almost  always 
occasioned,  with  that  diminution  of  irritability  in  the  parts  which  is  so 


LARYXG-ITIS.  597 

favourable  to  cure,  and  why  it  is  that  strong  solutions  of  the  salt  are 
much  more  efficacious  than  weak  ones.  It  may  be  easily  conceived  that 
such  good  effects  must  be  more  or  less  advantageous  in  almost  all  the 
diseases  that  affect  parts  so  sensitive,  fi-om  whatever  cause  they  may 
arise ;  and  that  this  treatment  is  not  only  adapted  to  one  of  the  diseases 
of  the  larynx,  but,  like  all  important  remedies,  meets  a  general  indica- 
tion of  wliich  the  judicious  practitioner  will  know  how  to  avail  himself. 

The  mucous  membrane  of  the  larynx  consists  of  ciliated  epithelium 
externally,  a  basement  layer  below  this,  and  areolar  tissue  internally, 
richlv  supplied  with  blood-vessels.  Scattered  over  its  surface  are  nume- 
rous follicles,  which  secrete  mucus.  It  is  liable  to  the  same  structural 
alterations  as  all  other  similar  membranes,  which  may  be  divided  into — 
1st,  Exudation,  into  the  areolar  tissue  between  the  basement  membrane 
and  epithelium,  or  upon  the  external  suiface  ;  ild.  Abrasions  or  desqua- 
mations of  the  epithelial  layer  ;  3d,  Ulcerations  extending  more  or  less 
deep  into  the  areolar  tissue  :  and  4th,  Obstruction,  swelling,  and  subse- 
quent ulceration  of  the  mucous  follicles,  a  lesion  particularly  described 
bv  Dr.  Horace  Green,  and  denominated  by  him  "  follicular  disease  of 
the  air  passages."  These  different  lesions  may  be  more  or  less  compli- 
cated with  each  other,  and  will  vary  in  intensity  according  to  the  rapidity 
of  their  progress,  and  the  extent  to  which  the  mucous  membrane  is 
implicated.  "Sometimes  the  exudation  is  thrown  out  quickly  and  infil- 
trates the  textures,  as  in  osdema  glottidis,  or  in  malignant  angina.  At 
other  times  it  is  poured  out  on  the  surface  as  in  croup.  More  frequently 
it  is  partial,  occasioning  subsequent  abrasion  or  ulceration,  and  the  acute 
disease  becomes  chronic.  Perhaps  the  most  common  form  it  assumes  is 
when  it  is  chronic  from  the  commencement,  sometimes  dependent  on 
atmospheric  changes,  at  other  times  on  repeated  attacks  of  "  cold  ;  "  in 
a  third  class  dependent  on  too  much  straining  of  voice,  as  occurs  in 
public  speakers,  clergymen,  singers,  etc.,  and  occasionally  it  is  connected 
with  some  general  constitutional  disorder,  as  syphilis,  tubcrcidosis,  or 
some  form  of  cancer.  All  these  forms  of  laryngeal  disease  may  be  further 
associated  with  similar  lesions  of  the  fauces,  tonsils,  uvulse,  and  pharynx. 

The  symptoms  will  of  course  vary  according  to  these  different 
circumstances.  The  acute  forms  are  accompanied  with  general  fever, 
considerable  local  pain,  more  or  less  obstruction  to  deglutition  and 
respiration,  and  loss  or  alteration  in  the  character  of  the  voice.  As  a 
general  rule,  it  may  be  said  that  lesions  of  the  fauces,  tonsils,  and 
neighbouring  parts,  are  indicated  by  greater  or  less  diflSculty  or  uneasi- 
ne^  in  swallowing,  whilst  the  laryngeal  disorder  is  evinced  by  changes 
in  the  character  or  power  of  sustaining  the  voice.  Then,  as  a  general 
result  of  the  local  irritation,  spasmodic  action  is  evinced,  and  we  have 
cough,  at  first  dry,  but  afterwards  attended  with  mucus  or  purulent 
expectoration,  and  not  unfrequently  with  discharge  of  blood.  Elongation 
of  the  uvula  may  produce  these  effects.  It  has  been  lately  supposed 
that  hooping-cough  is  only  an  obscure  form  of  laryngeal  disease.  In 
the  more  acute  and  extensive  cases  of  exudative  laryngitis,  the  spasms 
are  more  violent  and  prolonged,  and  the  greatest  caution  is  necessary  in 
watching  persons  so  affected,  lest,  from  sudden  and  continued  closui-e  ot 
the  glottis,  fatal  asphyxia  be  induced.  The  following  case  is  very 
instructive  in  this  point  of  view. 


598  DISEASES   OF   THE  •  KESPIRATORY   SYSTEM. 


Case  CXVI.* — Acuie  (Edema  of  the  Glottis — Chronic  Pharyngitis  and  Laryngitis — 

Sudden  Death. 

History. — Frances  Nichol,  fet.  25,  a  shoe-binder,  married — was  admitted  in  the 
evening  of  February  26,  1851,  complaining  of  sore  throat,  but  breathing  easily,  and 
otherwise  presenting  no  urgent  symptoms.  She  has  suffered  from  cough  upwards 
of  four  years,  had  secondary  syphilis,  and  ulcerations  in  the  tlu'oat  for  twelve 
months. 

Symptoms  on  Admission. — At  the  visit  I  found  her  breathing  to  be  laborious  and 
noisy ;  cough  frequent ;  expectoration  difficult,  with  fr-othy  sputum  tinged  with 
blood;  countenance  anxious;  lips  livid;  pulse  130,  small  and  soft;  cannot  speak, 
nor  can  any  one  give  any  account  of  her.  On  examining  the  mouth  and  fauces,  the 
mucous  membrane  was  seen  to  be  covered  with  tenacious  muco-purulent  matter. 
The  soft  palate  is  perforated  by  ulcerations  the  size  of  a  pea  in  three  places ;  there 
is  another  ulcer  the  size  of  a  fourpenny  piece  on  the  roof  of  the  mouth.  The  tonsils 
and  mucous  membrane  surrounding  the  glottis  were  somewhat  swollen,  but  not 
unusuallj'  red.  On  percussing  the  chest,  no  dulness  could  anywhere  be  detected. 
Eespiratory  murmurs  over  the  large  air-tubes  loud  and  harsh,  with  occasional 
mucous  rale,  but  their  character  masked  by  the  loud  snoring  noise  in  the  larynx. 
To  have  §  ss  of  wine  every  half  hour ;  an  antispasmodic  mixture  of  sul2)huric  cether, 
ammonia,  and  opium:  the  idcers  and  mucous  membrane  of  the  fauces  to  he  sponged 
with  a  iveak  solution  of  nitrate  of  silver,  and  the  steam  inhaler  to  he  used  assiduously. 

Progress  of  the  Case  — These  remedies  alleviated  all  her  symptoms,  so  that  in 
the  evening  she  gave  a  history  of  her  case.  Seeing  that  she  was  so  much  better  at 
the  evening  visit  of  tlie  house-clerk,  the  intensity  of  the  disease  was  supposed  to  have 
abated,  but  in  the  morning  she  was  found  dead  in  bed. 

Sectio  Cadaveris. — Fifti)  hours  after  death. 

Pharynx,  Larynx,  and  Trachea. —  The  opening  of  the  fauces  was  considerably 
contracted;  and  the  mucous  membrane  of  the  tonsils,  soft  palate,  and  from  this  to 
the  root  of  the  tongue,  presented  numerous  ulcerations,  extending  to  the  submucous 
tissue,  and  undermining  to  some  extent  the  mucous  membrane.  The  ulcers  were 
mostly  rounded  in  form,  of  exceedingly  various  size,  up  to  a  diameter  of  three-eighths 
of  an  inch;  the  edges  not  at  all  elevated,  and  for  the  most  part  smooth,  as  though 
scooped  out  by  a  punch.  The  floors  of  the  ulcers  consisted  of  the  submucous  tissue, 
perfectly  clean  and  pale,  without  the  least  trace  of  granulations  or  pus.  The  neigh- 
bouring mucous  membrane  was  scarcely  at  any  point  more  vascular  than  natural. 
The  aryteno-epiglottidean  folds  were  hypertrophied, — that  of  the  right  side  being 
thickened  and  oedematous,  that  of  the  left  being  flaccid  and  relaxed.  They  could 
be  made  to  lie  in  apposition,  so  as  almost  to  close  the  opening  of  the  glottis.  The 
mucous  membrane  of  the  entire  larynx  was  somewhat  rose-coloured ;  and  the  sub- 
mucous tissue  of  the  epiglottis,  the  chorda3  vocales,  and  the  ventricles,  considerably 
infiltrated  with  fluid.  Throughout  the  trachea,  the  membrane  was  of  a  rose  colour, 
becoming  deeper  towards  the  bronchi,  and  was  everywhere  covered  with  a  thick 
mucus,  which  lay  in  semi-transparent  drops,  the  size  of  a  very  small  pin's  head,  on 
the  opening  of  the  follicles. 

Thorax. — The  tissue  of  the  lungs  was  for  the  most  part  healthy,  but  here  and 
there  a  few  small  portions  of  its  substance  Avere  collapsed.     The  mucous  membrane 

^  *  Reported  by  Mr.  Henry  Thom,  Clinical  Clerk. 


LARYNGITIS. 


599 


of  the  larger  bronchi  was  congested,  and  the  smaller  ones  on  the  right  side  yielded 
drops  of  purulent  mucus,  on  compressing  the  cut  surface  of  the  lung. 

ABDOiiEX  — There  were  several  small  cancerous  nodules  in  the  liver,  but  all  the 
other  organs  were  health}'. 

Commentary. — In  tins  case  I  tliink  there  can  be  little  doubt  that 
durino-  the  night  some  obstruction  occurred  to  the  breathing,  dependent 
on  the  local  disease,  which  caused  asphyxia  and  death.  Neither  can  we 
have  anv  hesitation  in  thinking-,  that  had  tracheotomy  been  performed 
in  time,*life  would  have  been  saved,  inasmuch  as  the  tissue  of  the  lungs 
was  healthy,  and  the  only  lesion  found  in  those  organs  was  a  trifling 
broncliitis.  No  doubt  the  amelioration  of  the  symptoms  which  was 
observed  at  the  evening  visit  removed  the  idea  of  urgency,  but  this  is 
just  the  reason  I  have  cMtedthe  case,  as  a  lesson  to  all  of  us,  Avith  regard 
to  the  watchfulness  which  is  necessary  in  the  treatment  of  such  disorders. 
In  another  case,  occurring  in  a  man  who  entered  the  clinical  ward, 
laboui'ing  under  symptoms  so  similar  that  I  need  not  detail  them,  I 
ordered  Iracheotorny  to  be  performed  at  once,  and  the  result  was  the 
preservation  of  life  'and  restoration  to  health,  although  the  ulceration 
destroved  the  vocal  cords,  and  the  aphonia  was  complete. 

Case  G^Yll.*— Chronic  Laryngitis  and  Fharyngitis— Tracheotomy— Rtcovery. 

History.— Hugh  Martin,  tet.  35,  labourer— admitted  Dec.  28th,  1849.  Says,  that 
six  years  ago  he  had  gonorrhoea,  without  any  other  form  of  venereal  affection. 
Twelve  months  since  he  was  treated  with  calomel  for  some  swellings  below  his  jaw, 
and  shortly  after  having  cauglit  cold,  was  affected  with  sore  throat.  Subsequently 
he  was  again  treated  with  mercury  in  the  Glasgow  Infirmary,  and  havuig  again 
caught  cold,  his  throat  became  worse. 

Sympto-ms  ox  Admission.— His  general  appearance  is  cachectic  and  emaciated.  His 
speech  is  almost  inaudible,  and  the  upper  part  of  a  large  ulcer  is  seen  deep  down  in 
the  pharynx.  Respiration  is  evidently  impeded  and  accompanied  by  hoarse  tubular 
breathing,  heard  on  placing  a  stethoscope  over  the  larynx.  Pulmonary  sounds  feeble, 
and  resonance  good  everywhere  on  percussion  over  the  lungs.  Has  slight  cough 
with  muco-purulent  expectoration,  not  so  cgpious,  he  says,  as  it  has  been.  Has  pain 
in  deglutition,  which  often  excites  violent  cough.  Pulse  82,  of  natural  strength. 
Other  functions  well  performed.  The  urine  contains  hexagonal  i)lates  of  cystine, 
mingled  with  crystals  of  uric  acid. 

Progress  of  the  Gxs^.—Decemler  30<ft.— Topical  applications  of  a  weak  solution 
of  nitrate  of  silver  internall}%  and  warm  fomentations  to  the  throat  externally,  have 
failed  to  cause  relief.  Breathing  still  impeded  and  difficult ;  voice  extinct.  Trache- 
otomy vjos  performed,  and  a  tube  inserted.  January  Wth. — Since  the  operation,  he 
has  breathed  freely  through  the  tube,  and  feels  much  easier.  The  ulcer  in  the 
pharynx  has  been  touched  occasionally  with  nitrate  of  silver,  and  is  now  healed. 
Has  considerable  difficulty  in  expectorating  mucus  through  the  tube.  To  have  steak 
diet.  Dec.  20th.— A  solution  of  nitrate  of  silver  (2  gr.  to  H  of  water)  to  he  ajJl^Ued  to 
the  inside  of  the  trachea  every  other  day,  by  means  of  a  sjwnge  attached  to  a  slip  of  bent 
whalebone.  Dec.  23(Z.— Has  been  greatly  relieved  by  the  topical  application  to  the 
trachea.  Strength  of  solution  to  be  increased  to  Argent.  ML  gr.  v.  to  §  j  tvater,  and 
applied  daily.     Dec.  2Gtli.— Strength  of  solution  further  increased  to  gr.  x.  of  the  salt  to 

*  Reported  by  ilr.  Hugh  M.  Balfour,  Clinical  Clerk. 


600  DISEASES   OF   THE   EESPIEATOEY  SYSTEM. 

"^i  of  water.     From  tliis  time  the  muco-purulent  expectoration  gradually  subsided. 

^.  Potass.  lodid.  §ss;  Tr.  Gent,  c.^j;  Inf.  Gent.  c.  Iv.  M-H  to  he  iaJcen  three 
times  a  day.  February  10th. — The  tube  was  removed.  The  voice  returned,  although 
it  remained  very  hoarse,  and  there  was  every  reason  to  believe  that  the  ulcer  in  the 
larynx,  if  not  perfectly  cicatrized,  was  nearly  so,  when  he  went  out,  February-  20th. 

Commentary. — In  this  case  traclieotomy  was  performed,  not  so  much 
with  the  view  of  relieving  urgent  s3'mptoms,  as  to  secure  rest  and  immo- 
bility to  the  larynx,  so  that  the  ulcerations  might  cicatrize.  This  object 
was  effected,  and  the  man  slowly  got  well.  First,  the  nicer  in  the 
pharynx  healed,  and  subsequently  that  in  the  larynx,  although,  when  the 
tube  was  removed  from  the  trachea,  it  was  apparent  that  the  vocal  cords 
had  been  partially  destroyed.  At  the  time  this  case  was  treated,  the 
mode  of  application  by  means  of  sponges  to  the  interior  of  the  larynx 
was  unknown.  The  record  shows,  however,  that  in  1849  I  applied  a 
nitrate  of  silver  solution  directly  to  the  trachea,  through  the  aperture 
made  for  the  tube,  w'hich  was  from  time  to  time  removed  for  that  pur- 
pose. I  then  found  its  use  very  beneficial  in  checking  the  amount  of 
muco-purulent  secretion,  and  increased  the  strength  of  the  solution  from 
two  to  ten  grains  of  the  salt  to  an  ounce  of  water.  The  man  complained 
of  no  pain  or  inconvenience  of  any  kind  from  these  applications.  He 
had  undergone  two  courses  of  mercury,  and  so  far  as  his  own  statements 
are  to  be  relied  on,  Avithout  any  other  form  of  venereal  disease  than  that 
of  gonorrhoea,  and  swellings  below  the  jaw.  Even  supposing  that  these 
latter  were  originally  venereal,  it  is  certain  that  the  mercury  produced  no 
benefit,  but,  on  the  contrary,  while  the  local  disease  was  making  progress, 
it  so  affected  his  general  health,  as  to  occasion  emaciation  and  general 
cachexia.  We  have  seen  that  the  ulcers  healed  under  a  non-mercurial 
treatment,  and  that  his  health  improved  under  tonics  and  good  diet. 

The  diagnosis  of  laryngitis  is  most  important,  and  must  be  derived, — 
1st,  From  the  general  symptoms ;  2d,  From  the  results  obtained  by 
careful  examination  of  the  air-tubes  and  lungs  by  auscultation  and  percus- 
sion ;  and  3d,  From  an  inspection  of  the  parts.  With  regard  to  the 
general  symptoms,  I  have  already  alluded  to  the  relative  value  to  be 
attached  to  difficulties  of  deglutition  and  of  speech.  Concerning  the 
difficulties  of  respiration,  the  nature  of  the  expectoration,  and  the  cough, 
Ave  cannot  with  certainty  refer  them  to  the  larynx,  Avithout  a  careful 
study  of  the  condition  of  the  pulmonary  organs.  Indeed,  the  attention 
Avhich  has  been  lately  directed  to  the  fauces  and  larynx,  in  consequence 
of  the  Avritings  of  Dr.  Horace  Green,  has  demonsti'ated  the  important 
fact,  that  many  of  those  disorders  which  have  sometimes  been  called 
"  chronic  bronchitis,"  and  others  which  have  not  unfrequently  been 
supposed  to  indicate  in  young  persons  incipient  phthisis,  are  really  a 
chronic  form  of  laryngitis,  altogether  local,  and  readily  removed  by  topi- 
cal applications.  The  distinction  betAveen  them,  hoAvever,  often  demands 
the  greatest  care  in  examination,  but  when  a  good  auscultator  fails  to 
detect  the  signs  characteristic  of  bronchitis  or  phthisis  pulmonalis,  Avhilst, 
on  the  other  hand,  there  is  unusual  hoarseness  or  shrillness  of  the  laryn- 
geal murmur,  dryness  of  the  throat,  and  hacking  cough,  sometimes 
accompanied  by  muco-purulent  expectoration,  or  even  occasional  spitting 


LAKYXGITIS.  601 

of  blood,  then  his  suspicions  may  be  directed  to  laryngeal  rather  than  to 
pulmonary  disorder.  It  is  the  more  important  to  notice  this,  because  a 
good  authority  has  lately  stated,— "  Expectoration  of  blood  in  persons 
labouring  under  chronic  bronchitis,  with  or  without  emY^hysema,  but  with- 
out notjTble  disease  of  the  heart,  justities  in  itself  a  suspicion  of  the 
existence  of  latent  tubercles."— (Walshe.)  In  making  this  diagnosis, 
however,  I  must  recommend  to  yon  the  exercise  of  the  greatest  caution, 
and  especially  not  to  confound  the  natural  hoarseness  _  heard  in  the 
larynx  of  some  individuals  with  the  coarse  sounds  heard  in  others  only 
when  the  oro-an  is  diseased. 

The  examniation  of  the  throat  and  upper  edge  of  the  epiglottis  will  do 
much  to  remove  any  difficulty  you  may  experience,  because  in  many  cases 
alterations  of  the  mucous  membrane  of  the  larynx  follow  and  accompany 
similar  changes  in  the  mucous  membrane  of  the  fauces  and  pharynx. 
Indeed,  it  may  be  accepted  as  a  general  law,  which  admits  of  but  few 
exceptions,  that  morbid  changes  in  the  mucous  membranes  of  the  pharynx 
and  larvnx  proceed  from  above  downwards,  as  is  well  observed  in  scarla- 
tina.    Lesions  often  attack  the  fjuices  or  tonsils  and  spare  the  larynx ; 
but  if  long  continued,  the  latter  is  affected  consecutively.     Hence  why 
chronic,  svphilitic,  and  mercurial  ulcerations  of  the  throat,  have  such  a 
tendency  to  attack  the  larynx.     Again,  when  the  larynx  is  first  attacked, 
as  occurs  among  clergymen,  and  in  the  ordinary  croup  of  children,  the 
follicular  disease  in  the  one,  and  the  coagulated  exudation  in  the  other, 
tend  to  pass  down  the  trachea,  and  not  upwards  into  the  fauces.     It 
follows,  that  when  hoarseness  of  the  voice,  cough,  and  other  laryngeal 
symptoms  are  accompanied  by  abrasions  or  ulcerations  in  the  mucous 
membrane  of  the  soft  palate  or  uvula,  by  thickening  or  irregularity  in 
the  epiglottis,  and  especially  by  the  follicular  disease  formerly  alluded  to 
— presenting  elevated  pimples  more  or  less  numerous  scattered  over  the 
parts — there  is  every  reason  to  believe   that   the    larynx    is    similarly 
affected.     The  tongue-depressor  previously  referred  to,  will  enable  you  to 
examine  these  parts  with  the  greatest  ease,  and  in  most  cases  the  upper 
edge  of  the  epiglottis  will  with  its  aid  be  brought  into  \\tv,\  _  Still  it  is 
only  by  inference  that  we  can  form  an  opinion  of  the  condition  of  the 
larynx!^     Indeed  in  many  cases,  even  the  summit  of  the  epiglottis  cannot 
be  seen,  the  larynx  being  so  deep-seated  that  it  cannot  be  brought  into 
view  Avith  the  tongue-depressor.     Hence,  as  regards  the  actual  examina- 
tion of  the  mouth\and  throat,  we  only  receive  exact  information  as  to  the 
state  of  the  fauces,  uvula,  tonsils,  and"  back  of  the  pharynx;  and  valuable 
as  such  information  is,  we  cannot  determine  by  it  with  exactitude  the 
condition  of  the  glottis.     Occasionally,  under  such  circumstances,  the  fin- 
ger will  give  us  "some  notion,  however  vague,  and  we  may  feel  swelling, 
induration,  or  irregularity  in  the  epiglottis.     But  to  derive  information  in 
this  manner,  tact  and  habit  are  necessary.     On  the  whole,  although  the 
local  examination  with  the  tongue-depressor  should  never  be  omitted,  it 
does  not  in  all  cases  enable  us  to  determine  the  condition  of  the  epiglottis. 
In  no  case  ought  you  to  depend  upon  examination  of  the  parts  alone  :  it 
should  be  conjoined  with  the  knowledge  derived  from  a  careful  gtudy  of  the 
symptoms,  and  of  the  physical  signs  furnished  by  the  air-tubes  and  lungs. 

"  With  regard  to  the  treatment,  you  will  gather  from  what  has  been 
previously  said,  that  I  regard  the  mode  of  applying  topical  remedies 


602  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

introduced  by  Dr.  Green  as  a  most  valuable  addition  to  oui-  other  means 
of  cure.  The  experience  of  that  physician  indicates,  that  the  earlier  it  is 
applied  the  greater  the  chance  of  success,  especially  in  acute  cases  of 
scarlatina  and  croup.  It  was  first  employed  in  hooping-cough  by  Dr.  E. 
Watson  of  Glasgow,  and  has  subsequently  been  tried  in  laryngismus 
stridulus,  hay  fever,  and  other  diseases  hitherto  considered  spasmodic, 
and  with  such  success,  as  to  lead  to  the  conclusion  that  these  disorders 
are  essentially  connected  with  local  irritations  or  an  obscui'C  foi'm  of 
catarrh.  In  various  kinds  of  laryngeal  disease  occurring  in  the  adult, 
whether  primary  or  secondary,  I  have  employed  it  very  extensively,  in 
many  instances  with  permanent  good  results,  and  in  a  large  number  with 
temporary  alleviation.  Indeed,  nothing  is  more  remarkable  than  the 
immediate  eft'ect  it  has  in  clearing  the  throat  and  improving  the  tone  of 
the  voice,  and  hence,  in  many  cases  which  do  not  admit  of  cure,  it 
may  be  employed  as  a  palliative.  As  such,  I  have  successfully  used 
it  in  old  cases  of  chronic  laryngitis  and  bronchitis,  clergyman's  sore 
throat,  spasmodic  asthma  with  accumulation  of  mucus  in  the  ti'achea,  and 
so  on.  In  syphilitic  and  confirmed  tubercular  laryngitis,  though  not  so 
beneficial,  it  is  still  in  some  cases  decidedlj'  useful.  I  have,  however,  met 
with  several  instances  where  it  has  been  very  injudiciously  employed, 
and  others  where  the  sponge  had  been  passed  by  unskilful  hands  repeat- 
edly down  the  oesophagus  without  any  good  effect,  the  patient  having 
been  persuaded  for  a  considerable  period  that  it  had  been  applied  to  the 
larynx.  Circumstances  of  this  kind  may  bring  the  practice  into  disre- 
pute with  some,  but  I  trust  you  will  discriminate,  and  neither  lightly 
abandon  it  from  a  few  failures,  nor  be  led  into  the  opposite  error,  of  sup- 
posing, from  one  or  two  favourable  cases,  that  it  is  capable  of  being  inva- 
riably' successful. 

BROXCHITIS. 

Case  CXVIII.* — Acute  Bronchitis — Recovery. 

History. — Catherine  Mulvie,  JEt.  21,  a  servant — admitted  July  21,  1851.  She 
states  that  two  weeks  ago,  when  in  a  state  of  perspiration,  she  took  a  batli  in  the 
open  sea.  Tlie  same  evening  slie  was  attacked  with  rigors  and  otlier  febrile  symp- 
toms, and  on  the  next  day  there  was  a  dry  cough,  difficulty  of  breathing,  and  a  sense 
of  oppression  in  the  chest.  The  cougli  has  continued  since  with  more  or  less  expec- 
toration, but  the  febrile  symptoms  have  al^ated. 

Symptoms  ox  Admissiox. — On  percussion  there  is  no  unusual  dulness  over  the 
lungs.  On  auscultation,  there  is  harshness  of  the  inspiratory  murmur  anteriorly ; 
and  posteriorly  and  inferiorly,  on  both  sides  of  chest,  coarse  crepitation.  There  is 
frequent  cough,  with  slight  muco-purulent  expectoration ;  general  debUit}* ;  head- 
ache; soreness  in  the  limbs;  occasional  palpitations  of  the  heart,  the  sounds  of 
which  organ,  however,  are  healthy.  Pulse  62,  full.  Digestive  and  genito-urinary 
sj'stems  normal. 

Progress  of  the  Case. — Under  the  use  of  small  doses  of  antimonials  with 
opiates,  followed  by  expectorants,  the  pulmonary  symptoms  rapidly  diminished.  On 
the  23d  the- coarse  crepitation  had  nearly  disappeared,  and  the  expectoration  was 
much  diminished  in  quantity.     Ou  the  25th  the  respirator}-  murmurs  on  the  right 

*  Reported  by  Mr.  D.  0.  Hoile,  Clinical  Clerk. 


BRONCHITIS.  603 

side  were  healthy,  and  on  the  left  side  there  only  remained  slight  harshness  with 
occasional  fine  sibilation  on  inspiration  posteriorly.  Cough  and  expectoration  were 
so  trifiing  that  she  was  dismissed. 

Comnientartj. — This  was  an  uncomplicated  case  of  acute  bronchitis, 
which  had  nearly  run  its  course  before  admission.  It  presents  an 
average  specimen  of  a  class  of  cases  exceedingly  common  both  in  hos- 
pital and  private  practice.  The  repose  of  the  house,  aided  by  expecto- 
rants and  opiates,  sufficed  for  the  cure. 

Case  CXIX.*— ^czite  BroncMiis. 

History.— Martin  Conolly,  set.  25,  a  robust  labourer— admitted  May  15th,  1857. 
On  the  7th  of  May,  after  working  some  days  standing  in  water,  he  had  a  rigor,  with 
great  heat  of  skin,  followed  by  profuse  perspiration,  but  no  headache.  He  continued 
at  his  work  till  10th  May,  when  he  was  confined  to  bed,  the  pain  having' got  worse. 
Cough  commenced  the  previous  day,  accompanied  with  a  tliick  yellow  sputum,  and 
these  symptoms  with  dyspnoea  have  gradually  increased  in  severity  up  to  his 
admission. 

Syjiptoms  on  Admission. — Form  of  chest  unusually  rounded  and  well  developed. 
Anteriorly,  percussion  is  clear  on  both  sides.  On  auscultation,  inspiration  is  short- 
ened ;  expiration  prolonged,  and  accompanied  by  long  sibilant  and  sonorous  rales. 
Vocal  resonance  weak,  but  equal  on  both  sides.  Posteriorly  there  is  clear  resonance 
on  percussion  on  both  sides.  On  auscultation,  the  same  sibilant  and  sonorous  rales 
accompany  expiration,  and  are  occasionally  but  rarely  heard  with  inspiration,  which 
at  the  right  base  is  accompanied  by  moist  rales.  Cough  and  dyspnoea  urgent. 
Respirations  .36  per  minute.  Expectoration  gelatinous  and  muco-purulent.  Cardiac 
sounds  somewhat  masked,  but  normal.  Fulse  122,  strong,  full,  and  regular.  Skin 
hot,  but  otherwise  normal.  Tongue  moist  and  clean.  Appetite  much  impaired. 
Thirst  great.  Bowels  regular.  Urine  high  coloured,  otherwise  normal.  Vene- 
section to  14  oz.  was  performed  by  Dr.  Bennett  without  any  immediate  relief,  and 
§  ss  of  the  following  mixture  ordered  to  be  taken  every  four  hours.  B  Aqua  Acetatis 
Ammonia  §  iss ;  Spirit,  ^ther.  Nitric.  3  ij ;  Fm.  Aniimonial.  3  ij ;  Mu<^  ad  %  vj. 
In  the  evening  dyspnoea  had  much  diminished.  Respirations  2A  per  minute.  Pulse 
108,  still  regular,  full,  and  strong.     Heat  of  skin  less. 

Progress  of  the  Case. — Next  day  improvement  was  found  to  continue.  Pulse 
116,  full,  but  softer  than  yesterday.  Sibilations  no  longer  audible  with  expiration. 
The  moist  sounds  are  fainter  and  less  abundant  than  at  last  examination.  May 
ISih. Sibilant  and  cooing  rales  accompany  both  respiratory  acts  posteriorly.  Ante- 
riorly these  sounds  are  less  intense,  but  are  accompanied  by  fine  crepitus.  Under 
the  left  nipple,  crepitus  is  mixed  with  a  certain  harshness,  both  on  expiration  and 
inspiration  (friction?).  Urine  rendered  turbid  by  the  presence  of  urates.  Pulse  116, 
of  the  same  character  as  yesterday.  3Iay  19th  (twelfth  day  of  the  disease).— 
Patient  was  found  bathed  ia  profuse  perspiration.  The  moist  sounds  are  diminish- 
ing in  amount.  Crepitation  still  audible  under  left  nipple.  Patient  still  complains 
of  pain  in  that  region,  but  tliere  is  no  friction.  Cough  continues,  but  is  less  severe. 
Sputum  still  copious  and  muco-purulent.  Pulse  102,  soft.  Appetite  improving. 
Skin  moist.  Urine  throws  down  a  copious  sediment  of  urates.  May  21st  (four- 
teenth day).— Patient  still  perspires  profusely.  Crepitation  with  fine  sibilus  still 
heard  anteriorly,  most  distinctly  under  left   nipple.      Pain  in  left  side  continues, 

*  Reported  hy  Mr.  W.  H.  Davis,  Clinical  Clerk. 


604  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

being  most  severe  on  deep  iDspiratiou.  Sputum  diminished  in  quantity,  muco- 
purulent. Pulse  100,  soft  and  full.  On  the  25th,  moist  rattle  had  nearly  disap- 
peared. On  the  29th,  sibilations  were  very  faint,  the  cough  was  trifling,  and  sputum 
nearly  gone.     June  Uli. — He  was  discharged  quite  well. 

Commentary. — This  was  a  case  of  violent  acnte  bronchitis  of  both 
lungs,  in  a  strong  vigorous  man.  On  admission,  so  great  was  his 
dyspnoea,  that  I  bled  him  with  a  view  of  determining  whether  the 
remedy  would  relieve  that  symptom.  I  satisfied  myself  that  it  had  no 
immediate  effect,  and  the  disease  subsequently  ran  ils  natural  course,  ter- 
minating in  perfect  recovery  on  the  twenty-first  day. 

Bronchitis,  like  laryngitis,  consists  of  an  exudation  infiltrated  into  the 
various  tissues  forming  the  bronchi,  or  coagulated  upon  their  mucous 
surface.  It  terminates  in  the  transformation  of  this  exudation — accord- 
ing to  laws  previously  explained,  p.  124,  et  seq, — into  matters  which 
permit  of  being  either  absorbed  into  the  blood  or  expectorated.  At 
first  the  lesion  causes  increased  dryness,  narrowing,  and  rigidity,  and 
subsequently  moisture,  dilatation,  and  relaxation  of  the  tubes.  Owing 
to  these  changes,  the  vibrating  sounds  caused  by  the  passage  of  air 
through  the  bronchi  undergo  variations,  which  indicate  pretty  clearlv 
the  dry  or  moist  nature  of  the  disease,  or,  as  some  term  it,  dry' or  moist 
catarrh. 

Acute  bronchitis  may  differ  in  intensity,  from  an  affection  very  trifling 
and  scarcely  regarded,  to  one  which  very  nearly  approaches  in  severity 
a  decided  attack  of  pneumonia.  It  may  be  epidemic,  and  constitute 
what  is  called  influenza.  It  may  follow  or  precede  a  similar  lesion  in 
the  lining  membrane  of  the  nasal  passages,  that  is,  coryza.  These  affec- 
tions are  so  common  as  to  be  generally  treated  by  domestic  medicines 
only,  or,  it  may  be,  totally  disregarded.  But  there  can  be  no  doubt  that 
a  disposition  to  attacks  of  this  kind,  though  they  may  often  occur  for  a 
long  time  with  impunity,  frequently  leads  to  the  incurable  and  distress- 
ing change  of  pulmonary  texture  known  as  emphysema,  with  its  fearful 
accompaniment  of  spasmodic  asthma  and  consecutive  disease  of  the 
heart.  (See  p.  523.)  Bronchitis,  therefore,  is  an  aft'ection  which,  if  not 
checked  early,  should  be  carefully  assisted  through  its  natural  progress. 

To  check  the  progress  of  an  acute  bronchitis  or  coryza,  no  remedv 
seems  so  good  as  a  full  dose  of  morphia  on  the  first,  or  at  latest  second 
night  on  going  to  bed.  In  the  morning  the  patient  should  breakfast  in 
bed,  and  keep  himself  warm  at  home  dui-ing  the  day.  Tliis  treatment, 
which  was  first  recommended  by  Dr.  Christison,  has*  the  effect  of  dimi- 
nishing the  irritation  which  causes  the  exudation,  and  preventing  its 
return.  Should,  unfortunately,  the  disease  progress,  patience  is  peHiaps 
the  best  remedy,  as  the  disease  will  run  its  course.  But  if  the  bronchi 
become  clogged,  sudorifics  and  expectorants,  especially  ipecacuanha,  will 
be  useful,  and  a  blister  will  sometimes  dissipate  any  lingering  trace  of 
the  disease.  The  chief  caution  to  be  given  should  be  to  get  perfectly 
rid  of  the  disorder  before  any  exposure  to  cold  air  be  allowed.  It  is  the 
disregard  of  this  point,  and  the  getting  "  cold  upon  cold,"  which  serves 
so  much  to  keep  up  the  aftection,  and  at  length  induces  the  chronic  form 
of  the  disease. 


BROXCHITIS.  605 


Case  CXX.* — Chronic  BroncMtis — Acute  Peritonitis — Collapse  of  the  Lung. 

History. — Mary  Nichol,  ret.  21,  a  servaut — admitted  July  Sth,  1851.  She  has 
suffered  more  or  less  from  cough  for  the  last  two  years.  Occasionally  it  has  been 
very  troublesome,  but  not  accompanied  by  much  expectoration.  Seven  weeks  ago 
experienced  severe  pain  in  tlie  epigastrium,  and  since  then  the  breathing  has  become 
short  and  hurried. 

Stjiptoms  on  Admissiox. — Anteriorly  the  lungs  are  everywhere  resonant  on 
percussion.  On  auscultation,  the  inspiratory  murmur  is  harsh,  and  towards  its  ter- 
mination flue  sibilant  rales  are  heard.  Posteriorly,  the  right  side  is  more  dull  on 
percussion  than  the  left.  This  is  more  marked  towards  the  apex.  At  this  point 
there  is  harsh  inspiration  and  increased  vocal  resonance.  There  are  also,  over  the 
whole  right  back,  sibilant  rales  during  inspiration.  Cough  with  trifling  mucous 
expectoration ;  respirations  short  and  hurried ;  great  tenderness  over  the  epigastrium, 
increased  on  taking  a  deep  inspiration;  appetite  tolerably  good;  no  nausea  or 
vomiting,  and,  with  the  exception  of  constipation,  digestive  system  healthy ;  pulse 
80,  soft  ;  heart  sounds  natural ;  catamenia  regular ;  urine  voided  with  pam,  and  in 
small  quantity,  otherwise  healthy. 

Progress  of  the  Case. — The  dry  rales  accompanying  the  inspiration  continued 
for  some  days ;  but  on  the  21st  they  became  moist,  and  coarse  crepitation  was  audi- 
ble over  the  inferior  third  of  right  back.  The  cough  became  more  loose  also,  and 
the  expectoration  increased.  On  the  24th,  the  moist  rattles  were  converted  into 
deep  sonorous  murmurs,  and  great  variations  were  heard  from  day  to  day,  evidently 
in  consequence  of  the  greater  or  less  amount  of  fluid  in  the  bronchi.  The  cough 
and  expectoration  also  varied  greatly  in  intensity.  Her  principal  complaint,  how- 
over,  was  the  epigastric  pain,  which,  notwithstanding  the  application  of  leeches, 
warm  fomentations,  opiates,  and  counter-irritants,  continued  to  increase.  On  the 
28th,  there  was  diffuse  swelling  of  the  abdomen,  general  tenderness  of  the  surface, 
and  all  the  symptoms  of  peritonitis  from  intestinal  perforation.  Latterly,  there  was 
dulness  and  absence  of  respiration  over  the  lower  third  of  right  lung.  She  died 
August  10th,  1851 ;  but  unfortunately  no  dissection  could  be  procured. 

Commentarij. — This  girl  laboured  under  a  chronic  bronchitis  of  some 
standing,  which  presented,  during  the  progress  of  the  case,  most  of  the 
physical  signs  characteristic  of  the  disease.  Her  chief  complaint,  how- 
ever, was  a  fixed  pain  in  the  epigastric  region,  which  proved  in  no  way 
amenable  to  treatment,  and  which,  as  the  event  proved,  was  evidently 
connected  with  an  ulcer  either  in  the  stomach  or  neighbouring  intestinal 
viscera,  probably  the  former,  considering  the  frequent  occurrence  of  ulcers 
in  that  viscus  among  servant  girls.  But  in  the  absence  of  the  facts 
which  a  dissection  only  coidd  have  afforded,  all  speculation  on  such  a  point 
is  evidently  useless.  The  dulness  on  percussion  at  the  apex  of  the  right 
lung,  the  harsh  inspiration  and  increased  vocal  resonance,  point  to  the 
existence  of  some  condition  of  the  organ  at  that  point,  giving  it  increased 
density.  They  constitute  the  signs  of  incipient  or  of  cretaceous  tubercle. 
But  percussion  over  the  whole  of  right  back  was  impaired  ;  and  towards 
the  close  of  life,  as  weakness  appeared,  there  was  dulness  and  absence 
of  respiration  over  the  lower  third  of  right  lung.  These  physical  signs 
indicate  collapse  of  the  organ  in  this  situation,  or  a  condition  which  has 

*  Reported  by  Mr.  C.  D  Philips,  Clinical  Clerk. 


606 


DISEASES   OF   THE   RESPIRATOEY    SYSTEM. 


been  variously  called  by  pathologists  "  condensation  " — "  infarction  " — 
"hypostatic  pneumonia" — "  peri-pneumonie  des  agonisaus,"  etc.  etc. 

In  a  series  of  observations  on  bronchitis,  by  Dr.  W.  T.  Gairdner,* 
lie  points  out,  as  one  of  the  most  common  results  of  the  disease,  more 
or  less  collapse  of  the  vesicular  tissue,  dependent  on  obstruction  to  the 
passage  of  air  during  inspiration,  by  glutinous  or  inspissated  mucus. 
This  collapse  is  often  confined  to  individual  lobules,  which  are  con- 
densed, comparatively  heavy,  indurated  to  the  feel,  of  dark  colour,  and 
present  the  usual  characters  of  the  unexpanded  portions  of  lung  in  the 
newly-born  infant  {atelectasis).  Doubtless,  also, 
such  collapsed  lobules  have  often  been  mistaken 
for  lobular  pneumonia,  or  pulmonary  apoplexy 
in  children.  Dr.  Gairdner  has  further  recorded 
facts,  which  render  it  highly  probable  that  this 
collapse  becomes  more  diifused  in  chronic  cases 
of  bronchitis,  when  a  large  bronchus  is  obstructed, 
as  represented  Fig.  427,  and  when,  from  the 
■weakness  of  the  individual,  from  abdominal  dis- 
ease, or  want  of  resistance  in  the  thoracic  walls, 
the  patient  is  unable  to  clear  the  air  passages  by 
a  strong  respiratory  efi^brt.  Hence  why  this  lesion 
is  common  in  fever,  in  bronchitis  accompanying 
pei'itonitis  or  ascites,  and  in  young  children. 
The  case  recorded  is  evidently  one  where,  from 
the  physical  signs  and  other  symptoms,  we  can 
have  little  doubt  that  collapse  in  the  right  lung  occurred  to  a  considerable 
extent. 


Fig.  427. 


Case  CXXI.f — Chronic  Bronchitis — Emphysema — Acute  Laryngitis. 

History. — Edward  Jackson,  set.  22,  a  robust  negro,  cook  to  a  vessel — admitted 
February  1-i,  1S51.  He  saj's  that  three  montlis  ago,  when  at  sea,  he  first  began  to 
suffer  from  cough,  expectoration,  and  shortness  of"  breath,  which  symptoms,  notwith- 
standing various  remedies  given  him  by  his  captain,  have  continued  to  increase  u^j 
to  the  present  time. 

Symptoms  on  Admission. — Anteriorly  the  thorax  is  unusually  arched  from  above 
downwards.  On  percussion,  there  is  everywhere  loud  resonance,  especially  in  front. 
On  auscultation,  the  expiration  is  much  prolonged,  and  accompanied  by  sibilant  and 
sonorous  rales,  louder  and  more  general  on  the  right  side.  There  is  frequent  and 
prolonged  cough,  accompanied  by  copious  frothy  mucous  expectoration,  great 
dyspnoea  on  making  an  exertion,  and  occasionally  coming  on  in  paroxj'sms  without 
any  obvious  cause.  Cardiac  sounds  normal.  Pulse  80,  strong.  Frequently  vomits 
after  a  severe  fit  of  coughing ;  but  tlie  digestive  and  other  systems  are  otherwise 
healthy. 

Progress  of  the  Case. — In  addition  to  the  dry  rales  heard  when  he  was  first 

*  Papers  in  Monthly  .Journal  for  1850. 

f  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 

Fig.  427.  Plug  of  mucus  or  coagulated  blood,  so  placed  that  while  it  admits  of 
partial  expiration,  it  prevents  inspiration  and  causes  collapse  of  the  pulmonary  tissue, 
to  which  the  smaller  bronchi  are  distributed. — [Gairdner.) 


BKOXCHITIS.  607 

examined,  it  was  soon  ascertained  that  copious  coarse  moist  rales  appeared  pos- 
teriorly and  inferiorly,  especially  ou  the  right,  but  also  on  the  left  side.  These 
rales  were  occasionally  absent,  but  continued  tolerably  constant.  The  dry  rales  also 
underwent  from  time  to  time  several  variations  in  tone,  intensity,  and  situation. 
During  February,  May,  and  June,  he  was  tortured  by  severe  and  prolonged  attacks 
of  dyspnoea,  during  which  he  gasped  for  breath,  and  appeared  on  the  point  of  suf- 
focation. Tlie  attack  generally  terminated  by  violent  cough,  expectoration,  and 
vomiting,  after  which  he  always  felt  reheved.  These  attacks  came  on  every  second 
or  third  night,  and  were  sometimes  occasioned  by  an  unusually  full  meal.  In  May 
there  was  noticed,  in  addition  to  the  other  physical  signs,  a  coarse  moist  tracheal 
rattle,  so  loud  as  to  mask  the  pulmonary  sounds.  On  one  occasion,  during  this 
month,  the  attack  of  dyspnoea  lasted  four  hours,  producing  partial  asphyxia,  delirium, 
and  stupor.  On  the  24th  of  May  he  was  attacked  with  sore  throat,  and  difficulty 
in  deglutition,  followed  on  the  30th  by  laryngitis  and  partial  aphonia,  which  greatly 
aggravated  the  asthmatic  attacks.  During  all  this  time,  expectorants,  antispas- 
modics, anodynes,  counter-irritants,  with  occasional  emetics,  and  cupping,  were 
employed,  with  temporary,  but  no  permanent  benefit.  In  April  and  May  the 
smoking  of  stramonium  evidently  afforded  him  considerable  ease.  He  also  expe- 
rienced marked  relief  from  a  draught  containing  3  iss  each  of  Tr.  Lobelipe  and  of 
^ther.  Towards  the  end  of  June,  a  sponge,  saturated  with  a  strong  solution  of 
nitrate  of  silver,  was  passed  into  the  larynx  several  times,  with  marked  benefit ; 
indeed,  so  much  so,  that  on  tlie  eleventh  of  July,  his  condition  was  greatly  improved, 
the  attacks  of  dyspnoea  ceased,  and  the  cough,  expectoration,  and  other  symptoms, 
were  much  abated.  On  the  16th,  he  was  dismissed  at  his  own  request,  to  resume 
his  occupation  as  cook  on  board  ship.  The  sore  throat  and  laryngitis  had  then  dis- 
appeared, but  the  chest  was  still  unusually  resonant  on  percussion;  there  was  loud 
tracheal  breathing,  prolonged  expiration,  and  occasional  sibilant  rale.  Respiration, 
however,  was  comparatively  easy,  and  he  considered  himself,  as  he  certainly  was, 
greatly  relieved. 

Commentary. — This  man  presented  all  tlie  physical  signs  and  symp- 
toms indicative  of  extensive  emphysema  dependent  on  chronic  bron- 
chitis, accompanied  with  the  most  severe  asthmatic  attacks.  These 
attacks  were  of  a  spasmodic  character,  referable  to  irritation  of  the  inci- 
dent tilaments  of  the  pneumo-gastric  nerve,  and  to  retiex  action  by  means 
of  the  excident  ones,  whereby  the  bronchial  titbes  were  contracted,  the 
glottis  closed,  and  the  muscles  of  inspiration  rendered  incapable  of  dilat- 
ing the  chest.  Violent  cough  and  vomiting  were  always  induced 
towards  the  close  of  the  attack,  followe<l  by  relief  The  dyspnoea  dui'ing 
the  course  of  the  disease  was  alleviated  by  antispasmodics,  and  the 
laryngitis  by  topical  applications,  of  which  I  have  previously  spoken. 
I  consider,  however,  that  his  recovery  was  mainly  due  to  the  advance 
of  summer  and  a  change  of  temperature — circumstances  which  should 
never  be  overlooked  in  estimating  the  effects  of  treatment  in  such  cases. 

Of  all  the  causes  vvhicli  excite  asthmatic  paroxysms  in  individuals 
labouring  under  emphysema,  the  eft'ect  of  certain  seasons  and  changes 
of  temperature  is  the  most  unequivocal,  and  yet  the  most  mysterious. 
Thus  some  persons  who  are  martyrs  to  the  disease  in  winter  are  per- 
fectly well  in  summer,  and  vice  versa.  Some  are  immediately  aftected 
by  the  foggy  air  of  London,  and  are  well  in  the  country ;  others  are 


608  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

attacked  when  tlie  wind  blows  from  a  particular  quarter,  especially  the 
east.  However  difficult  it  may  be  to  explain  such  idiosyncrasies,  there 
can  be  no  doubt  that  a  knowledge  of  these  circumstances  will  enable 
those  who  can  change  their  residence  to  alleviate  their  sufferings  in  no 
small  degree. 

Emphysema  is  characterized  anatomically  by  a  permanent  enlarge- 
ment of' the  air-vesicles  of  the  lung.  These  may  frequently  be  seen 
through  the  pleura,  with  an  ordinary  lens,  like  groups  of  minute  pearls. 
Two  or  more  of  them  may  break  into  each  other,  and  produce  others  of 
larger  dimensions,  say  the  size  of  a  millet  seed,  and  this  process  may  go 
on,"  until,  by  the  breaking  down  of  the  intervening  partitions,  every  size 
of  emphysematous  cavity  may  be  formed,  up  to  that  of  a  large  orange. 
The  walls  of  such  cavities  remain  permanently  open,  having  lost  their 
elasticity.  The  tissues  which  form  them  also  are  evidently  atrophied, 
and  their  paleness  proves  that  the  capillaries  have  been  so  compressed  as 
to  be  either  obliterated  or  impervious  to  the  passage  of  blood. 

In  order  to  account  for  emphysema,  numerous  theories  have  been 
advanced,  of  which  I  shall  allude  to  only  the  first  and  last.  Laennec 
supposed  that  the  fine  bronchial  tubes  became  rigid  and  more  or  less 
impervious  from  swelling  of  their  lining  membranes  or  impaction  of 
mucus.  He  conceived  that  inspiration  was  a  more  powerful  action  than 
expiration,  so  that  while  air  could  be  drawn  through  the  obstructions,  it 
could  not  be  breathed  out.  In  consequence,  it  accumulated  in  the  ulti- 
mate pulmonary  vesicles,  became  expanded  by  heat,  and  so  acted 
mechanically  as  a  dilator,  distending  them  from  witliin,  and  causing 
them  to  enlarge  more  and  more  according  to  the  duration  of  the  disease, 
and  extent  of  the  respiratory  eftbrts.  Dr.  Gairdner,  however,  has  pointed 
out  that  expiration  is  a  much  more  powerful  act  than  inspiration,  and 
that  there  is  never  any  difficulty  in  causing  expulsion  of  air.  It  is  the 
inspiration  which  is  laborious  in  all  bronchitic  cases,  and,  as  has  been 
previously  stated,  when  the  tubes  are  obstructed,  so  far  arc  the  air-cells 
beyond  tliem  from  being  dilated  that  they  are  in  truth  collapsed.  Emphy- 
sema, then,  does  not  occur  in  the  vesicles  connected  with  obstructed 
tubes,  but  in  those  healthy  ones  which  are  adjacent.  When  the  lungs 
are  in  a  normal  state,  the  column  of  air  presses  equally  on  all  the  tubes 
and  vesicles,  but  when  one  portion  connected  with  any  obstruction  is 
collapsed  or  otherwise  diminished  in  bulk,  then  the  neighbouring  portion 
is  over-expanded,  so  as  to  occupy  the  space  previously  filled  by  the 
former.  Hence  why  emphysema  occurs  not  only  as  a  result  of  bronchi- 
tis, but  of  chronic  phthisis,  or  any  other  disease  which  causes  contraction 
and  hypei'trophy  of  the  pulmonary  fibrous  tissue.  Dr.  Jenner  also  says,  * 
"The  atmospheric  air  moved  by  the  inspiratory  efi'ort  can  exert  com- 
paratively little  pressure  on  the  inner  surface  of  the  air-cells  situated  at 
the  extreme  margin  of  the  base,  the  root  of  the  lower  lobe  {i  e.  that 
part  immediately  next  the  spine  and  below  the  primary  bronchus)  or  at 
the  part  of  the  apex  situated  in  the  furrow  postei-ior  to  the  trachea  on 
the  right  side.  While  violent  expiration,  being  chiefly  performed  or 
greatly  aided  by  the  abdominal  muscles  forcing  upwards  the  liver,  etc., 
drives  the  air  (in  consequence  of  the  highly  arched  form  of  the  dia- 
phragm in  violent  expiration)  from  the  central  part  of  the  lung,  not  only 
*  Medico-Chir.  Trans,  of  London.     Vol.  xl. 


BRONCHITIS.  609 

through  the  bronchi  towards  the  larynx,  but  also  towards  the  circumfer- 
ence of  the  kings,  i.  e.,  towards  those  parts  which  are  the  least  com- 
pressed during  expiration."  This  view  is  confirmed  by  all  that  we  know 
of  the  usual  seat  of  emphysema,  and  by  the  effects  of  expiration  as 
made  visible  under  particular  circumstances.  In  the  case  of  M.  Groux, 
in  whom  the  sternum  was  deficient,  it  could  be  demonstiated  that  it  was 
only  by  a  forced  expiration  that  the  lungs  so  expanded,  as  to  protrude 
through  the  aperture.* 

The  treatment  of  chronic  bronchitis  must  be  directed  to  facilitate 
expectoration,  by  means  of  various  expectorants,  and  to  allay  the  irrita-. 
bility  of  the  bronchial  passages  by  means  of  anodync-s.  I  have  already 
alluded  to  the  circumstance,  that  chronic  pharyngitis,  tonsillitis,  elonga- 
tion of  the  uvula,  and  follicular  disease  of  the  epiglottis,  keep  up  a  cough, 
often  mistaken  for  chronic  bronchitis ;  and  it  is  in  these  disorders  that 
demulcents,  lozenges  of  various  kinds,  astringent  and  stimulating  gargles, 
etc.,  are  found  temporarily  beneficial.  In  such  cases  the  employment  of 
the  sponge,  saturated  in  a  solution  of  nitrate  of  silver,  is,  as  we  have 
seen  in  Case  CXXI.,  of  the  greatest  advantage.  Perhaps  there  is  no 
disease  in  which  blisters  and  counter-irritations  are  more  useful  than  in 
bronchitis. 

When  chronic  bronchitis  is  associated  with  emphysema,  and  accom- 
panied by  spasmodic  attacks  of  dyspnoea,  the  various  kinds  of  antispas- 
modics are  most  serviceable.  Sulphuric  and  chloric  aether  often  act  like 
magic ;  and  the  smoking  of  stramonium,  with  or  without  opium,  and 
other  remedies  of  this  class,  though  it  seldom  cures,  procures  great  relief. 
The  idiosyncrasy  of  the  asthma  should  also  be  studied,  and  a  change  of 
temperature  or  locality  advised,  according  to  the  peculiarities  of  the 
case. 

Case  CXXII.f — Chronic  Bronchitis — Emphysema — Injection  of  the  Bronchi  iciih  a 
Solution  of  the  Nitrate  of  Silver. 

History.— Eliza  Dawson,  set.  24,  a  servant — admitted  27th  Maj-  18.57.  About 
fourteen  months  ago,  after  exposure  to  damp  and  cold,  she  was  seized  with  a  severe 
pain  in  the  chest  accompanied  by  cough.  The  pain  in  the  chest  disappeared  in  a 
few  days,  but  the  cough  persisted,  though  it  was  not  very  troublesome,  till  twelve 
months  ago,  when  it  again  became  very  severe,  the  house  in  which  she  was  living 
being  damp.  The  pain  in  the  chest  at  the  same  time  returned.  In  the  middle  of 
last  January,  the  pain  and  cough  increased  in  severity,  and  were  accompanied  by 
considerable  dyspnosa.  She  derived  no  benefit  from  treatment,  and  was  at  length 
compehed  to  apply  for  admission,  because  her  weakness  was  such  as  to  prevent  her 
continuing  at  work. 

Symptoms. — On  percussion  over  the  chest,  resonance  is  very  loud  both  anteriorly 
and  posteriorly.  On  auscultation,  expiration  is  everywhere  prolonged.  Sibilant  and 
snoring  sounds  accompany  inspiration  and  expiration  on  both  sides,  anteriorly  and 
posteriorly.  Vocal  resonance  everywhere  diminished.  Cough  and  dyspnoea  parox- 
ysmal; the  respiration  being  laboured  even  in  the  intervals.  Expectoration  in 
moderate  quantity,  consisting  of  frothy  fluid  floating  over  tough  gelatinous  mucus. 
Apex  of  heart  cannot  be  felt.     Cardiac  sounds  normal,  but  masked  by  the  pulmo- 

*  Edin.  Med.  Journal,  vol.  iii.,  p.  853.     1858. 
f  Reported  by  Mr.  Stephen  Scott,  Clinical  Clerk. 
39 


610  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

nary  sounds.  Pulse  74.  of  moderate  strength.  Tongue  clean,  but  somewhat  dry. 
Appetite  impaired.  Feels  pain  in  the  epigastrium  after  taking  food.  Bowels  gene- 
rallj'  constipated,  requiring  the  occasional  use  of  aperients.  Other  functions  normal 
3  Spirit.  JEther.  Nitric.  3iij;  Spirit.  Amnion.  Aromatic.  3  iv;  Aquae,  ad  3  vi. 
A  table-spoonful  to  he  taken  thrice  a  day.  Tlie  chest  to  he  dry  cupped  anteriorly  and 
poste7-imiy. 

Progress  of  the  Case. — She  has  experienced  great  relief  from  the  treatment, 
and  on  1st  June,  the  snoring  sounds  are  reported  to  have  disappeared.  On  that  day, 
however,  the  dyspnoea  again  became  distressing,  and  on  3d  June,  the  sibilant  and 
sonorous  rales  had  returned.  Was  ordered  Spirit.  JEther.  Sulphuric.  3  ij ;  Sol.  Mur. 
Morph.  3  iss ;  Decoct  Senegae  ad  3  vi.  A  tahle-spoonful  to  he  taken  thrice  a-day.  A 
blister  (3  by  4)  to  he  applied  over  the  chest.  This  was  followed  by  great  relief;  sibilus 
continued  audible,  but  the  sputum  diminished  in  quantity,  becoming  altogether 
mucous.  On  the  13th,  cough  and  dyspnoea  again  became  severe,  with  pain  in  the 
chest.  A  blister  (3  by  4)  was  again  applied  with  benefit.  21  th  June. — The  dys- 
pnoea has  returned  during  the  last  few  days,  the  paroxysms  occurring  chieflj'  during 
the  night.  Durmg  the  fit  she  sits  up  in  bed ;  the  whole  chest  heaves ;  the  head  is 
thrown  back  during  inspiration ;  the  face  is  unusually  pale  and  moist  with  perspira- 
tion ;  lips  pallid ;  articulation  slow  and  measured ;  respiration  accelerated  with  pro- 
longation of  exijnation.  A  drachm  of  sulphuric  tether,  and  half  a  drachm  of  Sol. 
Mur.  Moiph.  in  a  draught,  gave  immediate  relief.  The  fits  now  became  less  frequent, 
diminishing  at  the  same  time  in  severitj'  and  duration.  On  13th  July,  after  the  pre- 
vious application  for  a  few  days  of  the  sponge  to  the  throat.  Dr.  Bennett  injected, 
by  means  of  a  catheter  introduced  into  the  trachea,  3  ij  of  a  solution  containing  half 
a  drachm  of  nitrate  of  silver  to  3  j  of  water.  The  operation  was  repeated  next  day. 
There  was  no  return  of  dyspnoea  till  loth  July,  when  she  had  two  paroxysms,  both 
followed  by  vomiting.  She  had  a  third  paroxysm  next  morning  at  4  o'clock,  which 
left  her  very  weak ;  respiration  at  2  p.m.  being  stQl  considerablj-  embarrassed.  On 
17th  July,  3  ij  of  the  solution  of  nitrate  of  silver  were  again  injected  into  the 
trachea.  Ko  difficulty  is  experienced  in  passing  the  tube,  nor  is  any  inconvenience 
felt  by  the  patient.  The  presence  of  the  catheter  in  the  trachea  was  demonstrated 
by  the  propulsion  of  2  or  3  drops  from  the  external  orifice  to  a  distance  of  3  feet 
during  a  forcible  expiration.  A  fter  the  operation,  she  passed  a  much  better  night  • 
the  cough  and  expectoration  being  very  much  less,  and  the  respiration  perfectly 
easy.  On  22d  July  the  operation  was  repeated;  she  vomited  in  an  hour  and  a  half 
after  it,  but  remained  comparatively  free  from  cough  and  dyspnoea  till  30th  July 
when  a  re-accession  occurred.  On  1st  August,  3ij  of  the  solution  were  again 
injected,  and  011  the  4th  August,  she  left  the  Infirmary  to  obtain  change  of  air. 

Commentary. — This  also  was  a  case  of  chronic  bronchitis,  with 
emphysema  and  severe  paroxysms  of  asthma,  in  which  various  remedies 
were  tried  with  the  effect  of  temporarily  alleviating  the  dyspnoea.  Dar- 
ing her  residence  in  the  house,  much  of  the  bronchitis  gradually  disap- 
peared, but  the  emphysema  and  asthma  continued  and  underwent  little 
change.  It  appeared  to  me  a  favourable  opportunity  for  trying  the  new 
practice  introduced  by  Dr.  Horace  Green  of  New  York,  of  bronchial 
injections  with  a  solution  of  nitrate  of  silver.  We  were  singularly 
favoured  in  this  case  by  the  high  position  of  the  epiglottis,  and  the  com- 
parative insensibility  of  the  larynx.  The  sponge  saturated  with  the 
nitrate  of  silver  solution  apparently  caused  no  irritation  whatever,  and 
on  passing  the  catheter  through  the  rima  glottidis  little  uneasiness  was 
manifested.      Two  drachms   of  a  solution  (  3  ss  of  the  salt  to   3J  of 


BRON"CHITIS.  611 

water)  were  injected  into  the  trachea  several  times,  producino-  only  a 
feeling  of  warmth  in  the  chest,  but,  as  she  frequently  declared,  greativ 
diminishing  the  cough  and  expectoration  from  one  to  two  davs  after- 
wards. This  woman,  with  the  catheter  deep  in  the  trachea,  closed  her 
mouth  round  the  tube,  respired  through  it,  and  could  blow  so  as  to  ren- 
der the  expelled  air  quite  sensible  to  the  finger.  No  one  could  doubt 
that  the  tube  was  in  the  trachea,  and  that  the  solution  had  passed  into 
the  lungs.  After  her  dismissal,  1  continued  to  see  her,  and  subsequently 
increased  both  the  strength  and  quantity  of  the  injection.  Latterly  I 
have  thrown  in  3  ss  of  the  strength  of  2)ij  of  the  salt  to  rj  of  water. 
She  emigrated  to  Australia,  May  1858. 


On  Injections  into  the  Bronchi  in  Puhnonari/  Diseases. 

In  a  publication  wdiich  I  received  from  Dr.  Horace  Green  of  New 
York  in  1856,  there  is  a  table  of  106  cases  of  pulmonary  disease,  which 
w^ere  treated  by  injections  into  the  bronchi  of  a  solution  of  nitrate  of 
silver.  A  flexible  catheter  Avas  introduced  through  the  larynx,  into  the 
right  or  left  division  of  the  trachea,  and,  by  means  of  a  glass  syrintre, 
the  injection  thrown  into  the  lung.  This  bold  proceeding  was  described 
as  producing  great  benefit  in  cases  of  pulmonary  tuberculosis,  bronchitis, 
and  asthma.  Whilst  tuberculosis  is  at  first  a  constitutional  disease,  its 
localization  in  any  part  reacts  more  or  less  on  the  general  health ;  and 
the  opinion  I  have  long  entertained,  that  any  means  which  could  enable 
the  physician  to  act  directly  on  the  tissue  of  the  lung  or  inflamed 
bronchi,  would  assist  his  efforts  at  cure — at  once  led  me  to  take  a  favour- 
able view  of  this  new  mode  of  treatment.  The  nitrate  of  silver  ouo-ht 
to  act  as  beneficially  on  the  mucous  membrane  of  the  trachea  and 
bronchi,  as  on  that  of  any  other  hollow  viscus,  and  we  have  seen  previ- 
ously that  the  remedy  may  be  applied  to  the  tracheal  mucous  membrane, 
by  means  of  an  artificial  opening  (see  Case  CXVII.),  not  only  without 
injury  but  with  decided  benefit.  The  difliculty  was  obviously  to  o-et 
it  there  through  the  rima  glottidis.  I  therefore  wrote  to  Dr.  Green, 
requesting  him  to  send  me  the  instruments  he  employed.  In  a  letter 
which  I  received  from  him  in  reply,  dated  New  York,  January  30,  1857, 
he  says : — 

"  I  would,  with  much  pleasure,  send  you  the  instruments  I  employ, 
but  they  are  simple,  and  may  be  obtained  at  any  surgical  instrument 
maker's  shop.  They  consist  of  an  ordinary  flexible  or  gum  catheter,  and 
a  small  silver  or  a  glass  syringe.  The  catheter  is  Ilutching's  gum-elastic 
catheter  (Nos.  11  or  12),  which  is  12^  inches  in  length;  and  as  the 
distance  from  the  incisor  teeth  to  the  tracheal  bifurcation  is,  ordinarily 
in  the  adult,  about  eight  inches,  if  this  instrument  is  introduced  so  as  to 
leave  only  two  inches  of  the  catheter  projecting  from  the  mouth,  its 
lower  extremity  must  of  course  (if  it  enter  the  trachea)  reach  into  one 
or  the  other  of  its  divisions.  I  first  prepare  my  patients  by  makino- 
applications  w4tli  the  sponge-probang,  for  a  period  of  one  or  two  weeks, 
to  the  opening  of  the  glottis  and  the  larynx,  until  the  sensibility  of  the 
parts  is  greatly  diminished.  Then,  having  the  tube  slightly  bent,  I  dip 
the  instrument  in  cold  water  (which  serves  to  stiffen  it  for  the  moment, 


612  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

and  obviates  the  necessity  of  nsing  a  wire),  and  with  the  patient's  head 
thrown  well  back,  and  the  tongue  depressed,  I  place  the  bent  extremity 
of  the  instrument  on  the  laryngeal  face  of  the  epiglottis,  and  gliding  it 
quickly  through  the  riraa  glottidis,  carry  it  down  to  or  below  the  bifur- 
cation, as  the  case  may  require.  It  is  necessary  that  the  patient  con- 
tinue to  respire,  and  the  instrument  is  most  readily  passed  during  the 
act  of  inspiration.  The  tube  being  introduced,  the  point  of  tlie  syringe 
is  inserted  into  its  opening,  and  the  solution  injected.  This  latter  part 
of  the  operation  must  be  done  as  quickly  as  possible,  or  a  spasm  of  the 
o-lottis  is  likely  to  occur.  Indeed,  if  the  natural  sensibility  of  the  aper- 
ture of  the  glottis  is  not  well  subdued  by  previous  applications  of  the 
nitrate  of  silver  solution,  or  if  the  tube,  in  its  introduction,  touches 
roufhly  the  border  or  lips  of  the  glottis,  a  spasm  of  the  glottis  is  cer- 
tain°  to  follow,  which  will  arrest  the  further  progress  of  the  operation. 
The  epiglottis,  which  is  nearly  insensible  (and  this  you  may  prove  on 
anv  person,  by  thrusting  two  fingers  over  the  base  of  the  tongue,  and 
touchino-,  or  even  scratching  with  the  nail,  that  cartilage),  should  be  our 
guide  in  performing  the  operation.  The  strength  of  the  solution  for  in- 
jecting is  from  10  to  25  grains  to  the  ounce  of  water.  Commencing 
with  10  or  15  grains  to  the  ounce,  its  strength  is  subsequently  increased, 
and  the  amount  I  now  employ  is  from  ^  to  1^  drachms  of  this  solution. 

"  In  cases  of  bronchitis,  as^thma,  and  in  phthisis,  even  the  employ- 
ment of  the  tube  once  or  twice  a  week  diminishes  the  cough  and  expec- 
torations with  great  certainty,  especially  in  the  two  former  diseases ;  and 
many  cases  have  recovered  under  the  local  treatment  after  other  means 
had  "failed.  The  applications  of  the  sponge-probang  are  continued  in 
the  intervals  of  the  employment  of  the  tube." 

My  period  of  attendance  on  the  clinical  wards  having  expired  in 
January,  it  was  not  until  May  1857  that  I  had  an  opportunity  of  making 
a  series  of  observations  on  this  subject.  I  was  then  fortunately  assisted 
by  Professor  Barker  of  New  York,  who  showed  me  the  kind  of  catheter 
he  had  seen  Dr.  Green  employ,  and  demonstrated  the  manner  in  which 
the  operation  was  performed.  Without  entering  into  minute  particu- 
lars, I  have  only  to  say  that  I  have  confii-med  the  statements  made  by 
Dr.  Horace  Green.  I  have  now  introduced  the  catheter  publicly  in  the 
clinical  wards  of  the  Royal  Infirmary,  in  several  patients  aftected  with 
phthisis  in  various  stages,  in  laryngitis,  and  in  chronic  bronchitis,  with 
severe  paroxysms  of  asthma.  In  other  cases  in  which  I  attempted  to 
pass  the  tube,  it  was  found  to  be  impossible  ;  in  some  because  the  epi- 
glottis could  not  be  fairly  exposed,  and  in  others  on  account  of  the  irri- 
tability of  the  fauces,  and  too  ready  excitation  of  cough  from  pressure  of 
the  spatula.  I  have  been  surprised  at  the  circumstance  of  the  injections 
not  being  followed  by  the  slightest  irritation  whatever,  but  rather  by  a 
pleasant  feeling  of  warmth  in  the  chest  (some  have  experienced  a  sensa- 
tion of  coolness),  followed  by  ease  to  the  cough,  and  a  check  for  a  time 
to  all  expectoration. 

In  making  these  injections,  I  have  observed  very  great  differences  in 
the  form  of  the  epiglottis,  as  well  as  in  the  irritability  of  the  fauces  and 
root  of  the  tongue  in  dift'erent  individuals.  In  some  persons  the  epi- 
glottis is  easily  exposed,  and  on  depression  of  the  tongue  may  be  seen 
standing  erect,  quite  insensible  as  stated  by  Dr.  Green,  so  as  easily  to 


PLEUKITIS.  613 

permit  the  passage  of  the  catheter.  In  other  cases,  the  top  of  the  epi- 
glottis can  only  be  reached  with  the  greatest  difticulty,  and  in  several  is 
not  to  be  seen  at  all.  In  such  cases  I  have  not  as  yet  attempted  to  pass 
the  catheter.  Again,  while  some  individuals  can  bear  without  difficulty 
forcible  depression  of  the  tongue,  and  considerable  freedom  in  touching 
the  fauces  and  rima  glottidis,  others  are  thrown  easily  into  violent 
spasms,  or  exhibit  great  irritation  in  the  parts,  from  the  mere  pressure  of 
the  spatula.  This  appears  to  me  to  be  more  constitutional  than  depend- 
ent on  local  disease  ;  some  persons  being  more  irritable  or  easily  excited 
than  others,  and  I  have  observed  the  same  difference  in  individuals  who 
are  in  all  respects  perfectly  well.  On  one  occasion,  I  put  the  sponge 
through  the  rima,  and  allowed  it  to  remain  some  seconds,  completely 
obstructing  respiration,  but  without  causing  cough  or  any  other  incon- 
venience. In  the  case  of  Dawson  (Case  CXXII.),  very  triHing  irrita- 
tion was  occasioned  by  the  pressure  of  the  catheter.  Whenever  great 
irritability  exists,  the  operation  cannot  be  peiformed. 

Further  experience  of  this  new  practice  is  required  before  its  perma- 
nent good  etfects  can  be  judged  of,  but  my  belief  is,  that,  in  appropriate 
cases,  it  will  prove  of  great  advantage.  Great  care,  however,  should  be 
taken,  especially  in  phthisical  cases,  not  to  make  the  injection  if  dyspncea 
or  cough  be  brought  on  by  the  insertion  of  the  tube.  In  the  case  of  one 
gentleman  who,  with  a  desire  to  have  the  operation  completed,  violently 
restrained  all  efforts  to  cough  when  I  was  in  the  act  of  injecting  the 
sohition,  great  pain  was  occasioned  in  the  chest  for  several  days. 


PLEURITIS. 

Case  CXXIII.* — Acute  Pleurisy — Recovery. 

History. — Mary  Harvej'',  fet.  21,  a  robust  servant  girl,  was  admitted  into  the 
clinical  ward  July  23,  1851.  She  enjoyed  good  health  until  seven  days  ago,  when, 
after  unusual  exposure  to  cold  and  wet,  whilst  washing  clothes,  she  was  seized  with 
difficulty  of  breathing,  and  a  sharp  cutting  pain  in  the  right  side.  She  shortly 
afterwards  experienced  headache,  general  soreness,  and  the  usual  symptoms  of 
fever,  but  does  not  remember  having  had  rigors.  The  dyspncea  and  local  pain 
have  increased  in  intensity,  although  the  febrile  sj-mptoms  on  admission  had  some- 
what abated. 

Symptoms  on  Admission. — On  percussing  the  right  lung  anteriorl^v,  there  is  com- 
plete dulness  over  its  lower  half,  and,  posteriorly,  the  dulness  extends  over  the  two 
lower  thirds  of  the  lung.  On  the  left  side,  the  lung  is  everywhere  resonant  on  per- 
cussion. On  listening  over  the  dull  portion  of  right  side,  there  is  complete  absence 
of  respiration,  with  loud  pealing  vocal  resonance.  In  tlie  centre  of  lung  posteriorly 
oegophony.  No  friction  or  crepitating  murmur  can  be  distinguished.  On  the  left 
side,  respiration  is  puerile.  Slight  cough,  but  no  expectoration;  dyspnoea,  but 
not  urgent ;  sharp  cutting  pain  in  right  side,  increased  on  taking  a  deep  inspira- 
tion. Considerable  headache  and  general  soreness ;  the  skin  of  natural  temperature, 
but  dry.  Pulse  100,  of  natural  strength;  tongue  furred;  face  flushed;  no  appetite; 
ereat  thirst ;  functions  of  the  body  otherwise  well  performed. 

*  Reported  by  Mr.  C.  D.  F.  Phillips,  Clinical  Clerk. 


61i  DISEASES   OF   THE   EESPIKATOEY   SYSTEil. 

Progress  of  the  Case. — On  the  following  day  the  dyspnoea  and  pain  had  dimi- 
nished. On  the  morning  of  the  25th  there  was  considerable  sweating,  and  next 
day  a  copious  sediment  of  phosphates  and  lithates  appeared  in  the  urine,  and  it 
was  observed  that  the  febrile  symptoms  had  disappeared.  The  pulse  was  84,  soft. 
On  auscultation,  a  friction  murmur  could  be  heard  at  the  upper  margin  of  the  dul- 
ness  on  the  right  side.  On  the  3d  of  August  the  pulse  was  72,  and  weak.  The 
pain  still  continued,  and  the  physical  signs  were  the  same.  On  the  6th,  the  extent  of 
the  dulness,  the  oegophony,  and  vocal  resonance  began  to  diminish,  and  the  friction 
murmur  to  increase.  On  the  9th,  no  friction  could  be  heard,  and  the  respiratory 
murmurs  were  audible  in  the  primarily  dull  portion  of  lung.  On  the  27th,  with  the 
exception  of  shght  dulness,  she  was  quite  well,  and  was  dismissed  by  her  own 
desire.  On  admission,  twelve  leeches  were  applied  to  the  affected  side,  followed 
by  warm  fomentations.  Two  purgative  pills  were  administered,  and  a  third  of  a 
grain  of  tartrate  of  antimony,  with  3  ss  of  solution  of  morphia,  ordered  to  be  taken 
every  four  hours.  Subsequently  a  succession  of  blisters  was  applied  to  tlie  right 
side.  On  the  3d  of  August  she  was  ordered  a  pill  of  calomel  and  opium  three  times 
a-day.  All  the  six  prescribed  were  not  taken,  and  no  physiological  action  of  the 
drug  resulted. 

Commentary. — This  was  a  case  of  uncomplicated  acute  pleuritis, 
with  all  the  characteristic  symptoins  and  signs,  as  desciibed  bv  sys- 
tematic authors.  The  fever  terminated  by  crisis  throuo-h  the  skin 
and  kidneys  on  the  tenth  day.  The  physical  signs  commenced  to 
disappear  on  the  seventeenth  day,  but  had  not  wholly  vanished  until 
the  thirty-fifth  day.  On  admission,  there  must  have  been  si  considera- 
ble amount  of  exudation,  with  serum  subsequently  separated  from  it 
compressing  the  lung,  so  as  to  destroy  the  respiratory  murmurs  infe- 
riorly.  At  the  upper  margin  of  the  dulness,  however,  oegophony  was 
heard,  a  sign  as  often  absent  as  present  in  pleurisy,  and  cei'tainly  not 
deserving  the  importance  which  Laeunec  attached  to  it.  The  dimi- 
nished action  in  the  compressed  lung  was  evidently  counteibalanced 
by  increased  action  in  other  poitions  of  the  pulmonary  organs,  as 
determined  by  the  puerile  respiration  on  the  opposite  side.  Lastly,  it 
was  very  instructive  to  observe  how,  as  the  fluid  became  absorbed,  and 
the  pleural  surfaces  were  thereby  allowed  to  come  into  contact,  friction 
sounds  were  developed,  and  then  ultimately  disappeared,  when  union 
between  these  surlaces  may  be  supposed  to  have  taken  place.  The 
treatment  slightly  diminished  the  pain  in  the  side,  but  in  other  respects 
evidently  had  no  effect  whatever  on  the  progress  of  the  disease. 


Case  CXXIT.* — Acute  Pleurisy  uithout  Functional   Symptoms — Ecqrid  Eecovtry. 

History. — Peter  M-Guire,  aged  21,  labourer — admitted  September  12th,  1856. 
States  that  in  June  last  he  was  seized  with  pain  in  right  side,  hot  skin,  and  slight 
fever,  for  which  he  was  bled,  bUstered,  and  confined  to  bed  for  a  fortnight.  He 
perfectly  recovered,  but  for  the  last  five  weeks  he  has  been  unable  to  carry  on  his 
usual  employment  in  consequence  of  pains  in  his  right  shoulder,  arm,  and  side.  On 
Tuesdaj-  last  (the  9th),  these  pains  were  unusually  severe,  accompanied,  as  he  says, 
by  dyspnoea,  thirst,  and  heat  of  skin.    On  the  following  day  (10th)  although  not 

*  Keported  by  Mr.  A.  Turnbull,  Clinical  Clerk. 


PLEURIT13.  615 

confined  to  bed,  he  could  not  go  to  his  work :   and  finding  no  improvement  take 
place,  he  came  to  the  hospital. 

Symptoms  on  Admission*. — Percussion  note  over  whole  of  the  left  side  of  thorax 
is  resonant.  Respiration  is  somewhat  puerile.  On  the  right  side  the  lung  is 
everywhere  resonant  on  percussion,  except  posteriorly,  where  there  is  slight  duhiess 
below  the  level  of  the  angle  of  the  scapula,  and  laterally,  below  the  level  of  the  sixth 
rib.  On  auscultation  over  the  dull  portion,  respiration  is  faint,  but  there  is  no 
friction  or  crepitation  to  be  heard.  At  the  apex  the  respiration  is  harsh,  and  the 
vocal  resonance  is  louder  than  on  the  other  side.  At  the  base  near  the  spine  there 
is  an  approach  to  cegoplionj-.  Cough  slight,  attended  by  little  pain.  Expectoration 
scanty  and  frothy.  No  pain  in  right  side,  nor  uneasiness  in  taking  a  deep  inspira- 
tion. Circulatory  system  normal,  with  the  exception  of  the  pulse,  which  is  96,  full. 
Bowels  constipated.  Appetite  bad.  Considerable  thirst.  Urine  clear;  does  not 
coagulate  on  being  heated,  nor  on  the  addition  of  nitric  acid.  Chlorides  abundant. 
5  Pulv.  Ipecac,   co.  gr.  xii.  to  he  taken  at  bed-time. 

Progress  of   the   C.^se. — September   lUli. — Has  not   perspired  much   during 
the  night.     Complains  of  slight  palpitation,  but  has  no  pain  of  any  kind.     Heart's 
sounds  normal.     On  percussion  over  the  right  side  of  chest,  the  line  of  duluess, 
which  in  the  recumbent  position  is  at  the  fifth  intercostal  space,  rises  as  high  as  the 
third  when  he  sits  up  in  bed.     15th. — Line  of  dulness  now  extends  up  to  the  second 
rib  anteriorly,  and  is  the  same  in  all  positions.     Yocai  resonance  above  the  right 
nipjjle  is  loud,  but  breathing  fiiint.      At  the  apex,  the  expu-ation  harsh  and  very 
much   prolonged.      TVas  ordered   one-twelfth   of  a   grain  of  antimony   every  four 
hours.      Had  a  blister  applied  last  nigJtt,  tvhich  has  risen  well.      Sept.  11th. — Xo  pain 
in  the  side  even  on  a  deep  inspiration.      Has  no  fever;   appetite  good;   expresses 
himself  as  much  better.    Pulse  100.  small  and  weak.    Dulness  has  become  universal 
over  the  right  side  posteriori}',  and  anteriorly  ascends  to  the  second  rib,  above  which 
a  cracked-pot  sound  is  audible.      There  is  now  no  difference  on  percussion,  when  hi 
the  upright  and  when  in  the  recumbent  position.    Respiratory  murmurs  posteriorly 
are  feeble  and  distant,  not   healthy ;    oegophouy  well  marked.     On  the  left   side 
posteriori}',  expiration  puerile.      Anteriorly  on   right  side,  respiration  exaggerated 
superiorly,  feeble  inferiorly,  and  vocal  resonance  increased.    Xo  friction  murmur  any- 
where audible.    Sejit.  18th. — Dulness  has  extended  higher.    Cracked-pot  sound  more 
limited,  but  increased  in  intensity  under  the  clavicle.     Posteriori}-  an  occasional 
friction  sound  was  detected;   ordered  to  have  this  part  painted  with  iodine.     Se2}t. 
19th. — Dulness  now  clearly  limited  by  a  line,  the  convexity  of  which  is  down- 
wards, its  greatest  distance  being  from  the  clavicle  one  and  a  quarter  inch,  and  its 
smallest  distance  one  quarter  of  an  inch.     Sept.   21st. — Cracked-pot  sound — now 
limited  to  a  spot  below  the  sterno-clavicular  articulation — is  not  so  audible.      Com- 
plains of  dyspnoea  when  walking.     Sej^,  2'2d. — Cracked-pot  sound  replaced  by  a 
somewhat  metallic  sound.     Patient  feels  so  much  better,  that  he  is  anxious  to  leave 
the  hospital  to  resume  his  labours.     23d — Yery  little  expansion  of  right  side  of 
chest  even  on  deep  inspiration.    A  warm  poultice  to  be  applied  over  the  whole  right 
side  of  chest.     2Qth. — Patient  complains  that  after  walking  quickly  he  experienced 
dyspnoea.    Hot  spongio-piline  to  be  applied  to  foment  the  whole  side.    Patient  takes 
three  ounces  of  wine  daily.     2~tth. — The  convex  line  of  dulness  anteriorly,  which  has 
for  seven  days  been  stationary  at  the  line  mentioned  on  the  19th,  has  now  become 
lower,  and  not  so  clearly  defined.  Xo  cough  nor  expectoration.  Pulse  80  per  minute, 
rather  feeble.     Appetite  pretty  good.     Fomentations  and  wine  continued.     October 
.    2d. — Resonance  hi  front,  and  internal  to  the  nipple,  extends  as  far  down  as  sixth 
intercostal  space.     Dulness  to  the  right  of  the  nipple  still  remains.     The  resonant 
portion  at  the  anterior  and  upper  part  of  right  side  may  be  bounded   by  a  line 


616  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

drawn  from  the  upper  part  of  the  axillary  region  to  the  nipple.  Pulse  gradually 
gaining  strength.  4tt. — The  anterior  portion  of  right  side  has  almost  entirely 
regained  its  normal  resonance.  Lateral  region  of  same  side  is  also  more  clear  on 
percussion.  Anteriorly  and  laterally  over  fourth  and  fifth  ribs,  and  posteriorly  to  a 
lesser  degree,  there  is  heard  friction  de  retour.  The  palpitation  has  again  returned, 
and  on  auscultation,  a  very  soft  murnmr  is  heard  with  the  first  sound.  13^;. — Per- 
cussion perfect  over  the  whole  of  anterior  surface  of  right  side  of  thorax ;  still  a 
little  dulness  posteriorly.  Friction  de  retour  is  only  slightly  marked  during  ordinary 
respiration.  IMi. — Both  sides  of  chest  expand  equally  on  deep  inspiration.  An- 
teriorly over  both  sides  of  chest,  resonance  equal.  Laterally,  external  to  nipple  of 
right  side,  there  is  marked  sense  of  resistance  and  slight  diminution  of  tone  on 
percussion  when  compared  with  opposite  side.  Posteriorly  over  whole  of  right 
side,  percussion  duller  than  over  left,  but  still  resonance  is  greatly  increased  to  what 
previously  existed.  On  auscultation  posteriorly,  respiratory  murmurs  equal  on  both 
sides ;  no  friction  anywhere  but  on  right  side ;  vocal  resonance  increased,  especially 
laterally  below  the  axilla.  His  general  health  has  long  been  quite  good,  and  he 
insisted  on  going  out.     Dismissed. 

Commentary . — On  the  admission  of  this  man,  it  was  supposed,  and  I 
still  think  correctly,  that  the  comparative  dulness  which  existed  on  per- 
cussion over  the  right  back  depended  on  the  pleurisy  he  had  had  in  the 
previous  June,  and  that  the  wandering  pains  and  slight  fever  were  owing 
to  rheumatism.  Two  days  afterwards,  fresh  exudation  was  evidently 
poured  into  the  right  pleural  cavity,  and  it  is  a  remarkable  fact  that  it 
continued  to  increase  until  the  whole  of  that  cavity  was  occupied,  and 
this  without  fever,  pain  in  the  side,  or  any  of  those  symptoms  which  are 
thought  the  usual  indications  of  acute  pleurisy.  In  this  state  the  exu- 
dation remained  stationary  for  seven  days,  then  began  to  be  absorbed, 
and  gradually  disappeared.  In  short,  we  had  the  most  distinct  evidence 
from  phvsical  signs  of  the  commencement,  onward  progress,  and  decline 
of  an  acute  pteurisy,  without  any  functional  symptoms  whatever,  the  man 
all  the  time  maintaining  he  was  in  perfect  health,  and  being  with  great 
difBculty  retained  in  the  house  for  the  sake  of  observation.  In  this 
respect,  the  case  proves  that  an  acute  pleurisy,  like  an  acute  pericarditis 
(Case  XC),  may  be  altogether  latent,  and  at  no  period  of  its  progress 
give  rise  to  those  symptoms  with  which  systematic  writers  have  made  us 
so  familiar.  For  another  remarkable  example  of  this  fact,  see  Case 
CXXYII.  It  is  unnecessary  to  comment  in  this  place  on  the  importance 
of  such  cases  in  reference  to  treatment,  and  to  former  views  as  to  tlie 
good  effects  of  blood-letting  and  antiphlogistic  remedies.  In  the  case  of 
Stanbroke  (Case  LXXXYII.),  we  saw  that  a  pericarditis  required  no 
such  remedies  to  enable  it  to  pass  through  its  natural  progress,  and  we 
have  here  another  illustration  of  the  same  fact  in  reference  to  pleuritis. 
Local  pain  appears  to  be  an  accidental  occurrence,  and  in  no  way  essen- 
tial to  a  true  inflammation. 


Case  CXXV.* — Chronic  Pleurisy  on  loth  sides — Bronchitis. 
History. — John   O'Xcill,   xt.   40,   a   writer — admitted  into   the   clinical  ward 
*  Reported  by  Messrs.  Cunningham  and  Calder,  Clinical  Clerks. 


PLEURITIS,  617 

November  28tli,  1850.  Three  weeks  before  admission,  he  was  suddenly  seized  with 
a  severe  pain  in  his  left  side,  which  impeded  breathing.  Three  days  afterwards 
feehng  better,  he  returned  to  his  employment,  but  in  the  evenmg  he  experienced 
distinct  rigors,  and  the  pain  returned.  Strong  febrile  symptoms  foUowed,  with 
cough  and  expectoration.  He  has  been  under  medical  treatment  since  then,  and 
now,  on  admission,  is  considerably  better. 

Stsiptoms  ox  Admission'. — On  percussion,  there  is  complete  dulness  over  the 
whole  of  left  side,  anteriorly  and  posteriorly,  with  the  exception  of  the  infra- 
clavicular region,  where  the  dulness  is  incomplete.  Over  the  whole  of  right  side 
there  is  unusual  resonance.  The  expansion  of  the  chest  is  greatly  diminished  on 
the  left  side  with  absence  of  vocal  fremitus.  On  auscultation,  the  resphatory  mur- 
murs are  inaudible  over  left  side,  except  at  the  apex,  where  there  is  prolonged  expi- 
ration accompanied  witli  sibUant  rale.  On  the  right  side  anteriorly,  loud  sibUant 
rales,  both  with  inspiration  and  expiration.  Posteriorly  the  respiratory  murmurs  are 
puerile.  Increased  vocal  resonance,  amounting  to  bronchophony,  heard  over  whole 
of  left  side,  assuming  an  oegophonic  character  over  scapular  region.  On  right  side 
vocal  resonance  normal.  Frequent  and  severe  cough,  foUowed  by  copious  expec- 
toration of  frothy  mucus.  No  pain  in  chest  on  taking  a  deep  inspiration,  but  occa- 
sional "  stitches  "  in  left  side.  No  dyspnoea.  The  apex  of  heart  beats  in  the  epi- 
gastrium, immediately  below  ensiform  cartilage,  and  its  sounds  (which  are  healthy  in 
character)  are  heard  most  distinctly  on  right  side  of  sternum  inferiorly.  Pulse 
68,  smaU.  Urine  turbid,  with  deposit  of  lithates.  Appetite  good.  Other  systems 
normal 

Progress  of  the  Case. — On  the  9th  of  December  a  friction  sound  was  heard 
below  the  left  clavicle,  and  the  resonance  on  percussion  was  more  ditiused.  On  the 
26^/i,  loud  friction  sounds  had  extended  from  above  on  the  left  side  down  to  an  inch 
below  the  nipple,  and  dulness  on  percussion  was  confined  to  the  two  lower  thirds 
of  the  lung.  The  bronchitis,  also,  was  diminished,  and  on  the  llth  of  January  the 
cough  and  expectoration  had  ceased,  and  the  bronchitic  rales  had  disappeared.  On 
the  23d  of  February  a  careful  examination  showed  that  there  was  complete  dulness 
over  left  lung,  from  the  nipple  downwards,  and  that  on  auscultation  there  were  loud 
double-friction  sounds  with  absence  of  respiration.  He  now  complained  of  duU  pain 
on  the  right  side  of  chest  inferiorly,  and  on  the  following  day  there  was  heard  in 
that  situation  a  double-friction  sound,  which,  however,  disappeared  on  the  5<A  of 
March.  It  returned  every  now  and  then,  accompanied  by  "  stitches"  more  or  less 
severe.  On  the  2d  of  April  there  was  dulness  over  both  sides  of  chest,  anteriorly 
from  the  nipple  downwards,  together  with  double-friction  sounds  on  both  sides. 
The  expansion  of  both  sides  of  chest  is  now  equal — that  on  the  left  side  having 
greatly  increased,  and  the  respiration  being  audible  over  its  two  superior  thirds. 
During  the  wliole  of  April  the  physical  signs  underwent  no  change,  and  he  sufiered 
considerably  from  dyspnoea.  In  May  the  dulness  was  more  circumscribed  on  the 
left,  and  more  extended  on  the  right  side.  The  dyspnoea,  however,  was  diminished, 
and  his  general  health  so  improved  that  he  was  enabled  to  take  walks  in  the  green. 
During  the  months  of  June  and  July  he  continued  to  improve,  but  complained  of 
occasional  pain  in  the  chest,  and  cough,  with  slight  expectoration,  originating 
apparently  from  imprudent  exposure  to  cold.  The  respiration,  however,  insensibly 
extended  itself  inferiorly  on  the  left  side,  and  towards  the  end  of  July  the  dulness 
was  greatly  diminished  on  the  right  side  also.  At  this  time  he  was  so  well  that  he 
was  dismissed,  August  4.  The  treatment  consisted  at  first  of  expectorants  and 
anodynes  to  mitigate  the  bronchitis,  together  with  a  course  of  the  iodide  of  potas- 
sium, and  frequent  blisters  applied  to  the  pleuritic  side.  In  February,  pills  of 
calomel  and  opium  were  ordered,  which  caused  slight  salivation  for  a  period  of  ten 


618  DISEASES   OF   THE   RESPIRATORY   SYSTEM, 

daj's.  On  the  appearance  of  pleuris}'  on  the  right  side,  it  was  combated  by  frequent 
applications  of  leeches,  followed  by  counter-irritation.  The  latter  remedy  was  con- 
tinued from  time  to  time  during  his  subsequent  residence  in  the  house,  together 
with  occasional  expectorants,  anodynes,  anti-spasmodics,  and  purgatives,  according 
as  his  symptoms  required  them. 

Commentary. — In  this  case  the  disease  ran  a  more  chronic  course, 
beginning  on  the  left  side,  and  subsequently  attacking  the  right.  As 
the  one  declined,  the  other  increased,  and  in  both  the  physical  signs 
determined  with  great  exactitude  the  extent  of  the  fluid  exudation,  its 
subsequent  absoi-ption,  the  rubbing  of  the  diseased  surfaces  against 
each  other,  and,  lastly,  their  subsequent  adhesion.  These  changes 
occupied  a  period  of  upwards  of  eight  months.  Seeing  the  slow  pro- 
gress of  the  case,  and  the  indisposition  the  exudation  exhibited  to  be 
absorbed,  mercury  was  tried,  and  salivation  maintained  for  ten  days. 
At  this  time,  such  was  the  state  of  discomfort  it  produced,  so  thoroughly 
did  it  destroy  the  appetite  and  thereby  diminish  the  vital  powers,  that  it 
was  discontinued.  So  far  from  causing  absorption,  the  action  of  the 
dnig  not  only  failed  to  do  so,  but  pleurisy  on  the  opposite  side  actually 
developed  itself  while  the  sj'stem  was  under  its  influence.  Surely 
facts  of  this  kind  ought  to  disabuse  medical  men  of  the  notion,  still 
A'ery  prevalent,  of  the  power  of  this  drug  in  causing  absoi'ption  of  an 
exudation.     (See  Pericarditis.) 

Pathology,  Diagnosis,  and  Treatment  of  Pleuritls. 

The  physical  signs  of  pleurisy  can  scarcely  be  understood  without  an 
accui'ate  acquaintance  with  the  appearances  which  the  exudation  assumes 
on  the  pleural  surface.  This  is  essentially  the  same  as  has  been  pre- 
viously described  in  the  case  of  Pericarditis,  p.  266. 

In  very  acute  cases  of  pleuritis,  which  have  proved  rapidly  fatal,  I 
have  repeatedly  observed  the  following  appearances : — On  elevating  the 
sternum,  care  having  been  taken  not  to  disturb  the  body  for  some  hours, 
the  pleural  cavity  on  the  side  affected  has  been  found  full  of  an  appa- 
rently clear  fluid  of  a  yellowish  or  greenish  tint.  On  removing  this  by 
means  of  a  small  shallow  cup,  the  first  portions  seem  perfectly  clear  and 
transparent.  On  continuing  to  empty  out  the  fluid,  it  has  been  observed 
that  the  deeper  we  descend  the  more  tuibid  it  becomes,  until  at  length 
nothing  but  a  semifluid  mass  is  removed.  It  will  frequently  be  found 
that  large  portions  of  this  mass,  although  tolerably  consistent,  are  semi- 
transparent,  resembling  a  light-coloured  calf's-foot  jelly,  whilst  other 
portions  present  the  usual  opaque  appearance.  Sometimes,  when  the 
body  has  been  undisturbed  for  twenty-four  hours,  the  whole  exudation  is 
separated  into  two  distinct  portions, — the  upper,  fluid  and  perfectly 
transparent,  whilst  the  lower  is  composed  of  a  pultaceous  mass,  resem- 
bling a  bread-and-water  or  oatmeal  poultice.  In  all  such  cases,  the 
fibrinous  portions,  from  their  superior  specific  gravity,  have  sunk  to  the 
bottom,  whilst  the  supernatant  serum  remains  clear.  The  semi-trans- 
parent lyuiph  is  the  portion  most  recently  exuded,  in  which  very  few 
of  the  plastic  corpuscles  formerly  described,  p.  128,  have  been  deve- 
loped. 


PLEURITIS. 


619 


When  the  proQ^ess  of  the  exudation  is  less  rapid,  the  coagulated  fibrin 
or  lynipli  assumes  a  more  consistent  appearance,  and  forms  over  the  part 
inflamed,  flocculi  of  different  sizes,  or  a  distinct  lining,  varying  in  thick- 
ness from  half  a  line  to  an  inch.  This  is  always  villous,  but  sometimes 
it  presents  a  honey-combed  appearance,  or  hangs  in  the  serum  in  loose 
flakes  of  a  dentritic  character.  A  serous  membrane,  when  inflamed, 
resembles  a  mucous  surface,  and,  in  point  of  fact,  performs  the  functions 
of  one  for  a  time,  and  is  very  active  in  absorbing  the  serum.  Occasion- 
ally also  it  assumes  a  lamellar  arrangement,  attributable  probably  to 
repeated  exudations  of  blood-plasma  at  diflerent  times.  This  may  be 
frequently  observed  on  the  pleura,  and  layer  after  layer  may  be  readily 
dissected'  off".  Sometimes  there  is  more  or  less  blood  extravasated  with 
exudation,  causing  it  to  assume  various  tints  of  red,  mahogany,  purple, 
etc.,  according  to  the  amount  thrown  out,  and  the  period  which  has 
elapsed  before  examination. 

AVhen  the  inflammation  has  been  less  acute,  or  is  of  longer  standing, 
we  find,  after  death,  that  the  coagulated  blood-plasma  or  lymph  has 
become  more  consistent.  It  assumes  a  more  distinctly  fibrous  appearance, 
often  extending  between  opposed  serous  surfaces  in  the  form  of  bands, 
which  have  considerable  tenacity  and  strength.  These  bands  have  a 
great  disposition  to  contract,  and  ultimately  become  shorter  and  shorter, 
and  assist  in  forming  a  dense  substance,  which  at  length  firmly  unites 
together  the  serous  surtaces.  This  uniting  substance  becomes  more  and 
more  dense,  and  not  unfrequently  resembles  ligament  in  toughness  and 
general  aspect.  In  this  form  it  may  frequently  be  seen  in  phthisical 
cases,  uniting  together  the  lobes  - 
of  the  lung  and  pleural  surfaces. 
Occasionally  it  assumes  even  a  car- 
tilaginous hardness,  resembling  the 
fibro-cartilage  of  the  intervertebral 
substance.  In  this  state  it  may  fre- 
quently be  observed  on  the  pleura?, 
and  I  have  seen  it  thus  half  an  inch 
thick,  intimately  uniting  the  lungs 
to  the  ribs.  When  it  has  been  very 
slowly  developed,  it  produces  white 
indurated  patches,  of  a  glistening 
cartilaginous  appearance,  varying 
in  extent,  the  surface  of  which  has 
assumed  the  character  of  a  serous 
membrane,  and  in  no  way  interferes 
with  the  movements  of  neighbour- 
ing organs.  Such  patches  are  ex- 
ceedingly common  on  the  surface 
of  parenchymatous  organs,  as  the 
lungs,  heart,  liver,  spleen,  and 
kidneys.  Occasionally  encysted 
abscesses  of  the   pleura    are   re-  r*?-  ^^■ 

solved,  and  their    walls   contracting  assume   a    cartilaginous  hardness. 


Fig.  428.  Remains  of  a  pleural  abscess.    {Markham.) 


620  DISEASES   OF  THE   RESPIEATOEY   SYSTEM. 

Dr.  Markham  lias  recorded  a  remarkable  example  where  the  pyogenic 
■svalls  in  this  mani)er  foi'ined  a  tube  surrounded  by  puckering  ot  the 
pleura  pnlmonalis,  the  lung  itself  being  quite  healthy.  The  hardish 
gritty  particles  sciaped  from  its  roughened  inner  surface  consisted  cliiefly 
of  cholesterine  and  granular  matter.*  (Fig.  428.)  Lastly,  false  mem- 
branes on  the  pleural  surfaces,  but  especially  on  the  costal  one,  may 
assume  a  stony  hardness,  from  the  deposition  of  calcareous  matter ; 
and  patches  of  this  character  may  be  scattered  over  the  serous  mem- 
brane, or  may  exist  in  disseminated  points. 

The  minute  structure  of  the  coagulated  exudation,  composed  of  plastic 
or  pyoid  corpuscles  and  molecular  fibres,  has  been  previously  described 
and  figured,  p.  128.  These  fibres  are  more  and  more  aggregated 
together  the  more  dense  the  lymph  becomes,  and,  in  cases  of  calcareous 
deposition,  are  associated  with  molecules  and  irregular  masses  of  eailhy 
salts,  mingled  with  crystals  of  cholesterine,  and,  it  may  be,  numerous 
fatty  molecules  and  granules. 

It  results  from  our  knowledge  of  the  morbid  anatomy  of  pleuritis,  con- 
joined with  careful  observation  at  the  bed-side,  that,  if  a  large  quantity 
of  fluid  be  interposed  between  the  pleura',  the  respiratory  murmurs  will 
be  lost,  v,hile  the  vocal  resonance  is  diminished.  If  the  amount  of  fluid 
be  small,  the  murmurs  are  obscure,  and  the  vocal  resonance  assumes  a 
peculiar  vibrating  character,  said  to  resemble  the  bleating  of  a  goat.  This 
is  ce^iophony.  If  strings  or  bands  of  chronic  lymph  exist,  which  are 
stretched  during  the  movements  of  the  chest,  then  the  rubbing  sound 
Avill  assume  a  leathery  or  creaking  character ;  and  if  there  be  calcareous 
deposition,  a  filing  or  grating  noise  may  be  produced,  although  this  is 
very  rarely  heard  over  the  pleurae.  Not  unfrequently  dense  adhesions, 
with  thickening  of  the  fibrous  tissue  uniting  the  pleurae,  may  occasion 
partial  dulness,  and  increase  of  the  vocal  resonance,  a  result  not  uncom- 
mon at  the  apices  of  the  lung,  but  which  must  be  carefully  distinguished 
from  the  condensation  from  tubercle. 

With  regard  to  the  treatment,  it  is  essentially  the  same  as  that  of 
other  acute  inflammations.  It  is  rare  that  a  case  enters  an  hospital  in 
its  incipient  stage,  that  is,  when  the  serous  membrane  is  unusually  dry, 
and  before  much  exudation  has  occurred.  But  in  private  practice  such 
cases  are  more  common,  and  occasionally  they  may  come  on  in  the 
ward  of  an  hospital.  At  this  early  period,  a  general  bleeding  was  for- 
merly recommended,  with  a  view  of  cutting  short  the  inflammation,  the 
possibility  of  which  we  have  discussed  at  p.  257.  AVhen,  however, 
exudation  has  been  poured  out  to  any  extent,  and  has  coagulated,  bleed- 
ing is  injurious,  and  we  must  endeavour  to  favour  the  development, 
absorption,  and  excretion  of  the  exudation,  by  means  of  warm  topical 
applications,  sudorifics,  and  diuretics.  The  urine  especially  should  be 
carefully  watched,  as  the  sediments  it  contains  will  serve  as  an  index  to 
the  amount  of  exuded  matter  excreted.  Care  should  also  be  taken,  at 
this  period,  not  to  allow  the  general  strength  to  sink,  for  it  is  only  by 
keeping  up  the  nutritive  functions  that  we  can  assist  the  vital  powers  in 
making  those  transformations  which  are  essential  in  procuring  the  dis- 
appearance of  the  fluid,  and  adhesion  of  the  solid  exudation.  By  some, 
calomel  is  considered  to  be  directly  indicated  as  a  means  of  favouring 
*  Path.  Soc.  Trans.     Yol  ix.  p.  51. 


PLEURITIS.  621 

absorption  from  the  serous  cavity.  It  was  fairl}^  tried  in  Case  CXXV., 
but  was  more  productive  of  harm  than  of  good  ;  and  although  I  have 
frequently  seen  the  drug  employed  for  this  purpose,  I  have  not  met  with 
a  sino-le  instance  where  its  good  eftects  have  been  unequivocal.  If  there 
be  much  local  pain,  warm  applications  at  first,  and  subsequently  blisters, 
tend  to  remove  it. 

On  some  occasions,  when  the  exudation  lias  been  very  abundant  in  the 
pleural  cavity,  and  the  vital  powers  of  the  economy  are  constitutionally 
low,  and  have  been  depressed  by  injudicious  antiphlogistic  treatment  or 
want  of  rest,  the  changes  described  do  not  occur.  The  exudation  in  such 
cases  passes  into  pus,  although  some  of  the  fibrous  element  attaches 
itself  to  and  lines  the  membrane.  This  termination  of  pleuritis  is 
denominated  empyema. 

Case  CXXVI.* — Empyema,  luith  Fistulous  Openings  between  the  Lung  and  Pleural 
Cavity,  and  between  the  Pltural  Canty  and  External  Surface. 

History. — George  Fair,  sat.  30,  a  ploughman— admitted  December  10th,  ISoO,  in 
a  very  exhausted  state.  Fourteen  months  ago  had  acute  pleuritis,  on  account  of 
which  he  was  confined  to  bed  for  eight  weeks,  and  was  bled  several  times.  Three 
months  afterwards  he  still  felt  occasional  pain  in  the  right  side,  which  gradually 
became  inore  constant  and  severe,  and  at  length  was  accompanied  by  cough  and 
expectoration.  He  now  perceived  a  small  swelling  below  the  right  nipple,  which, 
at  the  end  of  last  July,  was  the  size  of  a  hen's  egg.  It  was  then  opened  by  incision, 
and  a  quart  of  purulent  matter  extracted.  About  the  end  of  August,  two  other 
apertures  formed  spontaneously  in  the  neighbourhood  of  the  previous  one.  As  soon 
as  matter  was  discharged  from  the  external  opening,  the  amount  of  expectoration 
was  diminished. 

Symptoms  on  Admission. — Thoracic  walls  much  depressed  under  right  clavicle ; 
right  side  of  chest  motionless  on  taking  a  full  inspiration ;  three  apertures  still  exist 
in  the  thoracic  walls ;  the  upper  one  (that  made  by  the  incision)  is  between  the  sixth 
and  seventh  ribs,  immediately  below  the  right  nipple,  the  two  others  a  little  lower 
down,  and  somewhat  smaller ;  from  all  three  there  is  a  copious  purulent  discharge. 
Circumference  of  the  thorax,  on  a  level  with  the  right  nipple,  measures  thirty-tive 
inches ;  from  the  spinous  processes  of  the  vertebrae  to  the  sternum  on  the  right  side, 
measures  sixteen  and  a  half  inches,  and  on  the  left,  nineteen  inches.  On  percus- 
sion, the  left  side  is  resonant  throughout ;  on  the  right  side  there  is  dulness  every- 
where, but  most  marked  in  the  inferior  two-thirds ;  posteriorly,  the  dulness  is  not  so 
marked  as  in  front.  On  auscultation,  the  respiratory  murmurs  on  the  left  side  are 
puerile ;  under  the  right  clavicle  the  respiratory  murmurs  are  harsh,  and  the  vocal 
resonance  increased;  a  little  lower  down  the  respiratory  murmurs  become  more 
feeble,  and  there  is  crepitation  with  the  inspiration ;  in  the  remaining  lower  two-thirds 
of  the  right  front,  the  respiratory  sounds  are  inaudible ;  over  the  whole  right  back, 
the  respiratory  murmurs  are  feeble  ;  the  vocal  resonance  increased  and  cegophonic  ; 
in  the  lower  third  crepitation  is  audible.  Pain  over  the  sternum  and  under  right 
clavicle  ;  cough  neither  frequent  nor  severe ;  expectoration  scanty,  partly  white  and 
frothy,  partly  tenacious  and  muco-purulent.  Apex  of  heart  beats  feebly  half  an  inch 
to  the  left  of  its  natural  position.  Pulse  92,  slightly  jerking,  but  compressible ;  gene- 
ral strength  much  reduced. 

*  Reported  by  Mr.  J.  M.  Cunningham,  Clinical  Clerk. 


622  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Progress  of  the  Case. — In  tlie  beginning  of  January,  he  was  attacked  with 
vomiting  and  diarrhoea,  accompanied  with  febrile  sj^nptoms,  which  greatly  diminished 
his  strength  ;  his  countenance  assumed  a  hectic  appearance,  and  the  openings  in  the 
thorax  became  painful  and  larger,  their  margins  were  inflamed  and  ulcerating,  and 
the  discharge  continued.  On  the  11th.  it  was  ascertained,  hj  means  of  the  probe, 
that  of  the  three  openings  the  middle  one  alone  enters  directly  into  the  pleural  cavity, 
and  admits  with  ease  a  No.  8  catheter ;  the  other  two  communicate  with  the  central 
one  underneath  the  integument.  On  the  29th,  diarrhoea,  and  purulent  discharge 
from  the  chest  had  diminished,  his  appetite  and  general  health  were  also  improved, 
but  he  was  removed  from  the  house  by  his  friends.  The  treatment  consisted  at  first 
of  good  diet  and  tonics ;  and,  when  the  vomiting  and  diarrhoea  appeared,  various 
remedies  to  check  these  symptoms.  On  the  18^1  of  January,  a  small  canula  and  No. 
8  catheter  were  introduced  side  by  side  into  the  opening  into  the  pleura.  By  means 
of  a  Read's  syringe  attached  to  the  former,  about  a  pint  and  a-half  of  distilled  water, 
at  the  temperature  of  90°,  was  injected  into  the  pleural  cavity.  The  fluid  escaped 
through  the  flexible  catheter,  but  did  not  equal  in  amount  what  was  thrown  in,  and 
was  at  length  discharged  clear  and  unmixed  with  pus.  During  the  half  hour  imme- 
diately following  the  operation,  a  quantity  of  clear  water  oozed  from  the  wound. 

Commentary. — Wlien  this  man  entered  the  house,  his  general  strength 
was  much  reduced ;  and  it  was  apparent  from  a  careful  study  of  the 
physical  signs  and  symptoms,  that  a  communication  existed  between  the 
lungs  and  pleural  cavity,  in  addition  to  the  external  fistulous  opening  into 
the  latter.  The  pleuro-pulmonary  fistula  had  evidently  formed  before  the 
opening  through  the  thorax  was  made  artificially,  as  evinced  by  the 
marked  diminution  of  expectoration  on  the  evacuation  of  pus  externallv. 
That  it  continued  to  exist,  I  was  satisfied,  by  observing  that  the  sputum 
was  increased  when  the  external  discharge  diminished,  and  vice  versa. 
Two  errors  had  been  made  in  the  previous  treatment.  These  consisted, 
— 1st,  In  the  "  frequent  bleedings,"  which  had  so  diminished  the  general 
powers  of  the  system,  as  to  have  checked  those  changes  in  the  exuda- 
tion necessary  for  recovery;  2d,  In  making  a  free  incision,  instead  of  a 
small  puncture,  to  draw  off  the  purulent  matter.  Of  these  two  errors, 
the  first,  however,  was  the  greatest ;  indeed  it  was  irremediable.  The 
second  was  probably  undertaken  with  the  idea  formerly  so  prevalent, 
that  pus  is  injurious  to  the  economy,  and  when  known  to  exist  should  be 
let  out  as  soon  and  as  freely  as  possible.  We  now  know  that  there  is 
nothing  to  be  feared  fi'om  the  mere  presence  of  pus,  either  in  the  lung 
or  pleural  cavity ;  and  that  the  most  natural  method  for  its  disappear- 
ance is  by  absorption  and  elimination.  Still,  when  large  in  amount  and 
either  pointing  externally,  or  displacing  the  heart  internally,  no  danger 
can  arise  fi'om  making  a  puncture  with  a  small  canula,  as  practised  by 
Messrs.  Cock  and  Syme,  and  sanctioned  by  Drs.  Hughes  and  Alison. 
Indeed  there  is  every  chance  of  producing  benefit,  for  we  thereb}^  save 
the  vital  powers  a  considerable  amount  of  unnecessary  work,  and  so  faci- 
litate the  disappearance  of  the  exudation  and  return  of  expansion  to 
the  compressed  lung.  AVith  regard  to  the  operation  of  paracentesis 
thoracis,  and  the  good  eff"ects  attending  it,  I  refer  you  to  the  excellent 
papers  of  Dr.  Hughes,*  and  the  lecture  of  Dr.  Alison.f 

*  Guy's  Hospital  Reports,  vol.  ii.     Second  Series. 
f  Monthly  Journal,  August  1850. 


PLEURITIS.  623 

In  the  case  before  us,  the  difficulty  experienced  was  to  rally  the  gene- 
ral strength,  especially  after  it  had  been  so  much  reduced  by  diarrhrea, 
and  this  was  to  some  extent  accomplished.  My  attention  was  then 
directed  to  the  cure  of  the  thoracic  disease ;  and  it  occurred  to  me  that 
if  the  pus  could  be  replaced  by  water,  there  would  be  less  labour  thrown 
upon  the  weakened  absorbing  surface.  The  pleural  cavity,  therefoi-e,  was 
washed  out  with  distilled  Avater,  heated  to  90'^  as  directed;  and  this 
would  have  been  repeated  at  intervals,  had  he  not  left  the  house,  and 
thus  put  an  end  to  every  efibrt  undertaken  for  his  benefit. 


Case  CXXA'IL* — Chronic  Pkuritis  and  Pneumo- Thorax,  icithoui  Symptoms — Arti- 
cular Rheumatism — Pericarditis — Recovery. 

History. — William  Dow,  set.  33,  boot-maker — admitted  26th  of  January,  1857. 
States  that  he  has  always  been  a  temperate  man  up  to  his  present  illness,  and  has 
had  pretty  good  health.  On  the  12th  of  last  December,  after  exposure  to  cold  and 
damp  during  the  day,  he  was  seized  with  articular  pains,  which  affected  most  of  the 
joints,  and  have  continued  to  wander  from  one  to  the  other  up  to  the  present  time. 
On  the  evening  of  the  7th  of  January,  independent  of  any  exertion,  the  patient  was 
suddenly  seized  with  acute  pain  in  the  umbilical  region,  attended  with  difficultv  of 
breathing ;  these  symptoms  were  at  once  removed  on  taking  a  powder,  which  caused 
the  expulsion  of  much  wind.  He  denies  ever  having  had  cough,  pain  in  the  side,  or 
any  pulmonaiy  symptoms  whatever. 

Symptoms  ox  Admission. — On  inspection  of  the  chest,  there  is  less  expansion  on 
the  right  tlian  on  the  left  side  anteriorly;  posteriorly,  the  right  side  bulges  considera- 
bly below  the  level  of  the  third  rib ;  the  measurement  of  the  corresponding  sides  is 
slightly  different ;  the  girth  of  the  left  side  being  fifteen  and  a  half,  that  of  the  right 
sixteen  inches.  The  movement  of  inspiration  on  the  right  side  is  very  slight ;  on  the 
left  the  girth  is  increased  half  an  inch  on  a  full  insi:)iration.  Percussion  note  over 
the  right  side,  anteriorly,  is  t}-mpanitic  from  apex  to  base,  being  flatter  at  the  apex. 
It  likewise  extends  on  a  level  with  the  nipple  over  the  left  side  to  about  half  an  inch 
beyond  the  sternum.  On  auscultation,  there  is  slight  harshness  of  respiratory  mur- 
murs at  the  apex  of  left  lung,  the  sounds  of  which  are  otherwise  normal.  On  the 
right  side,  the  vesicular  murmur  is  supplanted  bj"  loud  amphoric  breathing,  more 
distinct  towards  the  base.  Expiration  is  mucli  prolonged.  In  the  recumbent  pos- 
ture, both  inspiration  and  expiration  are  accompanied  by  a  clear  prolonged  metallic 
note,  exactly  like  the  distant  lilast  of  a  trumpet,  somewhat  louder  with  expiration. 
Yocal  resonance  over  the  middle  third  is  of  a  loud  brazen  metallic  character.  Pos- 
teriorly on  this  side,  percussion  superiorly  is  tympanitic,  but  below  second  dorsal 
spine,  dulness  commences,  becoming  more  intense  as  it  extends  to  the  base  of  the 
lung.  Laterally  its  extent  is  bounded  by  a  line  drawn  verticall}'  from  the  posterior 
fold  of  the  axilla.  At  the  apex,  inspiration  is  blowing,  with  prolonged  expiration, 
and  at  the  close  of  inspiration  a  moist  click  is  heard.  Towards  the  base,  the  respi- 
ratory sounds  are  scarcely  audible,  and  inspiration  is  accompanied  w'ith  an  obscure 
crepitation  (?)  Vocal  resonance  at  apex  and  base  is  oegophonic,  but  over  the  mid- 
dle third  it  is  normal.  No  cough,  expectoration,  dyspnoea,  pain,  or  other  pulmonary 
symptom.  Impulse  of  heart's  apex  felt  in  the  usual  position.  Transverse  dulness 
and  sounds  normal.  Pulse  108,  feeble.  Patient  is  somewhat  deaf;  has  still  pain  iu 
both  knee  and  ankle  joints,  and  in  the  right  shoulder  and  carpo-phalangeal  joints. 

*  Reported  by  Mr.  T.  J.  Walker,  Clinical  Clerk. 


624  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

Tongue  dry  and  furred,  otherwise  normal.  Copious  deposit  of  litliates  in  the  urine. 
He  is  much  emaciated,  and  for  the  last  seven  weeks  has  perspired  very  freely.  Ilabeat 
Fulv.  Doveri  gr.  xij.  hord  somni  sumenda. 

Progress  of  the  Gase.— January  28^/i.— Pain  in  the  joints  is  now  so  much 
relieved,  that  he  can  move  the  limbs  with  comparative  freedom.  He  slept  well  last 
night.  ^.  Foiass.  Nitrat.,  Foiass  Bicarb,  aa.  3ij.;  Aquoi  ad  §  vj.  M  Cajnat  §  ss. 
ier  indies.  Jan.  29ih.—On  examining  the  patient  to-day,  Dr.  Bennett  found  that, 
while  lying  on  his  left  side,  percussion  note  was  duller  over  the  sternum  than  when 
he  lay  on  his  back,  and  the  slightly  dull  tone  over  the  right  lateral  region  became  clear. 
When  also  the  patient  is  placed  in  a  sitting  or  recumbent  posture,  dulness  extends 
from  the  back  forwards  to  the  centre  of  the  right  lateral  region,  and  upon  being  laid 
on  his  left  side,  the  posterior  part  of  the  lateral  region  becomes  resonant.     Jan. 

31si. Physical  signs  over  right  side  of  chest  continue  as  before.     Apex  of  cardiac 

oro-an  beats  with  a  visible  impulse  somewhat  to  the  inner  side  of  a  line,  vertical 
from  the  nipple  between  the  firth  and  sixth  ribs.  At  the  margm  of  sternum  a  double 
rumbling  sound  is  audible,  not  quite  synchronous  with  the  systolic  or  diastolic  move- 
ments. Transverse  dulness  of  heart  on  percussion  still  two  inches.  Pulse  100,  small, 
rather  hard.  Respirations  twenty-two.  Feb.  2d. — Friction  murmurs  at  the  base  of 
the  cardiac  organ  more  audible;  the  patient  has  no  pain  over  pericardium,  nor 
uneasiness,  except  after  cough,  over  the  chest  generally ;  feels  very  slight  tender- 
ness on  percussion  over  the  sternum  at  the  level  of  fifth  and  sixth  ribs.  To  have 
spongiu-piline  saturated  ivith  warm  water,  applied  over  theproicordiul  region.  Feb.  5th. — 
Patient  so  well  as  to  get  up  in  the  morning,  and  from  this  time  he  rapidly  regained 
bis  strength.  The  pulmonary  signs  have  undergone  no  change.  The  friction  mur- 
murs over  the  heart  gradually  diminished,  and  disappeared  on  the  12th,  while  a 
blowing  murmur  was  gradually  established,  heard  loudest  with  the  first  sound  over 
the  apex.     He  was  dismissed  March  11th. 

June  12d. — He  was  re-admitted  to-day,  having  in  the  interval  again  lost  strength 
in  consequence  of  his  work  being  too  fatiguing,  and  his  appetite  having  failed  hmi. 
The  amphoric  respiration,  metallic  notes,  and  brazen  resonance  of  voice,  have  now 
disappeared  from  the  right  side,  which  is  dull  on  percussion,  immoveable  during 
inspiration,  with  slight  trace  of  respiratory  murmur,  and  great  increase  in  the  vocal 
resonance.  Left  lung  healthy,  with  puerile  respiration.  Still  a  blowing  murmur 
with  the  first  sound  of  the  heart,  loudest  at  the  apex.  To  have  nutrients,  with  §  iv. 
of  wine  daily.  July  28th. — Since  last  report  his  general  health  has  been  improving, 
and  he  now  looks  fat  and  well  nourished,  and  says  he  is  much  stronger.  Has  no 
pain,  cough,  dyspnoea,  or  inconvenienceof  any  kind.  There  is  now  decided  flatten- 
ing anteriorly  over  the  upper  third  of  the  right  chest.  On  deep  inspiration  it  expands 
much  more  than  formerly.  It  is  still  everywhere  dull  on  percussion,  with  great 
increase  of  vocal  resonance  amounting  to  bronchophony  anteriorly,  and  pectoriloquy 
posteriorly  and  superiorly.  Respiratory  murmurs  are  absent  over  upper  third  of 
lung,  l)ut  inferiorly  and  anteriorly  inspiration  is  audible  but  feeble,  and  posteriorly 
is  much  stronger.     Discharged. 

Commentary. — It  is  no  uncommon  tiling  for  men  who  have  previously 
had  pleurisy,  to  be  seen  walking  about  the  streets  with  one  side  of  the 
chest  luore  or  less  dull  on  percussion  and  incapable  of  action,  although 
complaining  of  nothing.  But  this,  so  far  as  I  am  aware,  is  the  only 
instance  on  record  where  jileurisy  has  come  on  and  proceeded  to  the 
formation  of  extensive  pneumo-thorax,  not  only  without  symptoms,  but 
without  the  cof>-nizance  of  the  patient.  Yet  such  is  the  case  before  us. 
For  when  I  demonstrated  to  the  clinical  class  at  the  bed-side  the  tym- 


PLEURITIS.  625 

paiiitic  sound  over  the  right  chest  on  percussion,  the  absence  of  heahhy 
respiration,  the  metallic  notes  Avith  the  respiratory  murmurs,  and  the 
brazen  amphoric  vocal  resonance,  he  himself  denied  that  there  was  any- 
thing wrong  with  his  chest,  and  smiled  at  the  trouble  we  gave  ourselves 
in  examining  it.  In  his  case,  as  in  Case  CXXIV.,  after  the  acute  rheu- 
matism subsided,  we  had  the  greatest  difficulty  in  keeping  him  in  the 
house  for  the  purpose  of  observation.  On  his  o;oing  out,  however,  he 
himself  at  length  became  satisfied  that  his  breathing  was  not  so  good  as 
it  ought  to  be,  and  on  his  re-admission  subsequently,  we  had  the  plea- 
sure, under  the  influence  of  nutrients,  to  see  the  morbid  murmurs  dis- 
appear, the  chest  gradually  contract,  and  his  general  health  re-establish 
itself.  What  might  have  been  the  consequence,  if  by  means  of  phy- 
sical signs  we  had  not  detected  this  morbid  condition,  but  had  dismissed 
him  from  the  house  as  soon  as  he  had  recovered  from  his  rheumatism, 
cannot  positively  be  said  ;  but  judging  from  what  followed,  I  have  myself 
no  doubt  that  he  would  rapidly  have  sunk  exhausted.  I  saw  him  several 
times  after  his  first  dismissal,  and  he  was  only  supported  by  the  most 
energetic  use  of  nutrients  and  wine. 

Case  CXXVIII.* — Empyema,  following  Chronic  Phthisis — Paracentesis  Thoracis — 
Paeuiiw-Thora.x  —  Singular  mode  of  Death  from  Enormom  Distension  of  the 
Sloraach  a?id  Emphysema  of  its  Coats — Tubercular  Pleuritis — Adherent  Peri- 
cardium—  Waxy  Spleen — Tubercle  in  the  Kidneys. 

History. — Allan  Brown,  aet.  26,  a  gilder — admitted  Xovember  26,  1856.  States 
that  about  twelve  months  ago,  he  suddenly,  at  night,  experienced  pain  about  the 
heart  in  drawing  breath,  together  with  shivering  and  febrile  symptoms.  For  three 
days  the  pain  was  acute ;  it  then  disappeared,  to  come  back,  however,  at  different 
times,  lasting  for  a  day  or  two.  and  then  disappearing  again.  During  the  six  months 
preceding  this  attack,  he  had  had  a  short,  and,  for  the  most  part,  a  dry  cough,  with 
frothy,  white,  and  gelatinous  sputum.  This  has  continued  ever  since  ;  and  on  one 
occasion,  eight  months  since,  he  spat  up  blood.  Six  months  ago  he  noticed  the  left 
side  enlarging ;  two  months  afterwards  he  became  unfit  for  work,  and  also  unable 
to  lie  in  bed  on  the  right  side.  About  this  period  he  was  subject  to  profuse  sweat- 
ings, which  have  since  gradually  declined.  His  appetite,  at  no  time  great,  has 
become  yet  more  defective,  especially  during  the  last  few  months.  His  thirst  has 
always  been  considerable. 

Symptoms  ox  Admission'. — There  is  marked  depression  of  the  right  chest  under 
the  clavicle.  On  the  left  side  there  is  a  bulging  in  the  mammary  region  outwards 
and  forwards  Posteriorly  there  is  a  general  protrusion  of  the  left  side  of  chest 
mferiorly,  and  fulness  of  the  intercostal  spaces,  but  to  no  great  extent,  except  at  the 
extreme  base  and  over  the  lumbar  region,  where  there  is  fluctuation  and  extreme 
tenderness  on  pressure,  with  redness  and  increase  of  temperature.  The  chest 
measures — 

Level  of       Four  inches 
Nipple.  lower. 

Left  side IS  17 

Eight  side 18J-  16i 

This  examination  was  conducted  throughout  while  the  patient  was  in  the  sitting 
posture.     During  respiration  there  is  an  expansive  motion  on  the  right  side,  espe- 
cially under  the  clavicle  and  in  the  infra-axillary  region,  but  on  the  left  side  there  is 
*  Eeported  by  Mr.  H.  X.  Maclaurin,  Clinical  Clerk. 
40 


626  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

no  correspondiDg  motion.  There  is  also  slight  vocal  fremitus  on  the  right  side,  but 
none  on  the  left.  On  percussion  there  is  absolute  dulness  on  the  left  side  anteriorly, 
laterally,  and  posteriorly.  On  the  right  side  anteriorly  there  is  comparative 
resonance,  but  not  loud  nor  clear,  down  to  the  level  of  the  third  rib.  Below  that 
level,  over  a  region  in  which  the  cardiac  pulsation  may  be  felt,  there  is  dulness. 
Laterally  and  posteriorly  the  percussion  is  good.  On  auscultation  on  the  right  side 
anteriorly  down  to  tlie  level  of  the  third  rib,  also  laterally  and  posteriorly,  the 
respiratory  murmurs  are  dry  and  somewhat  blowing  in  character  and  intensified  in 
tone.  On  the  left  side  no  respiration  is  audible,  except  near  the  sternal  end  of  the 
clavicle  anteriorlj^,  and  near  the  inferior  angle  of  the  scapula  posteriorly.  In  these 
regions  the  respiratory  murmur  is  heard  faintly.  Vocal  resonance  is  greater  over 
right  apex,  and  posteriorly  over  the  whole  side,  than  over  the  corresponding  left. 
There  is  great  dyspnoea,  so  that  the  patient  frequently  cannot  answer  questions 
until  he  recovers  breath.  The  cough  is  short,  shallow,  and  gasping,  and  when 
excited  continues  for  a  considerable  time,  the  patient's  face  becoming  flushed, 
Sputum  is  scanty,  and  expectorated  with  difficulty.  The  cardiac  impulse  is  between 
the  fifth  and  sixth  ribs  on  the  right  side,  an  inch  and  a  half  below  and  to  the  outside 
of  the  right  nipple.  Cardiac  sounds  healthy.  Pulse  130,  small  and  weak.  At  this 
stage  of  the  examination  the  patient  Ijccarae  much  troubled  with  spasmodic  cough, 
so  that  further  interrogation  was  considered  unadvisable.  To  have  5  iij-  of  icine, 
steak  diet,  extra  milk,  and  an  egg  for  breakfast. 

Progress  op  the  Case. — On  the  8th  and  9th  N'oveniber  he  was  troubled  with 
slight  diarrhoea.  On  the  10th  he  had  slight  rigors.  At  evening  visit  the  following 
facts  were  elicited : — At  the  base  of  the  right  lateral  region,  strong  fremitus  corre- 
sponding to  the  respiratory  rhythm  ma}'  be  felt  on  applying  the  hand.  No  particular 
pain  exists  in  this  spot,  except  on  pressure,  and  no  dulness  can  be  made  out.  Fric- 
tion may  be  heard  with  inspiration  and  expiration  as  high  as  the  lower  third  of  the 
scapula  posteriorlj%  laterally  as  high  as  the  eighth  rib,  and  anteriorly  only  at  the 
base.  Vocal  fremitus  unimpaired.  Pulse  120;  small,  weak,  and  somewhat  hard. 
Kov.  llth. — Friction  was  still  audible;  the  pulse  was  112,  soft;  the  skin  was  cool; 
the  diarrhoea  stopped,  or  nearly  so ;  the  urine  gave  a  large  precipitate  of  lithates, 
and  contained  abundant  chlorides.  Nov.  12th. — The  operation  of  paracentesis 
thoracis  was  performed  by  Mr.  Syme  in  the  following  manner:  A  free  incision  was 
made  in  the  lower  part  of  the  left  back  at  the  spot  where  the  tumour  was  pointing. 
A  considerable  thickness  of  muscle  had  to  be  cut  through,  and  the  wound  enlarged 
by  means  of  the  finger  before  any  matter  escaped.  After  this,  about  sixty  ounces 
of  dirtj'-yellow  sanious  pus  were  withdrawn,  passing  with  force  at  each  expiration. 
In  tlie  evening,  forty  ounces  more  of  pus  escaped.  Breathing  was  easier  than 
before  the  operation ;  cough  not  so  readily  excited ;  patient  lies  more  on  his  back 
than  before.  Pulse  9G,  weak  and  soft.  Nov.  ISih. — Percussion  is  now  tj-mpauitic 
over  the  left  side  anteriorly;  laterally  and  jiosteriorly,  where  the  integument  is 
oedematous,  percussion  gives  great  sense  of  resistance,  with  deep  amphoric  resonance. 
Vocal  resonance  posteriorly  and  anteriorly  on  the  same  side  is  amphoric,  with  whis- 
pering pectoriloquy.  With  inspiration  under  left  clavicle,  friction  sound  is  audible; 
anteriorly,  respiration  is  exceedingly  faint ;  posteriorly  there  is  tubular  breathing 
less  distinct  towards  the  base ;  close  to  the  spine  over  upper  two-thirds  of  the  lung, 
respiratory  murmur  is  audible,  but  feint  in  comparison  with  the  right  side.  On  the 
right  side,  harsh  inspiration  and  prolonged  expiration  continue  to  be  heard,  and 
vocal  resonance  is  loud ;  friction  murmurs  have  disappeared  from  the  anterior  and 
lateral  regions.  Cardiac  apex  beats  two  inches  to  the  left  and  one  inch  below  the 
right  nii^ple.  Pulse  108,  soft  and  feeble.  Tongue  dry  and  bright  red;  appetite 
defective;    occasional  thirst;   bowels  regular.     Great  weakness,  and  considerable 


PLEURITIS.  627 

general  uneasiness,  but  no  local  pain ;  occasional  rigors.     Xov.  loth. — At  tlie  left 

apex,  and  over  left  infra-mammary  region,  metallic  tinlcling  was  heard  at  the  close 

of  inspiration,  and  vocal  resonance  was  loudly  metallic  in  character.     Xov.  lUtli. — 

The  following  measurements  were  taken  at  the  same  levels  as  those  mentioned  when 

he  was  admitted: — 

Level  of         Four  inches 
Xipple.  lower. 

Left  side 15f  15| 

Right  side 17^  17 

At  tliis  time  the  pulse  varied  from  120  to  130;  it  was  small  and  feeble.  The 
patient  complained  much  of  the  heat  and  foetor  of  the  discliarge.  Small  granulations 
were  seen  ou  the  edges  of  the  wound.  Xov.  20th. — The  following  report  was  made ; 
— Three  and  a  half  inches  below  right  nipple,  rough  friction  sound  with  inspiration 
and  expiration ;  five  inches  below,  and  two  and  a  half  inches  to  the  outer  side  of 
right  nipple,  a  rumbling  friction  with  expiration ;  inspiration  harsh  and  short,  but 
otherwise  free.  One  inch  below,  and  four  inches  to  the  outer  side  of  the  same  point, 
a  finer  friction  sound  with  expiration  alone.  An  inch  and  a  half  above  same  nipple 
respiratory  murmurs  are  heard,  intense  in  tone,  accompanied  during  close  of  inspira- 
tion, and  during  expiration,  with  a  sound  superficial,  and  rough,  resembling  coarse 
crepitation.  Two  and  a  half  inches  above  the  same  nipple,  a  mucous  rale  of  the  same 
character,  coarse  and  dragging,  accompanies  inspiration  only.  Above  this  point) 
over  the  upper  two  ribs,  the  respiratory  murmurs  are  harsh  and  loud.  These  obser- 
vations were  made  while  patient  lay  on  his  left  side ;  his  weakness  precluded  an 
examination  of  the  back.  His  eyes  are  sunk;  there  is  a  cold  clammy  sweat  on  the 
face;  occasional  feeling  of  chiUiness.  Nov.  26th. — No  change  since  last  report. 
To-day  his  appetite  has  improved  to  such  an  extent  that  he  was  able  to  take  two 
eggs  for  breakfast.  Loud  metallic  tinkling  still  audible  over  the  left  chest.  Xuv.  30ih. 
— Metallic  tinkling  is  now  no  longer  audible.  Dec.  -iih. — The  following  measure- 
ments were  taken : — 

Level  of         Four  inches 
Xipple.  lower. 

Left  side    .        ,         ,         .         .         .         15  15 

Eight  side 16  15^ 

The  second  level  was  that  of  the  ensiform  cartilage.  Dec.  8th. — A  sore  of  the  size  of 
a  fouqjenny  piece  was  observed  over  the  sacrum,  which  caused  the  patient  consider- 
able pain.  He  continued  to  improve  up  to  the  12th.  His  appetite  increased ;  he 
slept  well;  no  more  rigors  occurred,  and  his  pulse  feU  to  96.  Dec.  13t?i. — Last  night 
about  eleven  o'clock  he  was  seized  with  severe  pain  in  the  upper  part  of  the  abdomen, 
which  prevented  him  from  sleeping.  This  morning  the  pain  still  continues ;  it  is 
increased  by  firm  pressure,  but  he  can  easily  bear  slight  pressure.  Respiration  is 
abdominal  as  well  as  thoracic.  Appetite  gone ;  bowels  opened  freely  a  few  hours 
ago;  dejections  natural.  Pulse  108,  small,  but  not  hard  or  strong.  Skin  hot;  the 
look  is  not  particularly  anxious.  Dee.  loth. — Three  discoloured  spots  were  found 
over  the  sacrum,  with  a  very  small  ulcer,  wliich,  however,  had  a  healthy  granulating 
appearance.  Continues  to  complain  of  abdominal  pain.  Yesterday,  four  loose  stools 
were  passed,  which  produced  considerable  uneasiness.  To-day  he  has  had  but  one 
stool;  there  is  considerable  tenderness  on  pressure,  and  distension  from  tympanitis 
over  tlie  whole  left  flank.  Pulse  96,  feeble,  soft.  Dec.  IGih. — He  was  greatly 
relieved,  and  he  continued  in  a  comfortable  condition  till  the  18th.  On  the  evening 
of  that  day  he  was  attacked  by  vomiting  and  a  sensation  of  fulness  in  the  abdomen, 
both  of  which  he  believed  to  be  due  to  his  having  taken  a  quantity  of  lemonade. 
The  vomiting  continued  till  eleven  p.ji.,  when  it  ceased;  the  matters  vomited  were 
partlj'  fluid  and  partly  solid,  and  evidently  consisted  of  alimentary  substances. 


628 


DISEASES    OF   THE   EESPIRATOEY   SYSTEil. 


Tenderness  on  pressure  in  the  region  of  the  recti  muscles  ;  bowels  opened  this  morn- 
ing; dejections  natural.  Respirations  30,  somewhat  laboured.  Pulse  120,  small, 
somewhat  hard,  but  quite  compressible ;  consciousness  perfect ;  skin  hot  and  dry ; 
cheek  tlushed.  Dec.  19th  — A  remission  of  the  symptoms  took  place.  On  the  20th, 
vomiting  recurred,  together  As-ith  abdominal  pain  and  tenderness,  as  described  in  the 
report  of  the  18th.  These  continued  to  become  severe  till  the  morning  of  the  22d, 
when  he  sunk,  with  all  the  marks  of  great  depression  of  the  entire  system.  He  died 
at  2  A.M.  on  the  2 2d. 

From  the  moment  of  the  patient's  entering  the  hospital,  every  eflbrt  was  made  to 
snstain  his  strength  by  means  of  the  most  nourishing  diet,  together  with  wine. 
Diarrhoea  was  put  a  stop  to  by  the  use  of  cretaceous  mixtures,  and  the  rigors  were 
successfully  treated  with  quinine.  The  vomiting  was  diminished  by  bismuth  and 
aromatic  powder,  and  towards  the  end  of  the  case  he  was  greatly  relieved  by  the  use 
of  brand}-,  and  ice  internally.  Effervescing  lemonade  was  allowed  latterly  to  allay 
the  patient's  thirst. 

Sectio  Cadaveris. — Twerdy-eujlit  hours  after  death. 

Body  considerably  emaciated.  On  reflecting  the  integuments,  and  removing  the 
sternum  and  ribs  anteriorly,  so  as  to  expose  the  thoracic  and  abdominal  cavities,  the 

contained  viscera  were  observed  to  be  dis- 
placed as  follows : — The  left  thoracic  cavity 
presented  an  empty  space,  in  consequence 
of  the  lung  being  compressed  and  tightly 
bound  down  to  the  spinal  column  (Fig. 
429,  h).  The  heart  was  in  the  centre  of  the 
body,  passing  somewhat  to  the  right  side. 
The  stomach  was  enormously  dilated,  ex- 
tending to  the  pubes,  and  concealing  all 
the  abdominal  viscera,  except  a  portion  of 
the  right  lobe  of  the  Uver  and  colon  (Fig. 
429,  e). 

Thorax. — On  opening  the  thorax,  there 
was  an  escape  of  foetid  air  from  the  left 
side.  The  ijericardium  was  everywhere 
strongly  adherent.  The  heart  and  its 
valves  healthy,  weighing  with  pericardium, 
8^  oz  The  left  pleural  cavity  contained 
about  6  oz.  of  dirty  foetid  purulent  fluid. 
The  surfaces  of  the  pleurse,  parietal  and 
visceral,  were  covered  with  a  layer  of 
chronic  lymph,  having  scattered  throughout 
its  substance  opaque  yellow  spots  of  the  size 
of  millet  seeds,  resembling  tubercle.  This 
layer  of  lymph  could  readily  be  scraped  off, 
and  was  seen  to  be  about  one  eighth  of  an 
inch  in  thickness,  having  a  soft  pulpy  layer 
internally,  and  where  attached  externally, 
to  be  highly  vascular.     The  lung  was  bound  down  to  the  spmal  column  by  firm  and 


Fig.  429.  Relative  position  of  the  thoracic  and  abdominal  viscera,  on  reflectmg  the 
integuments  in  Allan  Brown's  case.  a.  Empty  left  thoracic  cavity ;  h,  left  lung ; 
c,  right  lung;  d,  heart;  e,  enormously  distended  stomach;  /,  liver;  g,  colon. 


PLEURITIS.  629 

dense  adhesions.  Its  tissue  was  compressed  and  carnified,  and  its  size  reduced  to  a 
spindle-sliaped  body  about  five  inches  long,  and  two  inches  in  its  greatest  diameter 
(Fig.  429,  b).  On  insufflation  it  expanded  very  imperfectly.  At  the  apex  there  was 
a  cavity  tlie  size  of  a  walnut,  having  a  distinct  lining  membrane,  and  filled  with  soft, 
cheesy,  tubercular  matter,  evidently  of  old  standing.  Scattered  through  the  sub- 
stance of  t}\e  lung  were  numerous  small  masses  of  tubercles,  but  no  other  cavities. 
The  right  lung  was  universally  adherent  by  dense  chronic  adhesions.  It  was 
moderately  voluminou.s,  and  at  the  apex  were  numerous  stellate  puckerings,  corre- 
sponding to  dense  fibrous  cicatrices  in  the  substance  of  the  pulmonary  tissue,  but 
without  concretions. 

Abdomex. — Tlie  stomach  was  enormously  dilated  as  formerly  described  (Fig. 
429,  e).  On  opening  it,  it  was  found  to  be  distended  with  air,  and  somewhat  twisted 
round  on  itself  at  the  junction  of  the  cardia  and  oesophagus.  All  the  coats  were 
very  thin,  apparently  from  the  distension.  The  mucous  coat  was  health}-,  and  no 
abrasions  could  be  discovered  in  it.  But  between  the  serous  and  muscular,  as  well 
as  the  muscular  and  mucous  coats,  numerous  bullae  of  air  were  visible,  which  could 
be  moved  about  bj'  pressure  of  the  fingers,  evidently  dependent  on  the  existence  of 
some  gas  in  the  texture,  which  was  in  no  waj'  putrid,  nor  was  the  gas  itself  of  foetid 
colour.  In  the  coecum  and  ascending  colon  were  numerous  small  depressions  in  the 
mucous  coat,  the  cicatrices  of  former  ulcers.  There  was  nowhere  any  trace  of  recent 
intestinal  ulcerations.  The  spleen  weighed  8  oz. ;  sp.  gr.  1063.  Its  pulp  was 
health}',  but  the  malpigliian  bodies  were  enlarged  throughout,  and  resembled  grains 
of  boiled  sago.  The  kidneys  were  pale,  and  had  two  or  three  small  masses  of 
tubercle  imbedded  in  the  cortical  substance.     Liver  and  other  organs  healthy. 

Commentary. — The  place  for  making  an  opening-  into  the  thoracic 
cavity  in  empyema  should  always  be  chosen  with  the  greatest  care. 
The  general  rule  is,  that  if  the  pus  causes  a  prominent  tumour,  to  punc- 
ture there,  but  if  not,  then  one  of  the  intercostal  spaces  between  the 
fifth  and  seventh  ribs  should  be  chosen,  but  so  as  to  avoid  the  heart  and 
diaphragm.  In  the  above  case,  with  bulging  of  the  thoracic  walls  infe- 
riorlv  and  posteriorly,  the  opening  was  made  at  the  most  prominent  part 
bv  a  large  incision,  and  the  offensive  matter  it  contained  replaced  by 
air.  This  proceeding,  which  converts  an  empyema  at  once  into  pneumo- 
thorax, it  is  argued,  can  have  no  ill  effect,  so  long  as  the  aperture 
remains  free,  and  the  air  thereby  prevented  from  becoming  iVx'tid.  The 
operation  was  had  recourse  to  more  as  a  palliative  than  as  a  curative 
proceeding  in  the  present  case,  the  phthisical  complication  rendering- 
ultimate  recovery  very  improbable.  My  impression,  however,  is,  that 
under  more  favourable  circumstances,  the  small  puncture,  avoiding 
admission  of  air  as  much  as  possible,  holds  out  the  best  prospect  of 
success. 

The  mode  of  death  in  this  case  was  very  remarkable,  and  indeed,  so 
far  as  I  am  aware,  unique.  The  man  to  relieve  his  thirst  was  allowed 
two  or  three  bottles  of  effervescing  lemonade  as  drink  during  the  day. 
It  would  appear,  that  on  the  15th  of  December  he  complained  of  fulness 
of  the  stomach,  and  tympanitic  distension  of  the  abdomen,  which  symp- 
toms, however,  excited  no  great  attention,  although  they  may  have  origi- 
nated in  the  same  cause,  which  apparently  produced  the  more  violent 
complaints  that  came  on  subsequently.  On  the  evening  of  the  ISth  he 
was  seized  suddenly  with  all  the  symptoms  of  perforation  of  the  bowel, 
and   on  examining  him  next  day,  such  was  what  I  believed  to  have 


0  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

occurred.  There  was  great  abdominal  tympanitic  swelling,  excessive 
pain,  vomiting,  etc.  But  on  dissection  we  found  that  these  symptoms 
depended  on  great  distension  of  the  stomach,  with  emphysema  of  its 
coats,  the  latter  a  lesion,  which  I  believe  was  then  observed  for  the  first 
time.  It  was  not  caused  by  putrefaction  ;  and  the  question  arose,  How 
was  it  produced  ?  It  turned  out  on  inquiry  fi-om  the  nurse  and  neigh- 
houring  patients,  that  the  man  had  kept  his  bottles  of  effervescing 
lemonade  till  the  evening,  and  drank  at  least  the  contents  of  two  of 
them  in  quick  succession.  It  is  probable,  therefore,  that  the  extrication 
of  gas  had  disteniled  the  stomach,  and  caused  it  to  twist  round  partly  on 
itself  at  the  cardia,  so  as  to  prevent  its  escape.  Hence  the  distension 
and  pain,  and  why  probably  the  contained  air,  not  finding  a  ready  exit 
through  either  the  cardia  or  pylorus,  had  forced  its  way  between  the 
coats  of  the  organ  itself. 

^Yith  regard  to  the  other  facts  of  this  case,  they  present  in  a  well 
marked  form  all  the  characteristic  phenomena,  first  of  empyema  of  the 
left  side,  and  secondly,  of  pneumo-thorax.  A  disquisition  on  these  two 
thoracic  diseases,  their  diagnosis  and  treatment,  would  lead  me  too  far. 
There  is  only  one  point  to  Avhich  I  think  it  necessary  to  refer,  namely, 
the  cause  of  metallic  tinkling;  and  I  do  so  merely  to  say  that  notwith- 
standing the  ingenious  theories  which  have  been  advanced  to  account  for 
it,  they  all  appear  to  me  faulty.  I  have  satisfied  myself  that  the  break- 
ing of  bubbles  of  air  on  the  sui-face  of  fluid,  or  the  splashing  of  water  in 
a  cavity  containing  air,  will  not  ahcays  explain  the  occurrence.  On  one 
occasion  I  heard  metallic  tinkling  most  distinct  over  the  lung  in  a  man 
dying  of  phthisis.  After  death  I  commenced  the  examination  by  mak- 
ing an  opening  between  the  ribs  cautiously,  over  the  centre  of  the  tym- 
panitic space,  thinking  that  air  would  escape.  But  the  pleurje  were  uni- 
versally adherent.  There  was  no  cavity  whatever,  but  simply  hard 
nodules  of  tubercle,  scattered  throughout  a  highly  emphysematous  lung. 


PNEUMONIA. 

Case  CXXIX.* — Pneumonia  on  Right  Side  and  slight  Pleuritis — Recovery. 

History. — Roderick  MTarlane.  set.  20,  a  gardener  of  healthy  and  robust  constitu- 
tion— admitted  December  ITlh,  1856.  On  the  12th  instant  felt  imwell,  with  a  sen- 
sation of  cold  in  the  back.  On  the  13th  had  pain  in  the  right  infra-axillary  region, 
increased  on  deep  inspiration,  with  hot  skin,  headache,  thirst,  and  loss  of  appetite, 
symptoms  which  have  continued  ever  since.  On  the  14th,  cough  appeared  with 
scanty  expectoration.     Has  taken  a  dose  of  castor-oil  and  some  pills. 

Symptoms  ox  Admissiox. — Expansion  on  both  sides  of  chest  equal.  Respirations 
twenty-four  in  the  minute,  not  laboured.  Can  lie  on  either  side,  but  prefers  lying  on 
the  back.  Pain  during  deep  inspiration  over  right  infra- axillary  region;  slight 
cough;  scanty  expectoration — frothy  and  mucous.  On  percussion,  cracked-pot  reso- 
nance extends  from  clavicle  to  fifth  rib  on  right  side.  Below  this  level,  percussion 
is  dull.  There  is  also  decided  dulness  posteriorly  from  spine  of  scapula  to  base. 
Elsewhere  percussion  natural.     On  auscultation,  puerile  respiration  over  left  front ; 

*  Reported  by  Dr.  J.  Glen,  Resident  Clinical  Physician. 


PNEUMONIA.  631 

over  right  front  superiorly  respiration  is  harsh,  witliout  rale ;  below  fifth  ril),  it  is 
suppressed.  Posteriorly  over  two  lower  thirds,  double  friction  is  audible,  with  fine 
crepitation  at  the  close  of  inspiration  ;  on  left  side  occasional  sibilus,  with  a  few  moist 
rattles  at  close  of  inspiration  over  lower  third.  The  vocal  resonance  is  increased 
and  sharp  on  right  side  anteriorly,  but  greatly  increased  and  oegophouic  posteriorly 
over  area  of  dulness.  Pulse  104,  incompressible  and  full.  Skin  hot  and  dry. 
Tongue  in  centre  brown,  dry,  and  cracked ;  edges  moist  and  clean.  No  appetite ; 
great  thirst;  bowels  always  regular,  but  have  been  opened  by  laxatives.  Urine 
natural.  Other  functions  normal.  I^  Sol.  Antim.  Tart.  3  ss ;  Aqum  Ammon.  Acet. 
§j;  Aquce  ^  viss.     M.  Habeat  sextam partem  quartd  qudque  liord. 

Progress  op  the  Case. — December  I8th. — Grazing  friction  audible  over  the 
right  infra-mammary  region.  Crepitation  distinct  over  rigiit  back  inferiorly.  Pulse 
120,  soft.  Sputum  scantj^,  consisting  of  orange-coloured,  gelatinous  masses.  Other- 
wise the  same.  Dec.  20th. — Crepitations  very  coarse  over  right  back.  Fever 
abated.  Tongue  moist  and  clean.  Pulse  72,  of  good  strength.  Temperature  of 
skin  natural.  Omiit.  mist.  Dec.  22d. — Crepitation  and  friction  disappeared  from 
right  back.  Abundant  sediment  of  lithates  in  the  urine.  5  Sp.  ^ther.  Kit.  3  iij ; 
Viii.  Sem.  Golchici,  3j;  Aqu(e.  ad  3  vj.  M.  Two  table-spoon  fids  to  be  taken  every 
four  hours.  Dec.  24</i.— Dulness  over  right  back  and  cracked-pot  sound  anteriorly 
greatly  diminished.  For  the  last  three  days  has  had  profuse  diaphoresis.  Urine 
again  natural.  Omitt.  mist.  To  have  steak  diet.  Dec.  26;/i.— No  dulness  any- 
where ;  respirations  natural.  Is  quite  recovered ;  but  as  the  weather  was  severe, 
and  he  had  to  work  immediately  in  the  open  air,  if  dismissed,  he  was  not  discharged 
until  January  2d. 

Commentary/. — This  young  man  was  first  seized  with  illness  on  the 
12th  of  December,  and'  was"  admitted  on  the  l7th,  when  hepatization 
of  the  lung  was  found  to  liave  occurred  in  the  lower  two-thirds  of  the 
or^an  on  the  right  side,  combined  with  slight  plenritis.  Fever  was 
well  marked,  thepulse  full  and  incompressible.  On  the  22d,  the  exuda- 
tion was  thoroughly  softened  and  passing  oil"  from  the  economy  princi- 
pally by  the  urine,  but  partly  by  the  skin.  On  the  26th,  all  trace  of  the 
disease' had  disappeared.  Tlie  treatment  consisted  at  first  of  slight 
salines  and  rest,  then  of  a  diuretic  mixture  to  favour  excretion  of  the 
etfete  products  by  the  urine,  and  lastly  of  steak  diet.  From  the  first 
commencement  to  the  complete  disappearance  of  the  disease  was  fourteen 
days;  and  to  the  abatement  of  fever  and  commencing  resolution  eight 
days.  The  febrile  phenomena  in  this  case  were  unusually  well  pro- 
nounced. The  pulse  was  full  and  incompressible — in  fact  hard  ;  the 
skin  hot  and  dry.  Tongue  furred  and  dry  ;  no  appetite,  great  thirst, 
etc.  In  short,  this  young  vigorous  lad  presented  all  those  symptoms  iu 
which  we  are  instructed  by  most  writers  to  bleed,  and  in  which  it  has 
been  argued,  that  without  bleeding  a  fatal  suppuration  was  likely  to 
occur.  I  need  scarcely  add,  that  the  propriety  of  such  practice,  as  well 
as  the  probable  fatality,  were  alike  negatived  by  the  result. 

Case  CXXX.* — Double  Pneumonia — Recovery. 

rnHiSTORY. Peter  Robertson,    ast.    51,   a  tolerably  robust  man,  house-painter — 

admitted  May  11,  1857.     On  Tuesday  last,  the  5th  instant,  when  washing  the  ou 

*  Eeported  by  Mr.  W.  H.  Davies,  Clinical  Clerk. 


632  DISEASES   OF   THE   EESPIRATORY  SYSTEM. 

side  of  a  house,  he  got  wet  through  from  the  dripping  of  water.  In  the  evening 
had  a  rigor,  which  continued  more  or  less  aU  night.  On  the  following  morning  had 
a  short  cough,  and  a  thick  yellow  sputum.  These  symj^toms  continued  the  two 
following  days  with  pain  in  the  left  breast  anteriorly ;  but  he  continued  at  his  work, 
although  feeling  very  weak.  On  the  9th  he  was  obliged  to  go  to  bed,  and  observed 
his  sputum  to  be  tinged  with  blood.  Yesterday  again  had  rigors,  with  cramps  in  the 
arms  and  elbows. 

Symptoms  ox  Admission. — On  percussion  there  is  marked  dulness  over  the  lower 
two-thirds  of  the  left  lung  posterioily,  with  tubular  breathing  and  coarse  mucous 
rale  on  inspiration.  The  vocal  resonance  is  oegoplionic  inferiorly,  and  bronchophonic 
over  the  middle  third.  Right  side  and  anterior  surfaces  normal.  Sputum  copious 
and  viscid,  mixed  with  dark  blood.  Pulse  100,  small  and  weak.  Respirations  36 
per  minute.  Skin  moist.  Other  functions  normal.  IJ  Liq.  Ammon.  Acet.  §  j ;  Sp. 
uElher.  Nitric.  %  ss ;  Vin.  Aniini.  3  iss ;  Aqvxe  ad  §  vj.  M.  One  iable-sjwonful  to  be 
taken  every  three  hours. 

Progress  of  the  Case. — May  12th. — Dulness  on  percussion  over  lower  third  of 
right  back,  in  addition  to  that  on  the  left,  with  tubular  breathmg  and  increased  vocal 
resonance.  Physical  signs  otherwise  the  same.  Respirations  are  40  in  the  minute, 
laboriou.s  and  catching.  Sputum  gelatinous  and  rusty.  Pulse  120,  weak.  Face 
livid,  and  expressive  of  great  anxiety.  Urine  liigh  coloured,  scanty,  and  deficient 
in  chlorides.  Warm  fomentations  to  be  applied  over  left  side,  and  to  have  3  iv  of  wine. 
May  I3th. — Much  better.  Respiration  easy.  Ko  lividity  or  anxiety  of  countenance. 
Cough  dismissed.  Pulse  80,  soft,  but  of  good  strength.  Omitt.  mist.  May  \Mh. — 
Less  dulness  and  crepitation  on  left  side ;  on  right  side  crepitation  fully  estabhshed. 
Chlorides  present  to  a  slight  degree  in  urine,  and  urates  abundant.  Pulse  14,  regu- 
lar. Appetite  returning.  Tongue  clean.  May  \Qth. — Is  now  convalescent.  Urine 
natural.  Percussion  resonant  over  both  backs ;  inspiratory  murmurs  harsli,  but  no 
moist  rales.  Cough  painless.  Still  gelatinous  sputum  without  blood.  Has  been 
out  of  bed,  and  feels  tolerably  strong.  Steak  diet.  May  \^th. — Has  been  up  aU 
day,  and  says  he  is  quite  weU.     May  20fh. — Dismissed. 

Cominentary . — This  was  a  severe  case  of  double  pneumonia,  with 
great  dyspncea,  inipending  suffocation,  and  great  weakness  on  the  seventh 
day,  when  wine  was  liberally  administered.  On  the  following  day  he 
was  better  and  continued  to  improve,  so  that  on  the  eleventh  dav  he  was 
fully  convalescent,  and  on  the  fourteenth  was  quite  well,  and  returned  to 
his  work.  I  never  saw  a  case  in  which  the  symptoms  were  more  uro-ent 
than  in  this  man  the  day  after  his  admission,  and  in  which  the  livid  and 
anxious  countenance,  the  intense  dyspnoea,  the  bloody  sputum  and  feeble 
pulse,  gave  stronger  evidence  of  impending  dissolution.  I  am  satisfied 
that  a  bleeding,  however  small,  at  this  juncture,  would  have  produced 
death  rapidly,  a  practice  which  formerly  I  have  too  often  seen  carried 
out  as  a  mere  matter  of  routine.  Under  an  opposite  treatment  of  wai'm 
fomentations  locally,  and  wine,  these  symptoms  quickly  subsided,  and 
next  day  he  was  found  breathing  easily,  and  from  that  moment,  though 
both  lungs  were  affected,  speedily  recovered. 


Case  CXXXL* — Pneumonia  on  the  Right  Side — Early  Bleeding — Slov)  Recovery. 

History. — James  M'Quair,  tailor,  jaet.  29 — admitted  June  4th,  1855.     This  man 
*  Reported  by  Mr.  Robert  Byers,  CUnical  Clerk. 


PNEUMONIA.  633 

has  been  of  intemperate  habits  during  the  last  five  years.  On  the  28th  of  May,  after 
severe  drinking  and  exertion,  followed  by  exposure  to  the  night  air,  he  was  attacked 
early  in  the  morning  with  rigor,  chilliness,  a  feeling  of  weight  over  his  whole  body, 
and  a  dull  heavy  pain  in  the  right  chest.  He  drank  several  glasses  of  whisky  and 
water  to  allay  his  thirst,  and  kept  his  bed,  occasionally  vomiting,  and  going  out  of 
doors  to  stool,  until  the  30th.  He  now  felt  very  feverish,  weak,  and  unwell,  and  a 
soup-plateful  of  blood  was  extracted  from  the  arm.  ( 3  xxiv.)  Venesection  to  the 
same  amount  was  made  on  the  following  day ;  but  the  pains  in  the  side,  with  san- 
guineous cough  and  expectoration,  continuing,  he  came  to  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  the  patient  has  an  anxious  and  flushed 
appearance,  and  feels  very  weak.  The  respiration  is  hurried,  42  in  a  minute,  and 
the  lower  part  of  the  right  lung  expands  little.  Cough  is  short,  frequent,  and  sup- 
pressed ;  the  expectoration  scanty,  consisting  of  gelatinous  mucus,  slightly  tinged 
with  blood.  On  percussion,  there  is  marked  comparative  dulness  over  the  inferior 
half  of  tlie  right  lung,  but  the  upper  half  anteriorly,  especially  at  the  apex,  though 
flat  in  tone,  gives  out  a  tympanitic  and  somewhat  intestinal  note.  On  auscultation, 
crepitation  is  audible  aU  over  the  right  lung,  botli  anteriorly  and  posteriorly,  and  the 
vocal  resonance  is  much  increased  over  the  dull  portion.  The  left  lung  is  normal. 
The  pulse  is  100,  hard  and  incompressible.  Heart  normal.  Tongue  drj-,  and  covered 
with  a  dark  brown  fur,  and  the  teeth  surrounded  by  sordes.  Appetite  gone ;  great 
thirst ;  the  vomiting,  which  existed  at  the  commencement  of  the  attack,  has  now 
ceased.  Abdominal  viscera  normal ;  bowels  regular.  Skin  dry  and  hot  to  the  feel. 
Urine  high-coloured  and  diminished  in  quantity,  clear  and  without  sediujent.  No 
trace  of  chlorides;  no  albumen.  Nervous  system  normal.  ]J.  Antim.  Tart.  gr.  iij; 
Aqim,   5  vj ;   Solve.      One  ounce  to  be  taken  every  three  hours. 

Progress  of  the  Case.— June  5th.— Says  he  feels  better ;  pulse  90,  full  and  com- 
pressible, but  in  the  evening  it  fell  to  80,  and  became  soft.  June  Gift.— Pulse  78, 
soft,  breathing  more  easy.  On  percussion,  the  lower  half  of  right  lung  is  dull,  but 
the  upper  half  is  resonant,  with  distinct  cracked-pot  sound.  Fine  crepitation  audible 
over  the  whole  of  right  chest.  June  8th.— The  whole  of  the  riglit  lung  in  front  has 
become  resonant  on  percussion ;  otherwise  the  same.  Faint  traces  of  chlorides  in 
the  urine.  June  9i7t.— Chlorides  abundant  in  the  urine.  June  lOth.  — Percussion 
resonant  and  equal  over  both  sides  of  chest  anteriorly.  Under  right  clavicle, 
cracked-pot  sound  still  audible.  Crepitation  much  less  inferiorly,  but  continues  at 
the  apex,  with  increase  of  vocal  resonance.  Posteriorly,  percussion  over  right  lung 
dull  inferiorly,  with  loud  crepitation  and  oegophonic  resonance  of  voice.  The  patient 
feels  much  better,  though  weak.  Respiration  free.  Pulse  72,  soft  and  regular. 
Considerable  diaphoresis.  .  Urine  deposits  on  cooling  a  large  amount  of  lithates. 
^  Antim.  Tart.  gr.  ij ;  Tinct  Camph.  co.  3  ij ;  Decoct.  Serpent.  5  iij.  3f.  5  J  ^o  be 
taken  every  three  hours.  June  I4th  —Physical  sigris  of  right  lung,  with  the  exception 
of  cracked-pot  sound,  mnch  diminished.  Has  been  taking,  during  the  last  three 
days,  good  diet,  with  5  iv.  of  wine.  From  this  time  he  improved  slowly,  the  crepi- 
tation and  dulness  posteriorly  gradually  disappeared,  but  the  cracked-pot  sound  con- 
tinued with  great  intensity  up  to  the  29th  of  June.  His  strength  was  not  sufficient 
to  admit  of  his  discharge  until  the  3d  of  July. 

Commentary. — This  was  a  case  in  wliicli  nearly  the  whole  of  the 
ris^ht  luno-  became  pneumonic,  and  where  we  had  an  opportunity  of  con- 
vincino-  ourselves  that  full  and  repeated  bleeding,  although  practised  so 
early  as  the  second  and  third  days,  had  no  beneficial  influence  on  the  pro- 
gress of  the  disease.  It  shoukl  also  be  remarked,  that  these  bleedings 
were  practised  in   accordance  with  the  rules  laid  down  in  systematic 


63-1  DISEASES   OF   THE   RESPIRATORY   SYSTE:M. 

^vritino•s,  that  is  to  say,  not  only  early,  but  when  the  pulse  was  accele- 
rated, hard,  and  incompressible,  with  all  the  characteristic  symptoms  of 
the  disease.  Surely,  if  bleedings  could  cut  short  or  diminish  the  dura- 
tion of  a  pneumonia,  it  might  have  been  expected  in  this  case.  Yet  so 
far  from  proving  beneficial,  they  appear  to  me  to  have  assisted  in  pro- 
longing the  case,  and  preventing  resolution  and  recovery.  For  although 
the  critical  diaphoresis,  and  discharge  of  lithates  by  urine,  occurred  on 
the  fourteenth  day,  the  subsequent  weakness  was  considerable. 

On  his  admission  into  the  house,  the  eighth  day  of  the  disease,  the 
chlorides  were  observed  to  be  absent  from  the  urine.  This  fluid  was 
tested  daily  for  these  salts,  which  returned  in  small  quantity  on  the 
twelfth,  and  were  abundant  on  the  thirteenth  day  of  the  disease.  If,  as 
we  shall  subsequently  see,  it  is  probable  their  reappearance  indicates  a 
cessation  of  fresh  exudation,  then  it  was  observable  that  on  the  day  fol- 
lowing, excretion  of  the  morbid  products  commenced  by  the  skin  and 
kidneys.  The  interval  between  the  return  of  chlorides  to  the  urine  and 
the  critical  period,  varies  considerably  in  different  cases ;  but  the  careful 
estimate  of  these  facts  in  future  will,  I  think,  furnish  us  with  valuable 
hints  as  to  the  vital  power  of  the  exudation.  If,  for  instance,  it  should 
ultimately  be  shown  that  the  return  of  chlorides  indicates  stoppage  of 
exudation,  and  the  presence  of  lithates  or  other  critical  discharge,  the 
commencement  of  excretion  of  the  exudation,  then  we  shall  possess 
evidence  not  previously  discovered,  as  to  when  the  pathological  lesion  is 
checked,  and  when  the  reparative  changes  in  the  economy  commence. 

Another  fact,  which  excited  considerable  attention  in  this  case,  was 
the  characteristic  cracked-pot  sound  under  the  right  clavicle.  The 
physical  signs  sufficiently  proved  that  the  pneumonic  condensation  com- 
menced at  the  base  of  the  lung,  and  proceeded  upwards,  where,  poste- 
riorly and  anteriorly,  a  considerable  amount  of  air  was  retained  in  the 
air  vesicles,  so  that  percussion  was  never  dull,  although  crepitation  and 
increased  vocal  resonance  existed.  This  presence  of  condensed  lung, 
covered  with  or  surrounded  by  air,  or  of  a  cavity  containing  air, 
surrounded  by  condensed  tissue,  seems  to  constitute  the  condition  under 
which  this  peculiar  noise  is  elicited  when  the  mouth  is  open.  Hence 
the  occurrence  of  the  cracked-pot  sound  {bruit  de  'pot  fele)  is  common 
in  pneumonia  and  in  a  variety  of  diseases  which  present  similar  physical 
conditions.* 


Case  CXXXII.f — Erysipelas  of  the  Face  foUoived  by  Pneumonia  of  the  Right  Side — 

Recovery. 

History. — Margaret  Araistrong,  set.  28,  wife  of  a  slioemaker,  of  robust  healthy- 
appearance — admitted  December  7,  1855.  She  states  that  she  was  quite  well  up  to 
Wednesday  evening  last  (December  5th),  when,  after  bemg  engaged  for  some  time 
in  washing,  she  was  seized  with  rigors  and  febrile  symptoms.  Next  morning  her 
face  felt  painful  and  swollen,  and  has  continued  so  up  to  the  time  of  admission. 
"When  examined  in  the  ward,  the  whole  of  the  face  and  forehead  was  of  a  fiery  red 

*  See  the  Author's  clinical  investigation  into  the  diagnostic  value  of  the  cracked- 
pot  sound — Edin.  Med  Journal,  vol.  i.,  p.  789.     1856. 
■)•  Reported  by  Mr.  G.  Robertson,  Clinical  Clerk. 


PNEUMOXIA,  635 

colour,  the  integuments,  and  especially  the  eyelids,  greatly  swollen,  with  a  few  bullae 
on  each  cheek,  full  of  yellow  lymph  ;  the  skin  everywhere  hot,  and  in  the  face  giving 
rise  to  a  severe  smarting  sensation.  Tongue  and  lips  dry,  covered  with  black  sordes ; 
great  thirst ;  no  appetite ;  cephalalgia ;  pulse  130,  soft ;  bowels  not  open.  Urine 
natural  in  quantity,  turbid  from  pinkish  sediment,  containing  a  considerable  amount 
of  albumen,  and  a  very  scanty  quantity  of  chlorides.  To  have  §  ss  of  castor  oil^  and 
the  face  to  be  covered  with  clutlis  wrung  out  of  warm  water. 

Progress  of  the  Case. — December  \lth. — To  day  the  face  is  assuming  its  natu- 
ral colour,  the  epidermis  desquamating.  There  is  no  albumen  in  the  urine,  and  the 
chlorides  are  abundant.  Dec.  I3th. — The  erysipelas  has  now  disappeared,  but  there 
is  a  general  aspect  of  prostration.  She  has  had  a  short  cough  for  the  last  two  days, 
whicli  cannot  be  ascertained  to  have  been  ushered  in  by  rigors.  Breathing  hurried 
and  laborious.  Pulse  92,  small  On  percussing  the  chest  posteriorly,  there  is  com- 
parative dulness  over  right  back  inferiorly.  On  auscultation,  a  fine  crepitation  is 
audible  there  on  inspiration,  with  sonorous  and  sibQant  rales  and  increased  reso- 
nance (almost  pealing)  of  the  voice.  Dry  rales  are  also  heard  anteriorly  on  this  side, 
causmg  deep  inspiration,  with  coarse  moist  rale.  Tliere  is  no  expectoration.  Urine 
abundant,  of  Ijrick  dust  colour,  which  disappears  on  the  addition  of  heat ;  sp.  gr. 
1022,  no  albumen,  and  the  chlorides  have  disapi^eared.  To  have  beef  tea,  and  §  vj. 
ofvji'de  daily.  Dec.  11  th. — The  pneumonia,  since  last  report,  has  produced  complete 
dulness,  with  bronchophony  in  the  lower  tliird  of  right  lung,  which  is,  however,  now 
disappearing.  To-day,  clilorides  in  lu'ine  are  more  abundant.  Dec.  19ih. — Diseased 
lung  more  resonant  on  percussion.  Breathing  more  natural,  free  from  moist  rale. 
Still  increase  of  vocal  resonance.  Chlorides  abundant  in  urine.  Diminish  ivine  to 
§  iij  daily.  Dec.  24th. — To-day  can  breathe  without  difficultj'^ ;  respiration  on  right 
side  normal,  but  still  some  increase  of  vocal  resonance ;  pulse  66,  of  good  strength. 
Expresses  herself  as  being  quite  well.  Has  been  for  the  last  few  days  on  good  diet, 
and  walking  about  the  ward.     Wishes  to  leave  the  hospital.     Dismissed. 

Commenfari/.— The  erysipelas  in  this  case  was  very  severe,  but  occur- 
ring, as  it  did,  in  a  healthy  young  woman,  gave  us" little  concern,  and 
■was  allowed  to  take  its  natural  course.  Wanu  water  applications  only 
were  employed  to  relieve  the  smarting.  The  disease,  in  con.sequence, 
bad  disappeared  by  the  seventh  day.  "The  chlorides  in  the  urine  were 
diminished  during  the  accession  of  the  fever  and  presence  of  the  erup- 
tion, and  returned  abundantly  when  the  erysipelas  had  disappeared. 
The  ward  at  this  time  was  very  cold,  from  sonie  of  the  ventilators,  which 
allowed  the  admission  of  frosty  air,  not  having  been  closed.  Pneumonia 
on  one  side  came  on,  and  the  chlorides  again  disappeared  from  the  urine. 
The  attack  supervening  on  an  acute  febrile  disease  was  characterised  by 
great  prostration  of  the  system  and  weak  pulse  througliout.  But,  under 
the  careful  exhibition  of  nutrients  and  six  ounces  of  wnie  daily,  she  made 
a  rapid  recovery.  The  pneumonia  was  detected  on  the  "l3th.  The 
chlorides  had  returned  on  the  19th,  and  she  was  dismissed  at  her  own 
request,  quite  well,  on  the  24th.  The  pneumonia  was  only  of  seven 
days'  duration,  up  to  the  time  of  commencing  resolution. 

Case  CXXXIII.* — Double  Pneumonia — Ti-eatment  by  Mercury,  which  caused  Profuse 
Salivation  before  Admission — Prolonged  Recovery. 

History.— Robert  Jude,  at.  36,  a  bricklayer— admitted  10th  December,  1855. 
*  Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


636  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

On  the  1st  instant,  while  engaged  building  bricks  round  a  boiler,  the  weather  being 
very  cold  and  windv,  he  suddenly  felt  a  pain  in  the  chest,  deep-seated,  half  way 
between  the  ensiform  cartilage  and  umbilicus.  The  pain  rapidly  grew  worse,  and 
caused  nausea,  but  he  could  not  vomit.  He  immediately  went  home,  took  some 
gruel,  and  went  to  bed.  On  the  4th,  a  medical  man  gave  him  some  pills,  one  of 
which  he  took  every  third  hour.  On  the  Gth  his  teeth  were  loose,  the  gums  very 
tender,  and  the  tongue  swollen  to  twice  its  natural  size,  so  that  he  could  not  spit 
out  the  excessive  amount  of  saliva  that  was  secreted,  and  which  consequently  flowed 
from  his  mouth.     He  also  had  pain  in  the  loins. 

Stmptojis  on  Admission.— On  admission,  the  excessive  salivation  had  much 
diminished,  but  there  is  stQl  tenderness  and  redness  of  the  gums,  with  considerable 
discharge  from  the  mouth.  The  breath  foetid,  the  tongue  covered  with  a  dense, 
dirty  white  coating.  The  bowels,  while  taking  the  pills,  were  open  from  six  to 
seven  times  a  day ;  they  are  now  regular.  His  diet  has  been  confined  to  farina- 
ceous articles.  On  percussing  the  chest  anteriorly,  it  is  everywhere  resonant,  but 
posteriorly  it  is  dull  on  both  sides,  most  so  on  left  side.  On  auscultation  anteriorly 
nothing  abnormal,  but  posteriorly  respiratory  murmurs  are  harsh  and  shrill,  with 
occasional  sibilation.  At  the  base  on  right  side,  there  is  crepitation  on  inspiration ; 
on  tlie  left  side  respiration  is  tubular.  Vocal  resonance  equal  superiorly  and  ante- 
riorly, but  posteriorly  everywhere  increased,  on  the  left  side  amounting  to  broncho- 
phony. Pulse  96,  weak  ;  heart  sounds  normal ;  skin  hot,  moderately  dry,  but  there 
has  been  profuse  perspiration ;  there  is  dull  pain  in  lumbar  regions ;  urine  opaque 
from  the  existence  of  a  reddish  cloud;  sp.  gr.  1024,  not  coagulable,  but  clear  on  the 
addition  of  heat;  chlorides  diminished  in  quantity.  IJ  S}}.  ^ther.  Nit.  5iij;  Potass. 
Acetat.  3  ij ;  AqucB  ad  §  vj.  M.  One  table-sjMonful  to  he  taken  every  four  Ixours. 
5  Liquor.  Soda  Cldor.  §j;  Sp.  Vini  Gallic.  I  ss;  In/us.  Rosar.  c.  ad  3  vj.  M. 
Ft.  gargarisma. 

Progress  of  the  Case.— Z)ece?«&er  llth. — Crepitation  more  diffused  over  right 
back.  On  left  side  respirations  still  dry  and  harsh.  Chlorides  absent  from  urme. 
Dec.  I2th. — Crepitation  now  audible  over  left  back.  Lithates  in  urine  more  abun- 
dant. Discharge  of  saliva  still  copious,  but  greatly  diminished  in  amount.  Pulse 
80,  weak.  Eabeat  vini  f  iij  per  diem.  Dec.  IStJi. — Chlorides  in  urine  again  percep- 
tible. Dec.  lith. — Chlorides  in  urine  abundant.  Crepitation  posteriorly  diminishing, 
sputum  still  copious,  frothy,  and  somewhat  gelatinous.  Breath  continues  to  give  off 
the  mercurial  fa?tor.  Dec.  I5th. — Last  night  had  copious  diaphoresis,  followed  by 
great  relief  in  his  breathing.  Still  a  few  crepitations  posteriorly,  increased  vocal 
resonance,  more  marked  on  left  than  on  right  side.  Urates  very  abundant  in  urine. 
From  this  time  he  gradually  improved.  On  the  21st  all  moist  rale  had  disappeared, 
but  respiratory  murmurs  harsh  posteriorly,  and  vocal  resonance  still  increased.  Dec. 
26th. — StiU  a  coppery  taste  in  the  mouth.  Yesterday  felt  hungry  for  first  time,  and 
was  ordered  an  egg  for  breakfast  and  steak  for  dinner.  From  this  time  he  rapidly 
recovered,  and  he  was  dismissed  January  2,  1856. 

Comme7itary. — In  tins  decided  case  of  pneumonia,  with  absence  of 
chlorides  from  the  urine,  we  had  an  opportunity  of  observing  the  eftects 
of  mercurial  salivation  on  the  progress  of  the  disease.  If  it  be  con- 
trasted with  man_y  other  cases  of  the  same  kind  previously  recorded,  it 
will  be  seen  that  the  disease  itself  was  in  no  way  shortened  by  the 
exhibition  of  mercury.  Resolution  commenced  on  the  fourteenth,  but 
was  not  completed  till  the  twenty-first  day.  On  the  other  hand,  the 
unpleasant  effects  produced  by  the  mercury,  the  severe  swelling  of  the 
tongue,   soreness  of  the  gums  and  profuse  salivation,   must  not  only 


PXEUMOXIA.  637 

be  resiiarclecl  as  so  many  increased  evils  and  unnecessary  symptoms 
supera^lded  to  the  orip;ina'l  disease,  but  as  being  the  cause  of  prolonging 
the  convalescence.  For  although  the  leading  physical  signs  had  dis- 
appeared on  the  twenty-tirst  day,  he  could  not  eat  until  the  twenty- 
sixth  dav,  in  consequence  of  the  coppery  taste  in  his  month.  But  as 
soon  as  nutrients  could  be  taken,  he  recovered  rapidly.  No  fact  could 
better  demonstrate  the  utter  uselessness  of  the  drug,  and  its  occasional 
mischievous  effects. 


Case  CXXXIV.*— P/6eM?«o?u'a  of  Right  Side— Critical  Diarrho&a  on  the  Twenty-first 

Da  y — Recovery. 

History.— James  Murray,  fet.  53,  a  hawker — admitted  June  30tb,  1S5-4.  Has 
been  much  subject  to  coughs  and  colds,  from  exposure  to  the  weather,  when  follow- 
ing his  employment.  On  the  2J:th  inst.,  at  noonday,  he  was  seized  with  rigors, 
sharp  cutting  pains  in  the  right  side,  anorexia,  thirst,  and  headache.  These  symp- 
toms confined  him  to  bed,  and  became  so  severe  that  he  says  he  was  occasionally 
delirious.  The  treatment  has  consisted  only  of  a  blister,  which  was  apphed  to  the 
right  side  of  the  chest. 

Symptoms  ox  Admissiox. — On  admission,  percussion  over  the  chest  anteriorly  is 
normal,  but  posteriorly  there  is  marked  dulness  over  the  lower  two-thirds,  on  right 
side,  where  there  is  much  pain  on  coughing,  and  on  taking  a  deep  inspiration.  On 
auscultation  over  the  dull  portion,  crepitation  is  audible,  especially  at  the  base, 
with  tubular  breathmg  above,  and  bronchophony.  Xo  expectoration.  Pulse  112, 
of  good  strength.  Tongue  furred,  great  tliirst,  loss  of  appetite  complete.  Severe 
headache,  urine  of  a  reddish  colour,  and  contains  no  chlorides.  Other  organs 
healthy.  ?  Antim.  Potass.  Tart.  gr.  iij ;  Sol.  Mur.  Morph.  3  j ;  ^5m«  ad  3  \].  M. 
One  ounce  every  second  hour.  Also  at  bed-time  to  take  a  draught  containing  a  drachm 
and  a  half  of  the  Tincture  of  Eyoscyamits. 

Progress  of  the  Case. — July  3d— To-day  the  clilorides  have  appeared  in  the 
urine  in  small  quantity;  paui  in  side  diminished.  Pulse  110,  soft.  Physical  signs 
the  same.  To  have  3  ij  of  vjine — discontinue  Tart.  Antim. —  IJ  Fotass.  Acet.  9iv; 
Sp.  ^tlier.  Mt.  3  ij :  Aqux  3  iv.  M.  §  j  to  he  taken  three  times  a  day.  July  4ih. — 
Urine  contains  abundance  of  chlorides.  July  9</i.— Still  duhiess,  crepitation,  and 
bronchophony  over  right  chest.  Xo  expectoration.  July  I3th. — Blister  to  be 
applied  to  the  riglit  side.  July  loth. — This  morning  he  was  seized  with  TomitUDg, 
followed  by  purging.  He  had  7  or  8  stools.  To-day  he  is  much  better.  The  right 
chest  unfortunately  could  not  be  exammed  on  account  of  the  soreness  of  the  bUs- 
tered  surface.  But  from  this  time  he  rapidly  improved.  On  the  24th  still  slight 
crepitation.  Has  never  had  expectoration.  On  the  26th  the  crepitation  still  con- 
tinuins,  I  ordered  him  to  lie  on  the  abdomen.  On  the  30th  crepitation  absent. 
August  ah. — Dismissed  cured. 

Commentary. — This  case  exhibited  a  rare  negative  symptom  in  pneu- 
monia, viz.,  the  complete  absence  of  expectoration,  all  the  other  symp- 
toms and  signs  being  present.  In  this  and  the  two  subsequent  cases  I 
looked  for  the  usual  critical  appearance  of  lithates  in  the  urine  about 
the  fourteenth  dav,  but  in  vain.  It  is  somewhat  remarkable  also  that 
in  these  cases,  instead  of  presenting  the  usual  signs  of  crisis  by  urine, 

*  Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


638  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

they  were  seized  with  sudden  diarrhoea,  of  a  severe  character,  hut  of 
short  duration,  which  ushered  in  convalescence.  Whether  this  was 
attributable  to  any  choleraic  disposition,  or  peculiar  state  of  the  atmo- 
sphere, must  be  unknown  ;  but  I  had  never  previously  seen  diarrha'a  so 
uniformly  critical  in  cases  of  pneumonia  as  during  the  summer  of  1854. 
The  crepitation  continued  to  linger  in  the  minute  bronchial  tubes  long 
after  the  pneumonia  had  disappeared.  This  I  attribute  in  such  cases  to 
congestion  from  decubitus,  and  find  it  easily  removable  by  causing  the 
patient  to  lie  as  much  as  possible  on  the  abdomen. 


Case  CXXXV.* — Pneumonia  of  Left  Side — Critical  Diarrhoea  on  the  Fourteenth 

Day — Recovery. 

History. — Thomas  Shepherd,  fet.  23,  a  brassfounder,  a  strong  healthy  man — 
admitted  July  11,  1854.  He  states  that,  on  the  third  instant,  when  rising  in  the 
morning,  he  was  seized  with  rigors,  dull  pain  in  the  left  side  and  loins,  thirst,  ano- 
rexia, headache,  and  cough.  On  the  i^revious  evening  he  had  walked  far,  perspired 
much,  and  gone  to  bed  exposed  to  a  draught  from  his  window.  On  the  5th,  a 
medical  man  administered  purgatives  and  other  medicines,  probably  salines.  On  the 
7th,  dyspnoea  became  urgent,  and  the  feverish  symptoms  were  augmented.  He  was 
then  bled  to  the  extent  of  18  or  20  oz.,  and  experienced  much  relief. 

Symptoms  on  Admission. — On  admission,  the  left  side  of  chest  does  not  expand 
equally  with  the  right.  Anteriorly,  the  left  lung  is  resonant,  but  posteriorly  it  is 
dull  on  percussion  over  its  two  lower  thirds  On  auscultation  over  the  dull  part, 
loud  tubular  breathing,  with  crepitation  and  bronchophonj^,  are  heard.  Respirations 
24  in  the  minute.  Sputa  scanty,  of  gelatinous  consistence,  tinged  of  a  rusty  colour. 
Pulse  84,  soft,  but  of  good  strength.  Tongue  red  and  dry;  appetite  diminished; 
urine  contains  no  chlorides.  Other  functions  healthy.  To  take  a  quarter  of  a  grain 
of  Aniim.  Tart,  and  five  minims  of  Sol.  Mur.  Morph.  every  second  hour. 

Progress  of  the  Case. — July  13th. — To-day  the  tubular  breathing  is  gone ; 
crepitations  abundant  and  coarser.  On  adding  a  drop  of  the  solution  of  Nitrate  of 
Silver  to  the  urine,  a  faint  ivhite  haze  is  visible.  July  \Uh. — Urine  to-day  contains 
abundant  chlorides.  Pulmonary  signs  the  same.  July  IGtli. — To-day  was  seized 
with  pains  in  the  abdomen  and  diarrhoea.  July  20th. — Diarrhoea  has  continued 
until  to-day,  but  has  now  ceased.  No  pulmonary  crepitation ;  no  expectoration, 
only  slight  bronchophony  and  dulness.  From  this  time  he  rapidly  recovered,  and 
was  dismissed  well,  July  31. 

Commentary. — The  bleeding  on  the  fourth  day  in  this  case,  though, 
according  to  the  patient,  it  caused  temporary  relief,  evidently  pro- 
duced no  modification  in  the  progress  of  the  pneumonia,  which  ran 
its  natural  course,  and  terminated,  like  the  former  one,  by  a  critical 
diarrluea. 


Case    CXXXVI.f — Double   Pneumonia — Critical  Diarrhoea  on  the  Tiuenty-first  Day 

— Recovery. 

History. — James  M'Naughlon,  xX.  34 — admitted  June  30,  1854,  a  shoemaker. 

*  Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk, 
f  Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


PXEUMOXIA.  639 

States  that  he  has  been  much  addicted  to  the  use  of  mtoxicating  hquors.  From 
the  21st  to  the  23d  inst.  he  was  in  a  continuous  state  of  intoxication,  and  on  the 
morning  of  the  24th  he  awoke  with  dull  pain  in  the  chest,  great  dyspnoea,  cough, 
and  expectoration  of  matter,  which,  he  says,  resembled  pure  blood.  He  has  under- 
gone no  medical  treatment. 

Symptoms  ox  Admission'. — On  admission,  the  respirations  are  44  in  the  minute. 
Sputum  copious,  of  deep  prune  juice  colour.  On  percussing  the  chest  anteriorly, 
there  is  slight  dulness  on  tlie  right  side  interiorly,  but  posteriorly  the  dulness  is  very 
marked  over  the  inferior  3-4ths  of  both  lungs.  On  auscultation,  dry  tubular  breath- 
ing is  heard  over  the  duU  parts,  with  bronchophony,  but  on  taking  a  forced  inspira- 
tion, coarse  crepitation,  deep-seated,  is  audible ;  respiration  at  both  apices  and  over 
chest  anteriorly  puerile.  Pulse  120,  weak.  Tongue  covered  with  a  yellowish  fur, 
thirst,  no  appetite,  headache ;  general  appearance  sallow — indicative  of  exhaustion ; 
he  complains  of  great  weakness.  Urine  of  deep  cherry-red  colour;  sp.  gr.  1020, 
contains  no  albumen  or  sediment,  and  no  chlorides.  Other  functions  normal.  To 
have  one-third  of  a  grain  of  Aniim.  Tart,  every  three  hours ;    §  iv  of  ivine  daily. 

Progress  of  the  Case. — July  3d — The  wine  was  increased  to  §  vj  daily,  his 
symptoms  having  undergone  no  change.  July  Mh. — To-day  chlorides  have  ap- 
peared in  small  quantity  in  the  urine,  which  presents  the  same  cherry-red  colour. 
Crepitation  audible  in  left  lung  posteriorly,  right  lung  as  before.  Sputum  hghter, 
with  less  of  the  prune  juice  appearance.  July  1t?i. — Since  last  report  there  has 
been  marked  improvement.  To-day  the  urine  contains  abundant  chlorides.  Cre- 
pitation over  both  sides  of  chest  posteriorly.  To  have  forty  minims  of  Sj).  ^ther. 
Nit.  and  twenty  grains  of  Potass.  Actt.  in  solution  thrice  daily.  July  lOih. — Over 
the  whole  of  back  posteriorly  coarse  crepitation;  still  bronchophony,  and  abun- 
dant sputum,  tinged  with  blood.  July  loth. — Last  night  was  seized  with  diarrhoea. 
He  had  six  copious  watery  stools.  To-day  no  crepitation  audible:  respirations 
natural,  except  in  left  supra-scapular  region,  where  bronchophony  is  still  aucUble, 
but  not  so  harsh  as  formerly.  Urine  now  clear  and  in  every  way  normal  From 
this  day  he  rapidly  improved,  and  was  dismissed,  August  2d,  quite  well. 

Commentary. — This  was  a  veiy  severe  case  of  double  pneumonia, 
in  a  broken  down  and  dissipated  individual,  who  was  saved  by  wine, 
and  in  whom  a  choleraic  diarrhoea,  accompanied  by  vomiting,  proved 
critical  on  the  twentv-tirst  dav. 


Case  CXXXTII.* — Pneumonia,  ushered  in  hy  Violent  Vomiting  and  Gastric  Pain — 
Recovery  in  five  days. 

History. — Edward  Xugent.  a^t.  28,  a  waiter — admitted  November  8th,  18.58. 
Has  always  enjoyed  good  health  untQ  about  three  weeks  ago,  when  he  went  to 
Liverpool  from  Glasgow  by  water,  and  suflered  very  severely  from  sea  sickness. 
Three  days  afterwards,  on  the  return  passage,  he  was  again  very  sick,  and  for  a 
few  days  after  felt  soreness  in  the  epigastric  region.  He  then  became  quite  well 
until  Monday  the  8th,  at  1  p.m  ,  when,  whilst  cleaning  plate,  and  about  ten  minutes 
after  eating  a  hearty  dinner,  he  was  suddenly  seized  with  severe  pain  in  the  epigas- 
trium, cold  sweats,  vertigo,  desire  to  vomit,  but  inabUity  to  do  so.  He  was  immedi- 
ately conveyed  to  the  Infirmary. 

Symptoms  ox  Admission. — The  patient  was  pale  and  hvid,  almost  pulseless, 
and  complained  of  sickness,  cold,  profuse  clammy  perspiration,  and  great  pain  in 

*  Reported  by  ilr.  Arthur  Garrington,  Clinical  Clerk. 


640  DISEASES   OF   THE   EESPIRATORY   STSTEil. 

epigastrium,  increased  on  pressure.  Shortly  after  admission  he  vomited  what 
he  had  taken  at  dinner,  but  was  not  relieved ;  warm  bottles  were  applied  to  his 
feet,  and  hot  fomentations  to  the  painful  part.  His  suffering  continued ;  at  4  p.ir. 
six  leeches  were  applied  to  the  epigastrium,  and  3  ss  of  Morphia  administered. 
These  remedies  gave  some  relief;  and  he  remained  in  comparative  ease  till  about 
10  P.M.,  when  some  Magn.  Sulph.  was  given,  as  the  bowels  had  been  costive  for 
some  days  previously. 

Progress  of  the  Case. — Xovember  dth. — He  had  no  sleep  during  the  night,  and 
his  symptoms  have  remained  stationary.  He  has  had  three  or  four  dark-coloured 
stools.  Early  in  the  morning  he  was  ordered  for  the  vomiting  5  Crea^uii  gtt.  ij ; 
Sol.  Mur.  Morph.  3  ss ;  ft.  Jiaust. ;  also  a  table-spoonful  of  Port  wine  every  hour. 
At  the  visit  (noon)  his  symptoms  had  in  no  way  abated,  and  he  was  ordered  to  con- 
tinue the  wine;  to  take  beef  tea  in  small  quantities ;  and  a  tea-spoonful  of  thefolloiving 
mixture  every  hour  until  the  pain  decreased : —  IJ  Sol.  Mur.  Mmph.  3  ij ;  Sp.  u£ih. 
Sulph.  3  vj ;  Ft  mist.  The  mixture  caused  great  relief,  and  in  the  afternoon 
he  was  able  to  bear  further  examination.  The  cardiac  sounds  were  indistinct; 
pulse  58,  extremely  feeble  and  intermitting.  Respiration  laboured,  and  the  pain 
in  epigastrium  increased  during  inspiration.  There  was  slight  harshness  of  inspira- 
tion, and  increased  vocal  resonance  under  both  clavicles.  He  had  great  pain  at 
the  back  of  his  head,  and  some  giddiness ;  tongue  dry  and  furred ;  no  appetite ; 
great  thirst;  no  perceptible  swelhng  in  epigastrium;  abdomen  tender  and  hot; 
urine  natural  in  colour  and  quantity,  but  only  a  slight  trace  of  chlorides.  In  the 
evening  he  was  better,  the  pain  had  greatly  subsided,  and  there  was  less  sickness ; 
he  was  able  to  retain  some  small  quantities  of  beef  tea.  Slight  dulness,  increase 
of  vocal  resonance,  and  crepitation,  were  detected  at  the  base  of  the  left  lung  pos- 
teriorly. Xov.  10th.— Ke  passed  a  tolerably  good  night,  and  had  some  sleep;  the 
epigastric  pain  and  sickness  still  further  dimmished.  Pulse  98,  weak.  The  physi- 
cal signs  observed  in  left  lung  last  evening  were  not  audible  at  visit,  but  were 
again  heai'd  in  the  evening.  Ordered  to  discontinue  the  mixture,  and  to  continue  the 
wine  and  beef  tea  in  small  quantities.  Nov.  llth.—B.e  passed  a  good  night;  he  still 
has  slight  sickness  and  tenderness  over  epigastrium.  He  complains  of  pain  in 
the  left  breast,  increased  during  inspiration ;  he  has  some  shortness  of  breatli, 
troublesome  cough,  and  a  greyish,  tenacious  sputum  containmg  a  few  rusty-coloured 
masses.  ^ilarked  dulness,  with  increased  vocal  resonance,  and  clear  crepitation, 
audible  over  lower  third  of  left  side  posteriorly.  Pulse  88,  tolerably  full ;  tongue 
loaded.  The  patient  says  he  has  had  rigors  every  day  since  admission,  and  yester- 
day was  so  cold  that  he  had  warm  bottles  applied  to  his  feet.  On  examination  of 
the  urine,  the  chlorides  were  still  diminished,  and  there  was  a  deposition  of  triple 
phosphates.  iYot.  12</i.— Now  sleeps  well.  His  appetite  is  much  improved.  The 
epigastric  pain  and  tenderness  and  the  sickness  have  disappeared.  Pulse  90,  full 
and  regular.  Crepitation  very  fine ;  vocal  resonance  still  increased.  Cough  not  so 
bad,  no  rusty  masses  in  the  sputum.  Xov.  13th.— The  crepitation  has  disappeared  ; 
there  is  some  harshness  of  inspiration.  Sputum  muco-purulent.  Chlorides  abun- 
dant in  the  urine.  His  bowels  being  confined,  he  was  ordered  an  enema  of  warm 
water.  Xov.  loth. — Respiration  quite  natural.  He  says  he  only  feels  a  little  weak, 
but  is  otherwise  so  well  that  he  insists  on  being  discharged. 

Commentary. — In  this  case  of  severe  gastric  irritation,  pneuinonia 
came  on  in  the  Infirmary — was  well  characterized  by  all  the  symptoms 
and  physical  signs  of  that  disease,  was  limited  to  the  posterior  tliird  of 
the  left  lung,  occurred  in  a  healthy  young  man,  and  was  treated  by  stimu- 
lants and  nutrients  from  the  beginning.      The   result  was  recovery  on 


PNEUMONIA.  641 

the  fifth  day  and  discharge  from  the  hospital  at  his  own  request  quite 
well  on  the"^ seventh  day.  It  is  the  most  rapid  recovery  from  decided 
pneumonia  that  has  ever  fallen  under  my  notice.  The  tacts  of  this  case 
are  also  entirely  opposed  to  the  notions  of  those  who  consider  that  inflam- 
mation is  in  some  way  connected  with  a  sthenic  or  excited  state  of  the 
system.  The  man  was  in  perfect  health  when  seized  with  the  gastric 
spasms,  and  was  by  them  reduced  to  a  pulseless  and  exceedingly  pros- 
trated state,  with  cold  clammy  sweats.  It  was  in  this  weakened  condition 
that  the  pneumonia  arose,  and  its  limited  extent  and  short  course  I 
ascribe  to  the  stimulants,  nutrients,  and  quietude  with  which  it  was 
treated  from  the  first. 


Case    CXXXYlU*~I)oiiUe   Pneumonia,  with  urgent   Symptoms,  and  full,  strong 
Pulse— Pleuritis  on  Left  Side — Recovery  in  Nine  Days. 

History.— John  MTarlane,  set.  30,  a  railway  labourer— admitted  Nov.  12,  185S. 
Has  been  subject  to  a  slight  cough  and  expectoration,  sometimes  tinged  with  blood, 
for  the  last  ten  winters ;  otherwise  he  has  enjoyed  good  health.  Ou  Nov.  9th,  whilst 
working  on  a  railway  bank,  which  was  much  exposed  to  wind  and  cold,  he  was  sud- 
denly seized  with  great  pain  in  his  lower  extremities ;  he,  however,  continued  at  his 
work  till  the  evening,  when  he  experienced  a  sharp  pain  in  his  left  side,  with  diffi- 
culty of  breathing,  and  general  febrile  symptoms.  He  went  to  bed,  and  on  the  10th, 
feeling  no  better,  he  sent  for  a  medical  man,  who  ordered  a  blister  to  be  applied  to 
the  left  side ;  he  also  gave  him  a  powder,  and  a  mixture  which  made  him  very  sick. 
The  pain  was  slightly  relieved  after  the  application  of  the  blister,  and  he  felt  much 
easier  on  the  11th,  but  on  the  12th  the  pain  increased,  while  the  difficulty  of  breath- 
ing and  of  expectorating  became  so  bad  that  he  was  brought  into  the  Infirmary. 

Symptojis  on  Admission. — His  face  was  much  flushed ;  skin  hot  and  dry ;  tongue 
moist,  and  with  a  white  fur;  great  thu-st;  pulse  95,  full  and  regular;  urine  orange- 
coloured,  with  a  copious  sediment  of  urates,  only  a  slight  trace  of  chlorides,  and  a 
trace  of  albumen.  His  respirations  were  quick  and  laboured.  Expectoration  very 
tenacious,  with  numerous  rusty-coloured  masses  in  it.  Cough  frequent  and  painful. 
On  the  left  side  anteriorly  percussion  was  good,  but  crepitation  was  heard  all  over 
the  front,  with  the  exception  of  a  space  2|  inches  below  the  clavicle,  where  the  re- 
spiratory sounds  were  very  harsh.  Posteriorly  on  this  side  there  was  marked  dulness 
i"rom  the  spine  of  the  scapula  to  the  base  of  the  lung,  over  which  space  loud  crepita- 
tion was  heard,  and  pealing  vocal  resonance,  more  especially  about  the  centre  of  the 
lung.  On  the  right  side  anteriorly  there  was  slight  comparative  dulness  over  a 
space  extending  from  the  clavicle  two  inches  downwards.  Posteriorly  on  this  side 
there  was  slight  comparative  dulness  at  apex,  where  expiration  was  prolonged,  and 
the  inspiratory  murmur  harsh.  ]J  Pulv.  Doveri,  gr.  x.,  to  he  taken  immediately.  ^ 
Sol.  Antim.  |  j ;  Potass.  Acet  1  ss ;  Aqiue  ad  §  viij ;  Ft.  mist.  Two  tahle-spoonfuls 
every  four  liours. 

Progress  of  the  Case. — Kov.  \Wi. — Passed  a  sleepless  night.  Cough  incessant, 
and  dyspnoea  urgent;  lace  livid  Pulse  112,  full  and  strong;  sputum  very  copious, 
rusty  and  gelatinous.  In  addition  to  physical  signs  formerly  reported,  there  was  faint 
crepitation  all  over  right  back  posteriorly  (most  distinct  at  apex),  but  no  great  increase 
of  vocal  resonance ;  friction  over  left  side  anteriorly  below  nipple,  both  with  expira- 
tion and  inspiration,  but  loudest  with  former,  and  posteriorly  marked  duhiess  over 

*  Reported  by  Mr.  Arthur  Garrington,  Chnical  Clerk. 
41 


642  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

inferior  two-tliirds,  witli  loud  crepitation  and  bronchopliony.  Ordered  to  he  cupped 
to  5  V  over  region  of  pain  on  left  side,  and  to  take  only  one  iabk-sjyoonful  of  the  mixture, 
to  ivhich  is  to  he  added  Sp.  uEth.  Nitr.  3  ij-  To  have  strong  heef-tea  and  milk.  Nov. 
lAth. — Patient  says  he  felt  relieved  by  the  cupping  for  3  or  4  hours,  but  the  pain 
returned  afterwards  as  bad  as  before.  There  is  still  great  dyspnoea  and  lividity  of 
face;  expectorates  about  18  oz.  of  purulent,  gelatinous,  frothy  matter,  tinged  with 
rusty-coloured  blood,  during  the  twenty-four  hours.  Pulse  98,  soft  and  irregular.  To 
have  a  table-spoonf  id  of  wine  every  hour.  Omit  mixture.  Nov.  I5th. — Dyspnoea  and 
pain  in  side  much  diminished.  Sputum  less  rusty.  Pulse  100,  strong  and  regular. 
Very  coarse  crepitation  (amounting  to  mucous  rattles)  heard  over  left  side  anteriorly. 
Respiratory  murmurs  harsh  and  dry  over  right  side  anteriorly.  Tliere  is  still  marked 
comparative  dulness  over  left  back,  and  also  in  upper  third  of  right  back.  Tubular 
breathing  over  upper  fourth  of  right  back,  harsh  inferior!}-.  Crepitation  over  left 
back,  but  more  feeble  than  before.  Vocal  resonance  the  same.  Urine  quite  clear, 
and  no  deposit.  Chlorides  have  been  increasing  since  the  13th,  but  are  not  yet  in 
normal  proportion.  Still  thirsty  and  feverish.  5  ^P-  -^i^i-  ^^i^^-  3  iij ;  Potass.  Acet. 
3  ss :  Aquce  ad  §  vj ;  Ft.  mist.  To  he  taken  as  hefore.  To  continue  the  milk,  wine,  etc., 
and  to  have  6  oz.  of  beefsteak.  Nov.  18th. — Patient  says  he  feels  very  much  better. 
All  crepitation  gone,  but  there  is  slightly  increased  vocal  resonance  on  left  side. 
Urine  loaded  with  urates.  Convalescent,  but  steak  to  be  increased  to  8  oz.,  and  wine 
to  he  diminished  to  §  iv.  daily.  Nov.  2Ath. — Has  been  getting  gradually  stronger 
since  last  report.  Yesterday  he  got  up  for  some  time,  walked  about  the  ward,  and 
exposed  himself  to  draughts  in  the  passages.  This  led  to  an  attack  of  acute  rheu- 
matism, for  which  he  was  again  confined  to  bed,  and  ordered  Potass.  Bicarb.  3j 
three  times  a  day.  He  gradually  got  better,  and  was  quite  free  from  muscular  pains 
on  Dec.  4th  ;  he  got  up  on  the  7  th,  and  with  the  exception  of  slight  weakness,  felt 
quite  well.  2  oz.  extra  beefsteak  were  ordered  on  the  11th,  and  he  left  the  Infirm- 
ary on  the  13th  in  perfect  health. 

Commentary. — This  is  wliat  some  former  writers  would  have  called 
an  "  exquisite  "  case  of  pneumonia,  occurring  in  a  man  who,  with  some 
emphysema,  was  accustomed  to  have  attacks  of  bronchitis  and  bloody 
expectoration  every  Avinter.  It  presented  all  the  symptoms  of  the  disease, 
including  pain  in  the  side,  great  dyspna^a,  lividity  of  the  face,  strong  and 
full  pulse,  with  copious  rusty  sputa.  Physical  signs  also  proved  it  to 
consist  of  hepatization  of  the  two  inferior  thirds  of  the  left  lung,  and  of 
the  superior  half  of  the  right  lung.  Occurring  in  the  year  1858,  it  dis- 
poses of  two  theoretical  statements  which  have  of  late  been  much  dis- 
cussed, viz. — 1st,  That  such  cases  are  now  not  to  be  met  with  ;  and,  2d, 
that  if  they  should  occur,  bleeding  would  again  be  required  for  their 
treatment.  In  this  respect  the  case  resembles  that  of  Roderick  M'Far- 
lane,  Case  CXXIX. ;  and  in  severity  that  of  Peter  Robertson,  Case 
CXXX.  In  consequence  of  the  dyspnoea  and  evident  engorgement  of 
the  right  side  of  the  heart,  he  was  cupped,  and  3  v  of  blood  extracted, 
with  the  effect  of  relieving  bis  symptoms,  but  for  a  time  only,  as  they 
returned  with  equal  intensity  in  a  few  hours.  This  is  the  result  which 
usually  followed  large  venesections,  and  which  misled  practitioners  as 
to  its  utility.  I  have  no  doubt  that  a  large  bleeding  in  this  case,  if  it 
had  not  proved  fatal,  would  have  seriously  prolonged  his  recovery,  which 
took  place  under  an  opposite  treatment  on  the  ninth  day.  The  case 
inculcates  another  caution,  viz.,  the  necessity  of  avoiding  exposure  to 
cold  during  convalescence,  as  in  the  debilitated  condition  which  then 


PNEUMONIA.  ^  643 

exists  there  is  very  likely  to  be  a  relapse,  or  some  other  form  of  febrile 
disease,  again  proving  that  these  are  the  results  of  weakness  rather  than 
of  strength. 

It  is  unnecessary  to  multiply  proofs,  or  to  give  stronger  evidence  of  the 
correctness  of  those  principles  of  treatment,  which  have  already  been 
given  at  length,  p.  264,  et  seq.  (For  other  examples  of  pneumonia, 
variouslv  complicated,  see  Cases  I\^,  XXL,  XXIL,  XXIII.,  XLIX.,  L., 
LVIII.,LXXXIX.,  XCIV.,  XCIX.) 

On  the  Diagnostic  Value  of  the  Absence  of  Chlorides  from  the  Urine  in 

Pneumonia. 

Simon  and  Redtenbacher  first  stated  that  chloride  of  sodium,  a  salt 
always  present  in  healthy  urine,  was  absent  from  that  fluid  during  the 
onward  progress  of  pneumonia,  and  returned  to  it  when  absorption  of  the 
exudation  was  about  to  commence.  This  statement  was  confirmed  by 
Dr.  Beale  of  London,  who,  in  the  3oth  vol.  of  the  Transactions  of  the 
Medico-Chirurgical  Society  of  London,  furthered  our  knowledge  regard- 
ing it  by  additional  valuable  researches.  My  attention  was  directed  to 
this  remarkable  fact  during  the  Session  1853-4,  by  Dr.  Robert  Cart- 
wright,  a  gentleman  attending  the  Clinical  Wards  of  the  Infirmary,  who 
informed  me  that  he  had  seen  it  occasionally  of  great  service  in  a  dia- 
gnostic point  of  view,  in  the  clinical  wards  of  Professor  Oppolzer  at 
Vienna.  It  so  happened  that  a  man,  John  M'Donald,  set.  25,  had  just 
been  admitted,  labouring  under  well  marked  simple  pneumonia  at  the 
apex  of  the  right  lung.  He  was  a  labourer,  who  had  enjoyed  perfect 
health  until  two  days  before  admission,  when,  on  being  exposed  to  wet 
and  cold,  working  in  drains,  he  was  seized  with  shivering,  followed  by 
fever  and  the  usual  symptoms  and  signs  of  pneumonia.  On  adding  a 
drop  of  nitric  acid  to  some  of  his  urine  in  a  test  tube,  and  then  dropping 
into  it  a  little  of  the  solution  of  the  nitrate  of  silver,  the  fluid  remained 
clear,  although  so  great  is  the  delicacy  of  this  test,  that  a  white  cloudy 
precipitate  is  at  once  formed,  if  a  very  minute  quantity  of  the  chloride 
of  sodium  be  present.  It  was  on  the  fourth  day  of  the  disease  that 
the  observation  was  first  made,  and  the  chlorides  remained  absent  during 
the  fifth  and  sixth  days,  during  which  period  the  disease  extended  from 
above  downwards,  until  it  occupied  the  upper  two-thirds  of  the  right 
lung.  On  the  seventh  day  a  slight  haze  was  observed  in  the  urine,  indi- 
cating that  the  salt  was  returning  to  that  fluid,  and  the  u)an  expressed 
himself  as  being  much  better.  On  this  day  there  was  great  dulness  on 
percussion,  all  crepitation  had  ceased,  the  breathing  was  tubular  with 
bronchophony.  On  the  eighth  day,  slight  returning  crepitation  was 
audible,  tlie  dulness  had  diminished,  but  the  urine,  owing  to  some  acci- 
dent before  the  visit,  had  been  thrown  away.  On  the  ninth  da}',  how- 
ever, the  chlorides  were  abundant  in  that  fluid,  together  with  lithates  ; 
loud  crepitation  was  now  universal  throughout  the  lung,  and  the  dul- 
ness had  nearly  disappeared.  From  this  time  the  man  made  a  rapid 
recovery,  never  having  been  bled,  and  was  discharged  quite  well  on  the 
sixteenth  day. 

I  now  requested  Mr.  Seymour,  one  of  the  clinical  clerks,  to  test  the 


64-i  DISEASES   OF   THE  RESPIEATOKY   SYSTEM. 

urine  of  all  tbe  patients  in  the  ward,  and  others  who  might  subsequently 
be  admitted,  which  he  did,  and  thus  collected  a  large  number  of  obser- 
vations, the  results  of  which  I  shall  allude  to  immediately.  In  the  mean 
time  another  case  entered,  which  seemed  to  point  out  the  value  of  this 
test  in  a  diagnostic  point  of  view.  It  was  that  of  a  man,  Donaldson,  a^t. 
26,  labouring  under  typhus  fever,  in  whom  the  disease  ran  its  usual 
course  to  the  tenth  day,  when  chlorides  were  demonstrated  in  it.  On 
the  eleventh  day,  however,  pulmonary  symptoms  came  on,  and  the  chlo- 
rides were  eutirely  absent  from  the  urine.  This  led  me  to  make,  with 
the  clinical  class,  a  careful  examination  of  the  chest,  when  all  the  signs 
of  pneumonia  were  detected  in  the  lower  half  of  the  right  lung.  On  the 
fourteenth  day  the  chlorides  reappeared,  the  pneumonic  signs  diminished, 
and  the  fever  ceased  with  a  critical  sweat. 

A  third  case  was  even  more  satisfactory  in  proving  the  moment  of 
commencing  and  departing  pneumonia  by  testing  the  urine  for  chloride 
of  sodium.  A  mau  called  David  Murray,  set.  43,  entered  with  pneumonia 
of  the  lower  two-thirds  of  the  right  lung.  No  consistent  account  could 
be  obtained  from  him  as  to  when  the  disease  commenced,  and  it  was 
impossible,  therefore,  to  determine  whether  the  coarse  crepitation  which 
was  audible  over  the  inflamed  lung  was  the  advancing  or  returning 
crepitation  ;  but  the  chlorides  were  absent  from  the  urine,  which  indicated 
that  the  disease  was  advancing.  The  following  day  complete  consolida- 
tion had  occurred,  with  dry  tubular  breathing  and  absence  of  crepitation, 
and  a  minute  cpiautity  of  the  chlorides  was  found  in  the  urine.  The 
patient,  however,  instead  of  getting  better,  showed  no  improvement,  and 
the  next  day  the  chlorides  had  again  disappeared,  indicating  extension 
of  the  pneumonia.  On  the  evening  of  this  day  he  was  seized  with  acute 
meningitis,  of  which  he  died.  On  dissection,  in  addition  to  universal 
cerebral  meningitis,  the  whole  of  the  right  lung  presented  the  usual 
characters  of  grey  hepatization.     (See  Case  IV.) 

It  will  be  observed  in  all  the  preceding  cases,  thirteen  in  number,  that 
with  the  exception  of  Case  CXXIX.,  the  absence  or  decided  diminution 
of  chlorides  marked  precisely  the  onward  march  of  the  pneumonia, 
whilst  their  presence  indicated  its  cessation,  and  was  generally  accom- 
panied by  the  returning  crepitation  and  commencing  absorption  of  the 
exudation.  It  still  remains  to  be  determined  whether  the  absence  of 
the  salts  is  a  cause  or  a  result  of  exudation  into  the  lungs — whether  the 
interference  to  the  respiratory  function,  by  diminishing  the  amount  of 
oxygen  absorbed,  gives  rise  to  those  chemical  changes  in  the  blood  which 
react  on  the  urinary  secretion.  If  so,  what  is  the  nature  of  these  changes  ? 
Indeed,  a  crowd  of  questions  will  be  suggested  to  the  mind  of  the  phy- 
siologist, from  the  establishment  of  the  remarkable  clinical  fact  of  which 
we  are  now  speaking.  That  such  is  an  important  diagnostic  sign  I  have 
now  no  doubt,  and  it  was  singularly  well  tested  in  the  following  case,  in 
which  there  were  many  signs  and  symptoms  of  pneumonia,  complicated 
with  heart  disease.  The  question  on  admission  was  whether,  with  heart 
disease  and  bronchitis,  j^neumonia  might  not  be  conjoined,  and  I  was 
assisted  in  answering  in  the  negative  by  the  abundance  of  chlorides  which 
the  urine  contained. 


PXEUMOXIA.  645 


Case  CXXXIX.* — Bronchitis   and  Pulmonary    Congestion,  from    Morbus    Cordis, 
resenibling  Pneumonia,  but  ?io  absence  of  Chlorides  in  the  Urine. 

History. — John  Dickson,  set.  44,  pensioner — admitted  July  21st,  1854.  Says 
that  on  the  evening  of  the  19th  he  was  seized  with  chilliness,  followed  by  sweating. 
heat  of  skin,  tliu-st,  impaired  appetite  and  expectoration  of  a  frothy  fluid,  resembling 
liquorice  juice.  He  has  for  some  time  felt  an  uneasy  sensation  in  the  epigastrium, 
which,  since  his  recent  illness,  has  amounted  to  pain.  Yesterday  he  experienced 
great  dyspnoea  and  anxiety,  symptoms  which  have  continued  until  now. 

Symptoms  oy  Admission. — On  admission  there  is  excessive  dyspnoea,  with  expec- 
toration of  a  tenacious  sputum,  of  a  reddish-brown  colour.  On  percussion,  there  is 
no  comparative  dulness,  but  posteriorly  the  resonance  is  impaired  on  both  sides.  On 
auscultation  anteriorly,  the  expectoration  is  everywhere  much  prolonged,  and  pos- 
teriorly there  is  considerable  crepitation  with  bronchophony.  Pulse  92,  of  good 
strength.  The  hearfs  sounds  are  entirely  masked  by  the  prolonged  wheezing  expi- 
ration and  agitation  of  the  chest.  He  cannot  lie  on  his  back  or  left  side,  is  easily 
agitated,  frequently  experiences  palpitations,  and  cannot  sleep.  Abundant  chlorides 
in  the  urine.  Other  functions  normal.  5  •  Sp.  ^Ether.  Suljyh.  §  ss  ;  Aq.  Cassice 
5  iv.  One  table-spoonful  to  be  taken  in  water  occasionally.  To  have  one  quarter  of  a 
grain  of  Antira.  Tart,  in  solution  every  two  hours. 

Progress  of  the  Case. — July  25(h. — Since  last  report  the  dyspnoea  has  dimi- 
nished, the  crepitation  posteriorly  continues,  but  the  wheezing  anteriorly  is  less. 
Still  gelatinous  sputum,  speckled  with  rusty-coloured  blood.  The  apex  of  tlie  heart 
cannot  be  felt,  but  a  double  blowing  murmm"  is  now  recognizable,  accompanying 
both  the  first  and  second  sounds — the  systolic,  loudest  at  the  apex,  and  the  diastohc. 
loudest  at  the  base.  Omit  the  Antimony.  July  3lst. — Tlie  pulmonary  symptoms 
and  signs  have  now  greatly  subsided,  whilst  the  cardiac  lesion  has  become  more  dis- 
tinct. For  this  latter  he  remained  in  the  house  until  the  commencement  of  Xovem- 
ber,  when  he  was  dismissed  greatly  reheved. 

Mr.  Seymour  tested  with  wreat  care,  and  at  repeated  times,  the  urine 
of  upwards  of  fifty  other  cases  in  the  wards,  embracing  a  great  variety  of 
disease.  He  found  the  chlorides  absent  in  one  case  of  phthisis,  with  inter- 
current pneumonia,  but  in  no  other.  They  were  also  absent  in  one  case 
of  peritonitis,  and  in  all  the  cases  of  small-pox.  Further  investigations 
will  probably  discover  these  salts  to  be  absent  in  other  diseases,  which, 
although  it  may  diminish  the  importance  of  the  sign  as  distinctive  of 
pneumonia,  leaves  unaffected  its  value  as  pointing  out  the  onward  pro- 
gress of  that  disease. 

In  one  or  two  cases  of  pneumonia,  in  which  the  disease  was  progress- 
ing, traces  of  chlorides  were  seen  in  the  urine.  This  was  discovered  bv 
Mr,  Seymour  (clinical  clerk)  to  depend  on  an  adulteration  of  the  nitric 
acid,  which,  for  testing  urine,  must  be  pure.  The  nitric  should  be  tested 
according  to  the  directions  of  the  Edinburgh  Pharmacopoeia  for  hydro- 
chloric acid,  with  which  it  is  very  apt  to  be  mingled.  It  is  of  import- 
ance that  white  nitric  acid  be  added  to  the  urine  in  the  first  in- 
stance, otherwise  the  nitrate  of  silver  is  veiy  apt  to  throw  down  phos- 
phates, which,  however,  may  be  distinguished  from  chlorides  by  being 

*  Reported  by  ilr.  Almeric  Seymour,  Clinical  Clerk. 


646  DISEASES   OF   THE   KESPIRATORY   SYSTEM. 

dissolved  in  an   excess  of  nitric  acid,  Avhicli  does  not  affect  tlie  latter 
salts. 

What  is  very  remarkable  -witli  regard  to  the  absence  of  chloride  of 
sodium  from  the  urine,  is  that  it  appears  in  the  sputum  of  pneumonic 
persons,  and  as  it  returns  to  the  urine,  it  disappears  from  the  sputum. 
I  have  not  myself,  however,  made  many  careful  observations  on  the 
chemical  reactions  of  the  sputum  in  this  disease,  but  propose  doino;  so, 
in  the  hope  that  it  will  throw  further  light  on  its  diagnosis  and  pathology. 


The  General  Pathology  and  Treatment  of  Acute  Pneumonia. 

The  pathology  of  pneumonia  is  comprised  in  what  has  been  formerly 
said  on  exudation,  p.  130,  and  more  especially  p.  265,  the  lesion  consist- 
ing of  liquor  sanguinis  poured  into  the  air  vesicles,  minute  bronchial  tubes, 
and  parenchyma  of  the  lung.  It  may  be  well,  however,  to  dwell  a  moment 
on  the  fact  that  the  exudative  process  may  be  very  limited,  indeed  con- 
fined to  a  few  vesicles,  and  the  minute  bronchial  tubes  connected  with 
them.  This  is  vesicular  pneumonia.  We  know  it  may  be  confined  to  a 
lobule  or  occupy  an  entire  lobe,  constituting  the  so-called  lobular  and 
lobar  pneumonia.  In  either  case  the  essential  phenomenon  of  infiamma- 
tion,  that  is,  exudation,  has  occurred,  distinguishable  on  careful  examina- 
tion of  the  pulmonaiy  tissue,  by  the  blocking  np  of  air  vesicles  in  the 
form  of  minute  granulations.  Occasionally  the  vesicular  exudation  may 
be  felt  on  handling  the  lung  in  the  form  of  minute  indurations,  varyino- 
in  size  from  a  millet  seed  to  that  of  a  pea — often  red,  but  occasionally 
yellow,  and  in  the  latter  case  very  liable  to  be  mistaken  for  tubercles. 
Such  small  indurations,  however,  at  length  soften,  and  are  converted 
into  pus,  like  the  lobar  and  lobular  forms  of  pneumonia. 

Microscopic  examination  of  the  pulmonary  tissue  shows  us,  in  the  fiist 
instance,  that  the  air  vesicles,  the  minute  bronchi,  and  the  areolar  tissue, 
are  infiltrated  with  a  molecular  and  granular  exudation,  which  often  forms 
a  complete  cast  or  mould  of  the  vesicles  and  bronchi,  easily  separated 
mechanically  by  washing  and  pressure.  Not  nnfrequently,  as  shown  by 
Remak,  these  moulds  are  expectorated  entire,  and  may  be  disengaged 
from  the  gelatinous  matter  with  which  they  are  associated,  by  tlirowing 
the  contents  of  the  spit-box  into  water,  and  teazing  out  the  branched 
alaments.  These,  when  magnified,  present  a  fibrous  exudation,  in  which 
fire  embedded  conmiencing  pus  corpuscles,  with  a  greater  or  less  num- 
ber of  epithelial  cells.  Such  portions  of  exudation  as  remain  in  the  lung 
are  transformed  into  pus  in  the  usual  manner  (Fig.  378,  p.  265),  become 
ultimately  disintegrated  and  absorbed  into  the  blood,  where  they  are 
chemically  changed,  and  at  length  excreted  from  the  system,  principally 
by  the  kidneys.  If,  from  the  extent  of  the  disease,  or  weakness  of  the 
patient,  this  process  is  checked,  the  patient  may  die,  either  from  inabi- 
lity to  excrete  the  effete  matter  in  the  blood,  or  from  interruption  to  the 
respiratory  functions.  If  the  exudation  be  limited  in  extent,  or  have 
been  poured  out  slowly  from  the  commencement,  it  may  become  wliat  is 
called  chronic.  Under  such  circumstances,  the  epithelial  and  pus  cor- 
puscles of  the  pulmonary  tissue  may  undergo  the  fatty  degeneration,  and 
numerous  compound  granule  cells  be  the  result.     If  blood  should  have 


PNEUMONIA.  6^7 

been  extravasated,  mingled  with  tlie  other  formations  described,  there 
■will  be  often  found  red  crystals  of  hsematine,  blood  corpuscles  surrounded 
by  an  albuminous  layer,  and  presentino-  the  numerous  transformations 
■which  they  are  known  to  undergo  after  extravasation.  (Fig.  391,  p. 
375.) 

Dr.  Todd*  observes,  "When  a  patient  suffers  from  pneumonia,  the 
tendency  is  for  the  lung  to  become  solid,  then  for  pus  to  be  generated, 
and  at  last  for  the  pus-infiltrated  lung-structure  to  be  broken  down  and 
dissolved.  Such  are  the  changes  ■when  matters  take  an  unfavourable 
course.  On  the  other  hand,  recovery  takes  place,  either  through  the 
non-completion  of  the  solidifying  process,  or  by  the  rapid  removal,  either 
through  absorption,  or  a  process  of  solution  and  discharge,  of  the  new 
material,  which  had  made  the  lung  solid."  Now  I  have  directed  especial 
attention  to  the  method  in  which  the  exudation  is  absorbed,  and  have 
frequently  examined  lungs  after  death  in  the  stage  of  red  hepatization, 
where  death  had  occurred  from  cerebral  h,iemorrhage  or  other  disease. 
In  some  lungs  there  has  been  a  pneumonia  in  all  its  stages,  incipient  in 
some  places,  solidified  and  red  in  others,  grey  and  purulent  in  a  third. 
In  all  these  places,  a  gradation  in  pus  formation  has  been  observable. 
In  the  most  solid  hepatization,  young  pus  cells  may  be  observed  some- 
where beginning  to  form,  so  that  I  am  convinced  that  the  exudation  is 
always  bi-oken  down  through  the  agency  of  purulent  formation — in  short, 
that  this  is  the  normal  process.  I  have  never  seen  any  evidence  that  a  coa- 
gulated exudation  is  simply  disintegrated  and  absorbed  without  the 
development  of  pus  cells,  and  I  conceive  that  all  analogy  as  well  as 
direct  observation  is  opposed  to  the  supposition.  It  follows  that,  so  far 
from  the  formation  of  pus  being  the  evidence  of  an  unfavourable  course 
of  the  disease,  it  is  the  normal  and  necessary  transformation  of  the  solid 
exudation,  whereby  it  is  broken  up  and  caused  to  be  absorbed.  See  Fig. 
378,  p.  265. 

I  have  previously,  at  some  length,  endeavoured  to  point  out  that  the 
principles  which  have  hitherto  guided  the  profession  in  their  treatment 
of  internal  inflammations  are  erroneous  (p.  257,  et  seq.).  An  inquiry 
into  the  results  of  the  past  treatment  of  acute  pneumonia  (p.  209,  et  seq.), 
shows  that  an  antiphlogistic  treatment,  as  formerly  practised,  was  attended 
with  a  mortality  of  1  case  in  3 ;  that  the  treatment  by  large  doses  of 
tartar  emetic  led  to  a  mortality  of  1  case  in  5  ;  that  the  result  of  more 
moderate  bleedings  is  a  mortality  of  about  1  case  in  7  ;  but  that  a 
treatment  directed  to  further  the  natural  progress  of  the  disease,  as  I 
have  explained  it,  has  been  in  my  practice  1  case  in  26.  The  three  fatal 
cases,  however,  as  previously  explained  (p.  274),  were  complicated  ones, 
so  that  I  have  arrived  at  the  conclusion,  that  pneumonia  occurring  pri- 
marily in  healthy  persons,  so  far  from  being  a  dangerous  malady,  will 
almost  always  get  well,  if  exhaustion  be  prevented,  by  securing  rest, 
avoiding  lowering  remedies,  giving  slight  salines  and  diuretics  to  favour 
excretion  of  the  morbid  products,  and  wine  nutrients  should  the  pulse 
be  weak.  Local  pain  will  be  best  relieved  by  warm  fomentations  or 
poultices. 

While  such  is  what  I  now  believe  to  be  the  best  practice  in  acute 
pneumonia,  it  is  not  to  be  denied  that  many  cases  have  got  well  rapidly 
*  Beale's  Archives  of  Medicine.     No.  1,  p.  2, 


64:8  DISEASES   OF   THE   RESPIRATORY  SYSTEiT. 

T\bo  have  been  moderately  bled.  If,  indeed,  from  twelve  to  eighteen 
ounces  of  blood  be  taken  from  a  strong,  vigorous  individual,  during  the 
first  two  or  three  days  of  the  disease,  it  frequently  for  a  time  diminishes 
dyspnoea  and  other  local  symptoms,  by  relieving  the  engorgement  of  the 
right  cavities  of  the  heart.  But  if  pneumonia  really  extst,  that  is,  if 
exudation  has  occurred,  Ave  have  no  proof  whatever  that  the  disease 
has  ever  been  shortened  or  otherwise  permanently  benefited  by  the  prac- 
tice. Whilst,  then,  it  seems  to  be  of  no  real  advantage,  there  can  be 
little  doubt  that  in  many  cases,  where  weakness  or  want  of  stamina  exists, 
it  prolongs  convalescence,  and,  if  this  be  excessive,  mav  render  the 
disease  fatal.  Still,  as  a  palliative,  blood-letting  to  a  small  amount,  say 
five  or  eight  ounces,  may  be  had  recourse  to,  always  taking  care  to  avoid 
it  in  individuals  with  a  weak  and  soft  pulse,  or  feeble  frame,  while  at  the 
same  time  nutrients  are  given,  and  the  other  treatment  described  is  prac- 
tised. A  case,  however,  requiring  even  such  modified  depletion  must  be 
regarded  as  a  great  rai-ity.  In  the  same  way,  some  pneumonic  patients 
may  escape  any  evil  from  mercurial  salivation,  but  that  this  is  ever  bene- 
ficial or  shortens  the  disease  has  not  yet  been  shown.     (See  p.  276.) 


Case  CSL.* — Chronic  Pneumonia  of  Upper  Third  of  Right  Lung— Gangrenous 
A  bscess — Beco  ve  ry. 

History. — Betsy  Brown,  £et.  48,  married,  a  washerwoman — admitted  September 
12th,  1856.  Had  always  enjoyed  good  health  untO  the  22d  of  last  mouth,  when,  in 
consequence  of  exposure  to  cold  and  wet,  she  experienced  rigors,  followed  by  heat, 
but  without  headache,  thirst,  or  loss  of  appetite.  This  was  followed  by  cough  and 
expectoration,  symptoms  which  have  continued  ever  since.  Two  days  ago  she 
brought  up  a  tea-spoonful  of  blood. 

Symptoms  ox  Admissiox. — She  complains  of  pain  in  the  right  hypochondrium, 
under  the  false  ribs,  not  increased  by  inspiration.  On  percussion  there  is  dulness 
ovier  right  apex  anteriorly,  and  upper  third  of  the  right  lung  posteriorly.  Inspira- 
tioa  heard  over  dull  area  is  harsh,  with  occasional  snoring  during  expiration.  Vocal 
resonance  greatly  increased.  Sputum  scanty,  tenacious,  purulent,  with  brownish 
streaks.  Other  portions  of  lungs  healthy;  no  friction  audible.  Slight  giddiness, 
tinnitus  aurium,  and  feeling  of  weakness.  Pulse  80,  equal,  and  of  moderate  strength. 
Hepatic  dulness  normal.  Other  functions  well  performed.  5  TV.  Opii  Camph. 
§ss;  Vin.  Ipecac.  3  ij ;  Mist.  Scillce  ad  3  yj.  A  table-spoonful  to  le  taken  three  or 
four  times  a  day. 

Progress  of  the  Case. — Sep)tember  liih. — Expectoration  more  free.  A  Mister 
to  be  applied  to  upper  part  of  right  chest  anteriorly.  Sept.  29th. — There  has  been 
little  change,  except  on  the  day  before  yesterday,  when  she  vomited  her  food, 
complained  of  headache,  and  presented  slight  febrile  symptoms.  Pulse  to-day  is  SO, 
and  weak ;  no  shivering.  Bowels  costive.  A  saline  mixture,  ivith  %  iv  of  wine,  and 
to  have  3  ss  of  Castor  Oil.  Oct.  2c?.— Sputum  and  breath  during  the  last  few  days 
have  been  of  an  offensive  odour.  Sputum  is  copious,  purulent,  of  a  somewhat  dirty 
yellow  colour.  Fine  crepitation  is  now  audible  on  inspiration  imder  the  clavicle, 
and  down  to  third  rib,  with  sibOus  during  prolonged  expiration.  Posteriorly  over 
dull  region,  respiration  is  feeble.  Over  lower  two  thirds  of  right  lung,  respiratory 
murmurs  greatly  exaggerated ;  patient  feels  very  weak.     To  have  3  vj.  of  wine  daily. 

*  Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


PXEUMOXIA.  649 

Oct.  bth. — Over  right  lung  posteriorly,  moist  rales  are  now  heard ;  below  spine  of 
scapula  they  are  very  coarse.  Expiration  is  prolonged,  loud,  and  tubular.  Yocal 
resonance  amounts  to  bronchophony  immediately  below  spine  of  scapula.  Oct.  \Qth. — 
Since  last  report  has  continued  to  be  very  weak,  with  feeble  pulse  at  SO,  notwith- 
standing employment  of  nutrients  and  wine,  which  she  has  no  appetite  to  avail  herself 
of  Cheeks  flushed ;  skin  hot,  with  general  febrile  symptoms.  Sputum  copious,  still 
fcetid,  and  considerably  stained  with  dark  blood.  No  evidence  of  lung  tissue  on 
microscopic  examination.  Posteriorly,  immediately  below  spine  of  scapula,  the 
moist  rattles  are  very  coarse,  with  bronchial  resonance  of  the  voice  approaching 
pectoriloquy.  Continue  nutrients  and  vnne.  Oct.  20th  — The  amount  of  sputum 
has  gradually  declined  since  last  report,  and  the  coarse  moist  rales  also  have  slowly 
disappeared  from  right  back.  There  is  now  dry  cavernous  breathing,  with  pectori- 
loquy below  spine  of  right  scapula.  Dec.  11th. — Since  last  report  she  has  been 
alternately  better  and  worse,  the  sputiun  being  sometimes  copious,  and  at  others 
scanty,  but  not  foetid.  Moist  rales  also  have  occasionally,  on  the  former  occasions, 
returned  in  the  right  back,  with  more  or  less  sibilus  on  expiration.  For  some 
days  there  has  been  harsh  inspiratory  murmur  at  apex  of  left  lung,  and  prolonged 
expiration,  without  dulness  on  percussion,  but  with  considerable  increase  of  vocal 
resonance.  Has  been  taking  cod-liver  oil.  Dec.  2Gth. — Since  last  report  there  has 
been  a  gradual  improvement  in  her  general  health.  Appetite  has  returned,  and 
her  strength  permits  her  to  sit  up  during  the  day.  No  moist  rales  are  audible  in 
right  back,  but  loud  tubular  breathing,  with  increased  vocal  resonance.  Jan- 
20th. — Has  been  for  some  time  apparently  quite  well,  and  says  she  enjoys  perfect 
health.  Tubular  breathing  and  bronchophonic  resonance  of  voice,  with  dulness  on 
percussion,  are  still  present  over  upper  third  of  right  back.  At  left  apex,  also, 
inspiration  somewhat  harsh,  with  increase  of  vocal  resonance.     Dismissed. 

Commentary. — In  this  case  a  woman,  48  years  of  age,  who  tells  ns 
she  had  always  enjoyed  good  health,  is  attacked  with  moderate  fever, 
cough,  and  expectoration,  with  all  the  physical  signs  of  a  pneumonia  in 
the  upper  third  of  the  right  lung.  The  sputum  becomes  fcetid,  and  a 
gangrenous  abscess  forms,  from  which  she  slowlv  recovers,  under  the 
action  of  nutrients  and  wine,  leaving,  however,  as  traces  of  the  disease, 
evidence  of  condensation  in  the  pulmonary  tissue  afiected.  In  all  such 
cases  there  is  extreme  difBculty  in  separating  the  disease  from  phthisis. 
Indeed,  there  is  little  pathological  distinction  between  a  chronic  pneu- 
monia and  pulmonary  phthisis.  Moreover,  the  latter,  though  the  real 
disease,  may  supervene  upon  the  former,  of  which  the  followino-  is  an 
example  : — 


Case  CXLI.* — Chronic  Pneumonia  of  both  Lungs,  unih  Ulceration — Death — Great 
Condensation,  with  Cavities  and  Pigmentary  Deposits  in  the  Lungs — Chronic 
Tubei-cle  in  various  Organs — Disease  of  both  Supra-renal  Capsules,  without  bronz- 
ing of  the  skin. 

History. — John  Cunningham,  set.  52,  married,  a  shoemaker— admitted  December 
Sth,  1S56.  He  states  that  having  previously  been  in  the  enjoyment  of  good  health, 
three  months  ago  while  walking  he  became  heated,  and  took  off  part  of  his  apparel- 
On  his  return  home  he  was  attacked  vrith  shivering  and  severe  pains  in  the  breast 

*  Eeported  by  Mr.  V.  Guy,  Clinical  Clerk. 


650  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

and  lumbar  regions.  A  violent  cold  ensued,  but  he  continued  his  employment. 
Three  weeks  ago  he  was  obliged  to  give  up  work.  A  blister  applied  to  the  chest 
to-day,  before  admission,  has  mitigated  the  pain  there. 

Symptoms  on  Admission. — Percussion  over  left  front  of  chest  gives  almost  tym- 
panitic resonance,  but  the  tone  is  flat,  with  a  strong  sense  of  resistance.  Cracked-pot 
sound  is  elicited  in  second  intercostal  space.  Over  right  side  resonance  more  full 
and  less  tympanitic,  but  still  somewhat  flat.  Posteriorly  same  flat  tone,  with  a 
resonance  not  fully  clear.  On  auscultation,  marked  increase  of  vocal  resonance  over 
left  apex,  also  over  left  supra-scapular  region ;  elsewhere  normal.  At  left  apex, 
inspiration  and  expiration  are  blowing  and  cavernous  in  character,  and  expiration 
is  prolonged.  After  cough,  fine  moist  sounds  are  heard  at  close  of  inspiration. 
Laterally  large  moist  sounds  are  more  or  less  heard  with  inspiration,  and  coarse  in 
character,  while  expiration  is  loud  in  tone.  On  right  side  the  same  moist  sounds  are 
heard,  coarser  in  character,  with  both  inspiration  and  expiration.  Posteriorly  respi- 
ratory murmurs  somewhat  loud.  No  moist  rales,  except  over  right  supra-scapular 
region.  Expiration  is  everywhere  prolonged.  Cough  is  violent,  accompanied  with 
a  great  quantity  of  frothy,  tenacious,  and  somewhat  dirty  and  blackish-looking 
sputum,  with  a  few  streaks  of  blood.  Pulse  88,  small  and  weak.  Urine,  sp.  gr. 
1020 ;  voided  in  small  quantities,  of  a  high  colour,  throwing  down  a  large  quantity  of 
lithates.     Chlorides  plentiful ;  other  functions  normal. 

Progress  of  the  C.\se. — December  Wth. — Under  left  clavicle  to-day,  hoarse 
cavernous  rales,  with  both  respiratory  murmurs,  accompanied  with  faint  but  distinct 
crepitation  and  bronchophony.  Posteriorly  at  left  apex,  loud  tubular  breathing,  with 
both  murmurs;  inferiorly  fine  crepitation,  mixed  at  the  termination  of  inspiration 
with  a  loud  sibilant  murmur.  Dec.  ISf/j.— To  have  a  blister  applied  over  sternum. 
Dec.  17th. — Complains  of  indigestion  and  feverishness.  Pulse  100,  hard,  but  com- 
pressible. B  Acetatis  Potass.  3j;  -Aquce  Acet.  Amnion.  §j;  Aqure  ad  3  vj.  3£ 
A  tahle-spoonful  to  he  taken  every  three  hours.  Dec.  I8th. — Feverishness  has  disap- 
peared ;  sputum  of  a  dark-brown  colour ;  is  not  foetid.  On  microscopic  examination, 
numerous  well-formed  pus  cells  are  seen,  but  no  pulmonary  tissue.  Dec.  23d — 
Takes  nourishing  diet  with  %  iv  of  wine.  Says  he  eats  all  his  food.  Anxious  to 
go  out,  but  cannot  on  account  of  weakness.  January  2d. — Countenance  expressive 
of  great  weakness,  sallow  and  pale.  Tongue  covered  with  a  brown  crust ;  dry, 
hard,  and  cracked.  Pulse  108,  weak;  cough  at  night  severe,  preventing  sleep 
Physical  signs  unaltered ;  cannot  I'ise  to  sitting  posture  without  aid.  Jan.  8th. — 
Died  at  1  o'clock,  p.m. 

Sectio  Cadaveris. — Forty-seven  hours  after  death. 

Thorax. — The  upper  lobe,  and  upper  half  of  middle  lobe,  of  right  lung  condensed 
and  indurated.  On  section,  the  cut  surface  presented  an  iron  grey  passing  into  a 
black  colour.  At  the  apex  there  was  a  cavity  resembling  a  tubercular  one  about 
the  size  of  a  walnut.  The  inferior  portion  of  this  lung  also  somewhat  condensed, 
but  more  spongy.  The  whole  of  left  lung  condensed  and  indurated.  On  section, 
the  same  iron-grey  colour  was  everywhere  observable  except  at  the  base,  where 
there  existed  masses  varying  in  size  from  a  hazel-nut  to  that  of  a  chestnut,  of  a 
dirty  red-coloured  hepatization.  Portions  of  tlie  condensed  tissue  everywhere  sunk 
in  water.  At  the  apex  and  at  the  back  of  this  lung  below  the  pleurpe,  which  were 
adherent,  there  was  a  cavity  four  inches  long,  and  about  an  inch  in  breadth,  with 
very  irregular  broken-down  walls.  This  communicated  with  several  smaller  anfrac- 
tuous cavities.     Heart  normal. 

Abdomen. — Slight  simple  constriction  of  the  pyloric  orifice  of  the  stomach. 
Over  the  mucous  surface  of  the  small  intestine,  extending  from  the  termination  of 


PNEUMONIA.  651 

the  ileum  to  about  two  feet  of  the  end  of  the  duodenum,  were  numerous  cicatrices  of 
former  ulcers  with  everted  edges,  and  the  surrounding  mucous  membrane  puckered 
and  drawn  in.  There  were  a  few  similar  cicatrices  in  the  large  intestine.  The 
mesenteric  glands  were  a  little  enlarged,  and  contained  yellow  tubercular  matter. 
The  right  supra-renal  capsule  felt  thick  and  hard,  and  weighed  290  grains.  It  was 
everyw^here  infiltrated  with  yellow,  opaque,  tubercular  looking  matter  of  solid  con- 
sistence, but  friable  under  pressure.  Perhaps  about  one  tenth  only  of  the  gland 
presented  its  natural  texture.  Two  tubercular  masses,  the  size  of  filbert  nuts,  were 
present  in  the  left  supra-renal  capsule,  surrounded  by  indurated  tissue.  One-fourth 
of  its  texture  was  natural.     Other  organs  normal. 

Microscopic  Examixatiox.— Fluid  pressed  from  the  iron-grey  and  black  hepa- 
tization contained— First,  A  great  number  of  large  granule  cells.  Secondly,  Nume- 
rous pigment  cells.  Thirdly,  Colourless  epithelial  ceUs,  isolated  and  aggregated  in 
masses.  Some  of  these  cells  were  peculiarly  colourless  and  resembled  those  in  waxy 
textures.  Fourthly,  A  few  starch  and  celloid  bodies.  Fifthly,  Numerous  pigmen- 
tary and  fatty  granules  floating  loose.  On  makmg  a  section  of  this  tissue  with  a 
Yalentine's  knife,  these  elements  were  seen  everywhere  infiltrating  the  pulmonary 
texture.  The  fluid  pressed  from  the  dirty-red  coloured  hepatization,  in  the  base  of 
the  opposite  lung,  contained  numerous  pus  corijuscles  with  epithelial  cells ;  compa- 
ratively few  granule  cells,  and  no  pigment.  A  portion  of  the  grey  exudation,  which 
here  and  there  resembled  infiltrated  tubercle,  was  composed  of  amorphous  molecular 
matter.  The  yellow  masses  in  the  supra-renal  capsules  presented  the  characteristic 
structure  of  tubercle. 

Commentary. — This  man's  account  of  his  case  (and  he  seemed  veiy 
intelliijent)  was,  that  the  pulmonary  disease  commenced  in  the  manner 
described,  three  months  before  admission.  He  also  denied  having  been 
ever  seriouslv  ill  before.  Yet  the  examination  after  death  revealed  evi- 
dences in  the  lungs,  intestines,  mesenteric  glands,  and  supra-renal  cap- 
sules, of  chronic  tubercular  disease.  The  fever,  rapid  ulceration  of  both 
luno-s,  and  subsequent  prostration,  as  in  the  last  case,  however,  were 
appareiitlv  owing  to  a  pneumonia,  which  became  chronic.  In  such  a 
case,  the  vital  powers  were  unable  to  effect  those  rapid  changes  which 
we  have  seen  to  be  the  characteristic  of  acute  pneumonia,  and  he  died. 
The  diagnosis  between  such  a  disease  and  phthisis  pulmonalis,  I  regard 
as  impossible.  The  two  forms  of  exudation  present  similar  physical  and 
vital  characters.  In  neither  this  nor  the  former  case,  Avas  the  general 
appearance  of  the  patient,  or  history  of  the  disease,  in  any  way  similar 
to  that  of  phthisis  ;  and  practically  it  is  of  little  moment  whether 
we  have  to  do  witb  a  low  form  of  exudation  in  young  persons,  which 
we  call  tubercle,  or  a  similar  one  in  old  persons  which  we  call  chronic 
pneumonia.  In  this  case,  however,  thei'e  was  tubercle  of  a  chronic  cha- 
racter in  several  organs,  and  among  others  in  both  supra-renal  capsules, 
althouo-h  there  wascertainly  no  bronzing  of  the  skin  during  life. 


Case  CXLII.* — Gangrene  of  the  Lungs — Dysentery. 

History. — Thomas  Marshall,  set.  29,  a  chimney-sweep — admitted  November  23, 
1852.     He  states  that  he  has  been  troubled  with  slight  cough  for  many  years  back. 

*  Eeported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


652  DISEASES   OF   THE   RESPIRATORY    SYSTEM. 

Eight  weeks  ago  he  experienced  rigors  without  any  obvious  cause,  followed  by 
increase  of  the  cough,  looseness  of  the  bowels,  severe  griping  pains  in  the  abdomen, 
and  frequent  desire  to  go  to  stool,  with  much  straining  and  tenesmus.  He  observed 
a  small  quantity  of  blood  in  the  stools,  which  sometimes  consisted  onl}'-  of  about  a 
table-spoonful  of  blood  mixed  with  frothy  mucus.  The  calls  to  stool  were  at  first 
so  numerous  that  he  cannot  state  even  the  probable  number  in  the  twenty-four 
hours.  They  abated  somewhat  under  treatment  at  one  of  the  dispensaries,  but  the 
diarrhoea  has  continued  more  or  less  ever  since.  During  the  last  eight  weeks  the 
cough  has  become  much  aggravated,  and  the  sputa  increased  in  quantitj-.  Two 
days  before  admission,  he  observed  that  the  sputa  were  of  a  dirty-red  colour,  having 
formerly  consisted  of  thick  purulent  masses  without  any  tinge.  He  states  that  for 
the  last  eight  or  ten  weeks  he  has  been  losing  flesh  and  strength  to  a  great  degree, 
though  he  does  not  present  a  very  emaciated  appearance.  His  diet  also,  during 
that  period,  has  been  very  defective,  both  in  quantity  and  quality ;  but  previously 
he  had  always  been  able  to  procure  good  food.  He  is  addicted  to  the  immoderate 
use  of  spirits,  and  has  several  times  had  delirium  tremens. 

Symptoms  ox  Admission. — On  admission,  the  chest  on  percussion  appears  resonant 
throughout,  except  over  the  upper  third  of  right  lung,  where  very  slight  dulness  can 
be  detected.  The  respiratory  murmur  is  heard  all  over  the  chest,  but  under  the  right 
clavicle  it  is  harsh  and  exaggerated,  and  the  vocal  resonance  greatly  increased. 
Posteriorly  there  is  comparative  dulness  on  percussion,  and  increased  vocal  resonance 
over  the  whole  of  right  side,  but  most  marked  at  the  apex.  Over  the  lower 
third,  on  the  same  side,  fine  crepitation  can  be  heard  during  forced  inspiration. 
Sputum  in  large  quantity,  consisting  of  frothy  tenacious  mucus,  of  a  dirty  brown 
colour,  becoming  more  fluid  upon  standing,  and  of  very  offensive  odour.  "\\'heu 
examined  by  the  microscope,  numerous  pus-cells,  some  blood  corpuscles,  and  large 
quantities  of  disintegrated  epithelium,  can  be  detected.  Has  no  pain  in  chest. 
Breathing  is  not  laboured,  but  cough  is  troublesome,  especially  at  night,  occurring  in 
paroxysms.  Expectoration  difficult.  The  tongue  is  dry,  with  slight,  dirty-yellow 
fur;  troublesome  thirst,  but  appetite  good.  No  nausea,  but  frequent  inclination  to 
vomit  when  the  cough  is  severe.  No  uneasiness  in  the  bowels  when  at  rest,  but 
griping  pains  are  generally  present  when  at  stool.  There  is  distinct  tenderness 
on  percussion  in  the  right  iliac  region,  over  a  space  of  about  two  inches.  The 
bowels  have  been  open  six  times  during  the  last  twenty  four  hours.  The  stools  are 
very  copious,  of  thin  fluid  consistence,  and  of  a  brownish-red  colour.  They  contain 
numerous  blood-corpuscles,  as  determined  by  the  microscope.  The  urine  is  passed 
in  small  quantity,  but  otherwise  normal.  There  are  slight  tremors  of  the  hands,  but 
no  other  symptoms  of  delirium  tremens.  Other  functions  normal.  IJ  Tind.  Opii, 
3  ij ;  Tinct.  Catechu,  5  ss ;  Gonfed.  Aromat.  3  ij ;  Mist.  Creice,  %  v.  M.  A  table- 
spoonful  to  he  taken  every  four  hours.  Haheat  enema,  cum  Tind.  Opii,  3j.  ^  ^th. 
Sulph.  m.  xl;  Mucilarjinis,  3ij;  Mist.  Camp)h.  ,'^'].  Fiat  haustus.  To  be  taken  at 
bed-time.     Ordered  also  nuiritioiirS  diet  and  4  oz.  of  wine. 

Progress  of  the  Case. — November  26. — Bowels  open  nine  or  ten  times  during 
the  twenty-four  hours ;  stools  watery,  having  distinct  traces  of  blood.  Much  griping 
pain  when  at  stool.  Cough  severe.  Expectoration  copious.  Dec.  1. — Diarrhoea 
continues,  notwithstanding  he  has  taken  regularly  the  astringent  mixture  and  opiate 
enemata.  To-day  the  skin  is  hot  and  dry,  the  appetite  bad,  with  great  thirst.  To 
have  a  5  gr.  pill  of  lead  and  opium  every  third  hour.  Dec.  2 . — Has  had  four  or  five 
stools  since  last  night.  They  are  fcBCulent,  but  of  very  thin  consistence,  unmixed 
with  blood.  He  feels  very  weak,  and  complains  much  of  pain  in  the  chest,  espe- 
cially on  the  right  side.  Dulness  on  percussion  is  increased  over  the  whole  of  the 
right  side  posteriorly,  and  is  most  marked  over  the  lower  third.     There  is  great 


PNEUMONIA.  653 

increase  also  of  the  vocal  resonance,  amounting  to  pectoriloquy  in  the  supra-scapular 
region ;  loud  moist  rales,  like  gurgling,  are  heard  over  the  right  back.  On  the  left 
side  the  respiration  is  harsh  and  exaggerated,  and  the  vocal  resonance  is  also  loud. 
Breath  and  expectoration  fojtid.  Omit  the  lead  and  opium  pill,  and  continue  the  medi- 
cines ordered  on  the  24:th.  Dec.  6. — Diarrhoea  abated ;  but  he  feels  very  weak,  and 
the  cough  is  troublesome ;  crepitation,  with  increased  vocal  resonance,  pretty  general 
over  the  left  back.  To  have  three  oz.  of  spirits.  Dec.  9. — Diarrhoea  has  returned — 
stools  thin  and  foecal,  containing  a  good  deal  of  blood.  To  have  a  starch  injection 
with  Tinct.  Opii,  3  iss.  Dec.  14  — Diarrhoea  abated  somewhat  until  to-day,  when  it 
has  again  returned  as  severely  as  before.  Much  pain  in  lower  part  of  abdomen ; 
considerable  griping  and  tenesmus;  pulse  100,  small  and  weak,  but  regular.  The 
opiate  enema  has  been  continued  every  evening  since  last  report,  and  he  has  been  taking 
a  chloric  cether  and  morphia  mixture  to  relieve  the  spasmodic  cough.  Apply  a  blister 
(4  by  3)  to  the  abdomen.  Increase  the  wine  to  6  oz.  Dec.  18. — Has  rallied  greatly 
since  last  report,  but  to-day  the  diarrhoea  has  again  returned.  The  cough  is  very 
troublesome — sputa  tinged  with  blood ;  over  the  whole  of  the  right  back  there  are 
harsh  gurgling  rales,  with  a  noise  approaching  to  a  metallic  character  when  he 
coughs;  mucous  rattles  heard  over  left  back ;  the  offensive  odour  of  breath  and  sputa 
has  increased  since  last  noticed.  To  have  the  following  draught  at  bed-time.  5  S<^1- 
Mur.  Morpih.  3j;  and  continue  the  three  oz.  of  spirits.  Tinct.  Catechu  3j;  Mist. 
Cretm  3J;  Spir.  Amman.  Aromat.  3  ss.  M.  Sumat hora somni.  Jan.  1. — Died  this 
morning  at  five  a.m.  Little  change  took  place  in  the  symptoms  after  last  report. 
One  day  he  appeared  to  sink,  but  he  rallied  again  the  next.  Diarrhoea  continued, 
averaging  about  twelve  stools  in  the  twenty-four  hours.  The  stools  consisted  of 
very  small  quantities  of  dark  matter,  with  mucus,  and  occasionally  a  little  blood. 
He  continued  taking  the  mixture  of  ammonia,  etc.,  and  the  astringents  with  an  opiate 
enema,  which  latterly  was  administered  twice  a  day. 

Sectio  Cadaveris. —  Thirty-one  hours  after  death. 

Body  much  emaciated. 

Thorax. — Heart  and  pericardium  normal.  Right  lung  united  to  thoracic  walls  by 
firm  and  universal  pleuritic  adiiesions.  On  its  being  removed  and  bisected,  a  black 
gangrenous  cavity,  five  inches  long  and  four  broad,  was  exposed,  occupying  the 
upper  and  middle  lobes.  It  contained  an  extremely  foetid  olive-green  diffluent  mat- 
ter, having  no  distinct  structure.  The  walls  of  the  cavity  presented  a  firm  lining 
membrane  of  condensed  fibrous  tissue,  internally  of  pulpy  consistence  and  blackish- 
brown  colour.  The  surrounding  pulmonary  tissue,  posteriorly  and  inferiorly,  was 
hepatised  and  friable,  with  a  few  antractuous  cavities  also  gangrenous.  Anteriorly 
the  lung  was  emphysematous,  with  here  and  there  portions  of  collapsed  tissue.  The 
left  lung  adhered  to  the  thoracic  walls  posteriorly  by  pleuritic  adhesions.  On  being 
removed  and  bisected,  the  lower  lobe  and  inferior  portion  of  upper  lobe  was  con- 
gested, and  presented  a  brick-red  colour;  hepatised  and  dense  in  various  places, 
with  irregular  cavities  containing  foetid  brown  sloughs,  varying  in  size  from  that  of 
a  pea  to  a  pigeon's  egg,  and  communicating  more  or  less  with  each  other. 

Abdomen'. — Mucous  surface  of  coecum  and  ascending  colon  closely  studded  with 
irregular-shaped  ulcerations,  varying  in  size  from  a  pin's  head  to  a  sixpence.  Some 
of  these  were  evidently  chronic,  and  in  process  of  healing,  with  a  thickened  worm- 
eaten  edge  and  a  bluish  granular  base ;  others  contained  a  sloughing  centre,  involv- 
ino-  more  or  less  of  the  muscular  coat.  Similar  ulcers  were  scattered,  but  more 
sparsely,  through  the  transverse  and  descending  colon.  Other  abdominal  organs 
healthy. 


65-i  DISEASES   OF   THE   RESPIRATOEY  SYSTEM. 

ConDiienfanj. — In  this  case  "\ve  have  an  example  of  pneumonia  in 
both  Kings,  ^vhic•h  passed  into  gangrene,  associated  with  acute  dysentery, 
occurring  in  an  individual  whose  constitution  had  been  impaired  by  ad- 
diction to  intoxicating  drinks.  Dysentery  generally  prevails  during  the 
autumn  montlis,  in  Edinburgh,  to  a  greater  or  less  extent ;  and  in  the 
case  of  Marshall  it  came  on  without  any  obvious  cause  in  September, 
and  was  ushered  in  by  rigors,  followed  by  bloody  and  purulent  dis- 
charges at  stool,  with  tenesmus  and  abdominal  pain.  About  the  same 
time,  also,  pectoral  symptoms  were  complained  of,  although  it  is  not 
probable  that  decided  pneumonia  was  then  occasioned.  Even  when  he 
came  into  the  house  it  was  limited  in  extent,  and  ran  a  tolerably  acute 
course  subsequently.  The  febrile  symptoms,  therefore,  which  existed 
previous  to  his  admission,  were  most  probably  connected  with  the  dysen- 
tery. This  ran  its  usual  course,  producing  sloughing  ulcers  in  the 
raucous  membrane  of  the  large  intestines  to  a  considerable  extent;  and 
by  the  irritation  and  continued  discharge  they  occasioned  (which  could 
not  be  checked),  gradually  prostrated  the  patient,  and  was  the  chief 
cause  of  his  death. 

It  is  seldom  we  have  an  opportunity  of  seeing  a  more  illustrative  case 
of  gangrene  of  the  lungs,  than  this  man  presented — large  and  circum- 
scribed on  the  right  side,  extended  and  diffused  on  the  left  side.  That, 
in  both  cases,  the  gangrene  was  preceded  by  pneumonia,  there  can  be 
little  doubt,  as  all  the  functional  signs  of  the  lesion  were  present  during 
life,  whilst  after  death  the  gangrenous  cavities  were  everywhere  sur- 
rounded by  distinct  pulmonary  hepatization.  There  is  every  reason  to 
suppose  that  the  same  general  causes  which  produced  the  sloughing 
sores  in  the  intestines,  occasioned  the  gangrenous  cavities  in  the  lungs. 
A  deficiency  of  vital  power  in  the  organism  prevented  those  transforma- 
tions necessary  for  the  absorption  of  the  exudation,  and  thus  it  died  and 
underwent  putrefaction.  Inllammatory  gangrene  and  ulceration  both 
depend  on  death  of  the  exudation,  but  in  the  former  case  there  occur 
those  peculiar  chemical  changes  which  induce  putrefaction.  The  only 
symptom  which  indicates  this  change  is  fo-tor  of  the  breath  or  of  the 
sputum,  which  was  very  apparent  in  Marshall  on  his  admission  to  the 
house,  and  was  greatly  increased  afterwards.  In  the  following  case 
which  entered  the  ward  in  1848,  and  was  the  subject  of  careful  examina- 
tion, I  diagnosed  a  gangrenous  cavity  in  the  right  lung,  and  separated  it 
from  phthisis,  partly  on  account  of  the  fcetid  odour,  and  partly  on  ac- 
count of  the  situation  and  limitation  of  the  cavern. 


Case  CXLIII.* — Gangrenous  Abscess  of  the  Bight  Lung,  caused  by  the  Swalloiving  of 
a  Piece  of  Chicken  Bone  four  and  a  half  years  jyreviously. 

History. — Thomas  Xeal,  £Et.  27,  a  footman,  of  sober  habits — admitted  December 
4th,  1848.  He  says  that  he  was  quite  well  up  to  four  rears  and  a  half  ago,  when, 
while  eating  part  of  a  chicken,  and  laughing,  he  was  suddenly  seized  with  coughing 
and  a  sense  of  suffocation  producing  lividity  of  the  face.  He  thinks  he  swallowed  a 
portion  of  chicken  bone,  but  is  by  no  means  sure.  At  all  events,  he  experienced  a 
severe  pain  at  the  time  across  the  lower  part  of  the  chest,  followed  by  a  short,  dry, 

*  Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


PNEUMOXIA.  655 

tickling  cough,  accompanied  by  a  wheezing  noise  in  the  throat.  In  an  hour  he 
recovered  and  went  about  his  usual  employment.  The  cough,  however,  continued, 
and  after  three  months  was  accompanied  by  a  fi-othy  expectoration,  which  gradually 
increased.  About  three  years  ago  he  entered  St.  George's  Hospital,  London,  but  was 
dismissed  in  a  fortnight.  Shortly  after,  he  observed  blood  in  the  sputum,  which  now 
became  foetid.  He  has  laboured  under  constant  cough,  with  expectoration  of  foetid 
pus  and  more  or  less  blood  ever  since. 

Symptoms  oh  Admission. — On  admission  he  complained  of  frequent  cough  and 
profuse  expectoration  of  a  viscid,  slightly  frothy  matter,  stained  with  blood  and  of 
gangrenous  odour.  He  was  pale,  but  by  no  means  emaciated.  On  percussing  the 
chest,  there  was  considerable  dulness  over  the  two  inferior  thirds  of  the  right  lung, 
both  anteriorly  and  posteriorly.  At  a  point  a  little  below  the  right  nipple,  the  dul- 
ness was  more  marked  than  either  above  or  below.  On  auscultation  there  was  great 
increase  of  the  vocal  resonance  over  the  whole  right  side  of  the  chest,  most  so  over 
the  dull  spot  below  the  nipple.  Posteriorly  about  the  middle  of  the  lung,  there  was 
a  circumscribed  gurgling  rale,  heard  over  an  extent  about  two  inches  square,  and 
not  audible  above  or  below  it.  At  this  point  also  there  was  perfect  pectoriloquy. 
The  respiratory  murmur  over  the  other  parts  of  the  lung  was  harsh,  and  here  and 
there  accompanied  by  mucous  and  sibilant  rales.  These  signs  were  less  evident  at 
the  upper  than  over  the  lower  two-thirds  of  the  organ.  Over  the  left  lung  the  per- 
cussion was  normal,  the  respiratory  murmurs  puerile  but  otherwise  healthy.  All  the 
other  functions  were  well  performed,  if  we  except  the  occasional  loading  of  the  urine 
with  litliates,  and  trifling  perspiration  at  night. 

Progress  of  the  Case. — The  treatment  was  directed  to  supporting  his  strength, 
giving  cough  and  antispasmodic  mixtures,  and  introducing  a  seton  below  the  right 
nipple.  This  produced  considerable  local  ii'ritation,  but  caused  diminution  in  the 
gurgling  rale,  expectoration,  and  cough,  so  much  so,  that  he  insisted  on  leaving  the 
Infirmary,  February  8,  1849.  He  continued,  however,  to  be  attended  by  the  clinical 
clerk,  now  Dr.  James  Struthers  of  Leitli,  from  whose  report  the  following  account  is 
taken: — "Towards  the  middle  of  March  Ms  appetite  and  strength  began  to  fail;  he 
lost  flesh  and  became  feverisli,  thirsty,  and  restless ;  was  obliged  to  confine  himself 
to  the  house;  and  suffered  from  shortness  of  breath,  even  when  at  rest ;  the  cough 
and  expectoration  continued  much  the  same ;  he  bad  no  rigors,  and  was  free  from 
pain.  On  the  morning  of  the  2J:th,  he  awoke  suffering  from  great  increase  of  cough 
and  shortness  of  breath,  and  continued  during  the  day  to  expectorate,  at  intervals  of 
a  few  minutes,  large  quantities  of  frothy  sputa,  deeply  tinged  with  blood,  and  much 
more  foetid  than  usual.  I  was  asked  to  visit  him  at  his  own  house  on  the  25th,  and 
found  him  much  weaker  than  when  I  had  last  seen  him  some  weeks  previously. 
The  cough  was  constant,  the  expectoration  profuse,  the  sputa  frothy  and  mixed 
with  florid  blood ;  the  breath  and  sputa  had  a  gangrenous  odour  which  was  very 
perceptible  on  approaching  the  bed.  He  had  no  pain,  his  chief  complaint  being  of 
great  weakness,  dyspnoea,  and  occasional  feeling  of  sufibcation.  The  respirations 
were  45 ;  the  pulse  130,  weak  and  wiry.  On  examining  the  chest,  the  right  side 
was  found  scarcely  to  move  on  inspiration,  and  was  universally  dull  on  percussion  ; 
all  natural  respiratory  sound  was  absent ;  gurgling  was  audible  over  its  greater 
part,  both  in  front  and  behind,  with  coarse  mucous  and  subcrepitant  rale  towards 
the  upper  and  lower  parts.  Although  the  voice  was  weak,  the  vocal  resonance  was 
much  increased,  and  there  was  very  distinct  bronchophony  over  the  inferior  two- 
thirds.  There  was  no  friction  sound  audible.  The  left  side  was  very  resonant,  and, 
with  the  exception  of  puerile  respiration,  and  some  subcrepitous  rale,  inferiorly,  pre- 
sented nothing  unusual.  During  the  next  three  days,  he  became  rapidly  weaker ; 
the  cough  and  dyspnoea  increased ;    he  could  speak  only  in  monosyllables ;    the 


656 


DISEASES   OF   THE   RESPIRATORY   SYSTEM, 


respirations  rose  to  68,  and  the  pulse  to  140;  and  he  expectorated  daily  about  two 
pints  of  thin  bloody  sputa,  which  had  a  strong  gangrenous  odour,  and  latterly  flowed 
in  an  almost  continuous  stream  from  the  mouth.  On  the  29th,  he  became  typhoid, 
had  hiccup  and  slight  delirium,  and  died  in  the  evening." 

Sectlo  Cadaveris. —  Thirty-six  hours  after  death. 

The  features  were  much  collapsed ;  there  was  some  yellowness  of  the  skin ;  and 
a  copious  discharge  of  thin  brown  fluid  from  the  mouth  and  nostrils.  Percussion  of 
the  chest  elicited  the  same  sounds  as  during  the  last  days  of  life. 

Thorax. — The  right  lung,  with  the  exception  of  the  lower  part  of  the  anterior 
border,  was  found  firmly  adherent  to  the  walls.  The  adhesions  were  short,  dense, 
and  of  a  white  colour.  The  lung  was  removed  without  laceration ;  it  was  some- 
what diminished  in  bulk,  of  a  dark  red  colour,  and  had  a  pulpy  feel.  The  apex  was 
occupied  by  a  closed  cavity,  the  size  of  a  small  orange,  which  was  distended  with  a 
brown  diity -looking  fluid  of  the  consistence  of  cream,  and  having  a  most  intense 
gangrenous  odour.  The  wall  of  this  cavity  approached  the  pleura  superiorly ;  its 
inner  surface  was  very  irregular,  presenting  numerous  shreds  of  disorganized  pul- 
monary tissue.  At  tlie  middle  of  the  lung  posteriorly,  and  about  half  an  inch  from 
the  surface,  there  was  another  cavity,  the  size  of  a  walnut,  lined  with  a  dense  grey- 
coloured  membrane,  one  line  in  thickness,  and  broken  up  in  several  places ;  it  was 

r>  -  partially  filled  with  a  dirty-coloured  fluid,  and  opened  directly  into  a 
#^^^^  bronchial  tube,  the  size  of  a  crow  quill,  at  the  other  extremity  of  which 
''^^i^^i       the  foreign  body  was  found  at  a  future  stage  of  the  dissection.     In  the 

Fig.  480.  neighbourhood  of  this  cavity,  and  throughout  the  whole  of  the  inferior  and 
posterior  parts,  the  lung  was  riddled  with  numerous  small  cavities,  vaiying  in  size 
from  that  of  a  hazel  nut  to  that  of  a  pea.  Some  of  these  were  closed  and  filled  with 
a  fluid  similar  to  that  found  in  the  one  at  the  apex ;  others  were  nearly  empty,  more 
or  less  aufractuou.s,  and  communicated  freely  with  the  bronchial  tubes ;  the  walls  of 
some  were  formed  of  a  thick  dense  membrane ;  those  of  others  were  soft  and  ragged. 

The  middle  part  of  the  anterior,  and 


•©•■. 


Fig.  431. 


a  small  portion  of  the  inferior  border 
were  in  a  state  of  grey  hepatization, 
and  were  the  only  parts  free  from 
cavities.  On  laying  open  the  right 
bronchus,  a  small  piece  of  bone  was 
found  at  the  bifurcation  of  the  middle 
primary  division ;  it  was  lying  almost 
loose,  and  came  away  witliout  any 
force  being  used ;  it  was  quite  clean, 
and  bore  a  strong  resemblance  to 
part  of  a  vertebra  of  a  small  animal, 
being  of  an  irregular  elongated  form, 
and  presenting  several  sharp  spicula. 
The  mucous  membrane  at  the  part 


was  thickened,  but  quite  free  from  ulceration,  and  not  more  vascular  than  that  of  the 
other  bronchi.  The  trachea  and  the  bronchi  of  both  lungs  were  stained  of  a  dark 
grey  colour,  but  otherwise  presented  nothing  abnormal.     In  the  left  2^leura  there 


Fio-.  430.  Fragment  of  chicken  bone  found  in  the  right  bronchus,  in  Neal's  case. 

Fig.  431.  Fluid  in  the  chronic  abscess  of  the  riglit  lung  in  Xeal's  case,  a.  Fibrous 
tissue;  b,  broken  down  pus  cells;  c,  crystals  of  triple  phosphate;  and  d,  urate  of  am- 
monia— (Jamts  Slruihcrs.) 


250  diam. 


PXEUMOXIA.  657 

were  three  or  four  ounces  of  clear  serum.  The  lung  was  healthy,  except  a  small 
portion  at  the  inferior  border  which  was  hepatized,  and  studded  with  small,  grey, 
indurated  nodules,  the  size  of  corn-pickles.  These  consisted,  as  ascertained  by  the 
microscope,  of  accumulations  of  altered  epithelium,  with  much  granular  fatty  matter. 
The  apex  of  the  lung  was  free  of  deposit,  and  there  was  no  tubercle  in  any  part. 
The  bronchial  glands,  especially  those  on  the  right  side,  were  greatly  h}-pertrophied, 
several  of  them  being  as  large  as  pigeon's  eggs ;  they  contained  no  foreign  matter. 
The  heart  was  of  the  normal  size ;  its  muscular  and  valvular  structures  were  healthy ; 
and  all  the  cavities  contained  both  firm  decolorised  and  dark  loose  clots.  The  blood, 
examined  under  the  microscope,  presented  the  red  and  while  corpuscles  in  the  usual 
proportions. 

Abdomex.— The  abdominal  viscera  were  in  all  respects  normal. 

Microscopic  Examixation.— The  fluid  from  the  abscess  at  the  apex  of  the  right 
lung,  on  being  examined  under  the  microscope,  was  found  to  contain  sm^ll  shreds  of 
fibrous  tissue,  broken  down  pus  globules,  and  a  large  number  of  crystals  of  the  triple 
phosphate  and  of  the  urate  of  ammonia.     Fig.  431. 

Commentary. — The  physical  signs  in  this  case  clearly  indicated  the 
existence  of  a  cavity  in  the  right  lung,  which,  from  its  position,  and  troni 
the  general  history'of  the  case,  was  not  likely  to  be  tubercular.^  On  the 
other  hand  its  gangrenous  character  was  revealed  by  the  peculiar  odour, 
and  his  account  oi  its  origin  rendered  it  probable  that  the  cause  was  a 
foreign  body  impacted  in  the  bronchus.  At  the  same  time,  he  was 
never  verv  certain  as  to  the  fact  of  having  swallowed  the  piece  of  bone, 
and,  in  many  conversations  I  had  with  him  on  that  point,  he  invariably 
stated  that  "such  was  merely  his  impression,  but  he  was  not  sure.  It  is 
of  importance  to  notice  this  fact,  because  it  seems  very  probable  that 
when  in  St.  George's  Hospital,  his  account  may  have  been  a  doubtful  one 
there  also,  and  may  have  prevented  recourse  to  an  operation  which  then 
might  possibly  have  been  undertaken  with  success.  It  would  be  inte- 
resTing  to  know  whether  at  that  time  his  chest  had  been  carefully 
examined  by  auscultation,  or  whether  general  symptoms  only  were 
attended  to,  and,  in  consequence  of  these  being  slight,  he  was  dismissed 
in  a  fortnight.  Certainly,  it  cannot  be  imagined  that  if  any  certainty 
existed  as  to  the  impaction  at  that  time  of  a  foreign  body  in  the  lung,  no 
effort  would  have  been  made  to  extract  it,  especially  when  the  uniform 
ultimate  fatality  of  such  an  occurrence  is  taken  into  consideration.  At 
all  events,  this  "case  points  out  how,  in  a  young  man  of  perfect  health, 
structural  disorganization  slowly,  but  surely,  proceeds  after  such  an 
occurrence,  and  it  strongly  inculcates  the  necessity  of  early  careful 
examination  and  of  operative  interference. 

Another  cause  of  gangrene  in  the  lung,  is  the  occasional  impaction  of 
clots  of  blood,  whether  t1ie  result  of  phlebitis  or  from  floating  coagnla 
coming  from  the  right  side  of  the  heart.  As  an  example,  we  may  cite  a 
well-imrked  case  given  by  Mr.  G.  W.  Callender,  in  the  ninth  volume  of 
the  Pathological  Society's  Transactions.  One  of  the  tertiary  divisions 
of  the  pulmonary  artery  was  occupied  by  a  layer  of  decolorized  fibrin 
in  the  form  of  a  hollow  globule.  Its  diameter  was  about  two  lines 
greater  than  that  of  the  artery  below,  so  that  at  this  point  the  vessel 
seemed  to  have  undergone  some  shght  dilatation.  Just  beyond  the  place 
at  which  this  clot  had  obstructed  the  canal,  the  artery  bifurcated.     The 

42 


658 


DISEASES   OF   THE   EESPIRATOEY   SYSTE:m:. 


blood  liad  penetrated  one  of  its  divisions  by  means  of  a  short  and  narrow 
channel,  formed  by  the  side  of  the  above-mentioned  clot,  which  was 
prolonged  into  the  vessel,  occupying  about  half  its  calibre.     The  other 

.  ^, .  division  at  the  point  where  it 

^ -/  "'  '        -     '  again  bifurcated,  had  one  of 

'"^■^      "  its    divisions    obstructed    by 

another  clot,  which,  unlike 
the  others,  was  solid  through- 
out. The  portion  of  pulmo- 
nary tissue  with  which  this 
arterv  communicated,  was  in 
a  state  of  gangrene,  as  also 
was  its  pleural  covering.  In 
this  case  various  masses  of 
coagulated  fibrin  were  ad- 
herent to  the  tricuspid  valve, 
Fit:.  432.  and  the   clots  found    in  the 

branches  of  the  pulmonary  artery  m  the  lung,  were  most  likely  derived 
from  them,  as  the  vein  itself  was  healthy.  The  hollowing  out  of  the 
nearer  of  these  coagula  to  the  heart  also  was  probably  owing  to  the  sub- 
sequent action  of  the  current  of  blood,  whilst  the  one  further  distant 
remained  solid,  and  completely  arrested  the  circulation. 


PHTHISIS  PULMOXALIS. 

Case  C^lAX .*—PhtMsis  Pulmonalis  in  its  last  Stage,  with  Incompetency  of  the 
Aortic  Valves— Cod  Liver  Oil  and  Nutrients— Compkle  Recovery. 

History.— Patrick  Barclay,  ?et  15,  admitted  June  25,  1849.  His  previous  history 
indicated  tliat  lie  had  been  of  scrofulous  habit  from  infancy.  He  attended  the  indus- 
trial school  regularly  until  a  week  ago,  but  could  not  take  much  exercise  on  accoimt 
of  a  sore  leg,  which  originated  twelve  months  previously  in  a  faU.  His  diet  has  for  a 
long  time  been  very  poor.  On  the  18th  he  was  attacked  with  cough,  and  this  has 
continued  till  admission.     He  also  complains  of  dyspnoea  on  exertion. 

SviiPTOMS  ON  Admissiox.— On  admission,  he  is  excessively  emaciated.  He 
complains  of  cough,  which  is  sometimes  very  prolonged,  but  has  no  pain  nor 
difficulty  of  breathing.  The  chest  expands  well  on  inspiration.  Cough  easily 
excited,  and  occasionally  severe.  Sputa  viscid,  frothy,  and  tinged  with  blood.  On 
percussion,  there  is  great  duluess  of  the  right  side,  especially  under  the  clavicle ; 
the  left  side  is  also  dull  to  a  slight  extent  On  auscultation,  distinct  bronchophony, 
loud  friction  rale,  and  mucous  rale,  approaching  cavernous,  are  heard  in  the  upper 
right  side  in  front;  and  these  become  more  faint  towards  the  lower  part  of  the 
lung.  On  the  left  side,  friction  rales  are  also  heard  in  the  upper  part  in  front. 
Behind,  on  the  right  side,  vocal  resonance  not  so  distinct,  but  rales  the  same  as  in 
front.     Pulse  111,  strong  and   sharp.     The   heart's  apex  beats  below  sixth  rib;' 

*  Reported  by  Messrs.  Hugh  Balfour,  Sanderson,  and  Dewar,  Clinical  Clerks. 


Fig.  432.  Part  of  the  left  lung,  with  clots  occupying  branches  of  the  pulmonary 
artery. — ( Calktider. ) 


PHTHISIS   PULMOXALIS.  659 

impulse  increased ;  but  percussion  does  not  indicate  lateral  expansion.  On  auscul- 
tation, a  chirping  musical  murmur  is  heard  over  the  apex  of  the  heart,  at  the  end  of 
the  first  sound.  This  murmur  becomes  much  more  faint  towards  the  base.  To 
the  lett  of  the  manubrium  of  the  sternum,  a  bellows  murmur  takes  the  place  of 
the  second  sound.  This  murmur  is  quite  concealed  by  loud  friction  rales,  when 
respiration  is  going  on,  but  is  immediately  perceived  when  the  patient  holds  his 
breatli.  Tongue  sUghtly  furred;  appetite  good;  some  thirst.  BoM'els  regular. 
Urine  natural;  sp.  gr.  1020 — not  coagulable.  The  chest,  face,  and  arms,  are 
covered  with  an  eruption  of  prurigo,  which  be  has  had  several  times.  On  the  right 
thigh,  towards  the  lower  part,  there  are  several  cicatrices,  and  three  sinuses,  which 
communicate  with  d5ad  bone.  Is  much  troubled  with  sweating,  wliich  at  night  is 
ver}^  profuse.  To  have  good  diet  with  sweet  milk  morning  and  evening,  and  a  dessei't- 
spoonfal  of  Ood- Liver  Oil  three  times  a  day.  5  ^'^i-  Scilke  §  iv ;  Tinct.  Opii 
Amnion.  |  ss ;  Aq  Cinnam.  §  iss ;  Aquce  §  iij.  M  Half-an-ounce  three  times  a  day. 
Progress  of  the  Case.— June  3(J<7t.— Friction  rale  less.  Gurglmg  rale  on 
right  side.  U})per  part  of  chest  to  be  rubbed  luith  Tartar  Emetic  Ointment.  July 
2rf.— Chirping  murmur  has  become  faint,  and  occasionally  is  inaudible.  Has  vomited 
his  food  several  times.  Half  a  drachm  of  Xaphtha  to  be  added  to  mixture ;  to  have  beer 
for  drink.  5 //i.— Chirping  murmur  quite  gone.  8//t. — Chirping  murmur  returned. 
Cough  severe,  causing  vomituig.  Eruption,  brought  out  by  ointment,  painful. 
Omit  the  Ointment  and  Mixture.  5  Pulv.  Tragacanih.  Co.  Zi;  Naphthce  Medic.  I  \] 
Sol.  Mur.  Morph.  3  iij ;  Syrup.  Aurantii  3  ss ;  Mist.  Scillce  3  v.  M.  A  table- 
spoonful  thrice  a  day.  2lst. — A  seton  was  introduced  beneath  the  right  clavicle. 
Still  vomits  in  the  niorniug,  but  takes  food  and  medicine  better.  Aug.  Gth. — The 
expiratory  murmurs  under  right  clavicle  are  now  quite  dry.  Vomiting  is  dimi- 
nished. Omit  the  Mi.xture.  'fy  Ferri  Oitrat.  3ss;  Tinct.  et  Syrupi  Aurantii,  aa 
lss;Infus.  Calumbce  '^yI  M.  A  table-spoonful  three  times  a  day.  12th. — The 
seton  discharges  freely,  causing  great  irritation,  and  is  to  be  withdrawn.  Sejii. 
'ilk. — Appearance  of  patient  much  improved.  Sounds  of  cavity  in  chest  continue 
dry.  Takes  now  again  a  table-spoonful  of  the  oil  three  times  a  day.  Oct.  28. — 
Musical  murmur  has  entirely  disappeared.  He  is  becoming  quite  fat,  and  is  able 
to  go  about  the  ward  all  day.  Complains  only  of  slight  cough  at  night,  and 
palpitation  on  exertion.  The  right  infra-clavicular  region  is  becoming  fiat.  Omit 
the  mixture  and  also  the  Cod-Liver  Od.  Xov.  18th. — Cough  has  returned,  with 
slight  mucous  expectoration;  and  on  auscultation,  mucous  and  sibilant  rales 
are  heard  all  over  the  chest.  Ordered  to  recommence  the  oU  g  Mist.  Scilke 
I  vss ;  Vini  Ipecac.  3  ij ;  Sol.  Mur.  Morph.  3  i-  M.  A  table-spoonful  three  times 
a  day.  From  this  time  he  rapidly  improved.  The  cavity  became  perfectly  dry,  and 
respiration  over  it  was  accompanied  by  blowing  murmurs.  Cough  and  expectora- 
tion greatly  diminished.  His  general  appearance  is  healthy,  and  he  is  very  stout. 
On  January  ISih,  it  is  noted  that,  on  percussion,  a  distinct  cracked-pot  sound  is 
heard  in  the  right  mfra-clavicular  region,  and  faintly  also  on  the  left  side.  On 
auscultation  the  heart's  sounds  are  loud  all  over  the  chest,  the  second  sound  being 
accompanied  with  a  distinct  bellows  murmur.  Musical  murmur  has  never  returned. 
There  is  bronchophony  and  prolonged  expiration  in  the  right  infra-clavicular 
region,  but  no  moist  sounds.  Sleeps  well,  and  is  very  little  troubled  with  cough. 
Does  not  sweat;  is  very  fat;  appetite  good.  This  boy,  as  far  as  all  general 
symptoms  are  concerned,  may  be  regarded  as  having  been  m  good  health  for  the 
last  two  months.  Feb.  21ih.—0n  percussion,  the  chest  was  tolerably  resonant 
on  both  sides;  but  there  was  slight  dulncss  under  the  right  clavicle.  On  ausculta- 
tion, the  inspiration  is  loud,  and  of  a  blowing  character,  in  right  infra-clavicular 
region ;  but  the  murmur  is  much  softer  than  formerly.    Expiration  is  still  prolonged, 


660  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

and  there  is  considerable  vocal  resonance,  but  not  amounting  to  bronchophony — 
no  naoist  rales.  In  the  corresponding  situation  on  the  left  side,  the  inspiration  is 
somewhat  harsh,  and  respiration  slightly  prolonged;  vocal  resonance  normal ;  loud 
bellows  murmur,  with  the  second  sound  of  the  heart,  heard  over  nearly  the  whole 
chest.  His  general  health  is  good;  he  expresses  himself  as  being  quite  well.  He 
appears  stout  and  strong ;  but  his  countenance  is  somewhat  sallow  and  cachectic. 
He  has  no  expectoration  or  sweating,  and  the  cough  is  trifling,  and  only  present  in 
the  morning.  He  is  about  to  return  to  the  Industrial  School,  and  resume  the 
learning  of  his  trade  as  a  shoemaker.     Dismissed. 

He  was  re-admitted  August  26(h,  18.50.  Since  leaving  the  house  he  has  been  at 
the  Industrial  School,  but  has  been  frequently  exposed  to  cold;  and  latterly  the 
cough  and  expectoration,  which  he  says  had  quite  left  him,  have  returned,  and  been 
gradually  getting  more  severe.  The  sweating  returned  with  the  cough.  A  week 
before  admission,  he,  with  the  other  boys  of  the  school,  went  to  Portobello  to  bathe, 
and,  notwithstanding  his  remonstrances,  the  master  insisted  on  his  going  into  the 
water,  saying  it  would  do  him  good.  He,  however,  became  much  worse.  On  admis- 
sion, the  physical  signs  were  coarse  moist  rale  uuder  the  right  clavicle,  imperfect 
pectoriloquy,  and  creaking  friction  noises,  harsh  inspiration,  and  prolonged  expira- 
tion under  left  clavicle ;  but  the  dulness  in  this  position  is  very  slight,  when,  com- 
pared with  that  of  the  opposite  side.  He  again,  by  means  of  cod-liver  oil,  good  diet, 
and  counter-irritation,  became  strong  and  stout;  again  the  cough,  expectoration, 
and  other  symptoms  ceased,  and  lie  was  discharged  March  1th,  1851.  The  report 
on  that  day  is,  "  marked  dulness  and  increased  vocal  resonance  under  right  clavicle ; 
the  inspiration  is  harsh  but  dry." 

Once  again  admitted  July  5th,  1851. — He  says  that  on  leaving  the  ward  in 
March  last,  he  had  two  detached  pieces  of  the  right  thigh-bone  extracted  by  Mr. 
Syme,  and  remained  in  the  surgical  hospital  for  five  weeks.  Since  then  he  has  been 
constantly  employed  in  light  garden  work,  and,  notwithstanding  poverty  of  food,  he 
continued  in  tolerably  good  health  till  a  week  ago.  On  percussion,  there  is  slight 
dulness  only  under  the  right  clavicle,  and  posteriorly  the  resonance  is  good  and  equal 
on  both  sides.  Under  the  right  clavicle,  the  inspiration  is  heard  to  be  harsh  and 
blowing — no  moist  rale.  There  is  also  loud  double  friction  murmur  over  the  upper 
fourth  of  right  lung,  especially  at  the  apex,  and  slight  friction  may  be  detected  here 
and  there  over  the  whole  of  the  right  side.  Under  the  left  clavicle,  inspiration  some- 
what exaggerated  in  tone,  but  the  breath  sounds  everywhere  normal.  He  looks 
pale  and  thin.  There  is  severe  cough,  with  mucous  expectoration,  but  the  appetite 
is  good,  and  there  is,  on  the  whole,  a  marked  improvement  in  his  general  appearance. 
Impulse  of  the  heart  and  loud  blowing  murmur  at  the  base  still  present.  'Wound  in 
the  thigh  nearly  healed. 

Further  Progress  of  the  Case. — He  has  continued  to  do  well  since  his  admis- 
sion into  the  house.  The  cough  rapidly  diminished,  and  is  now  only  present  in  the 
morning  on  waking.  His  bodily  functions,  he  says,  are  in  every  respect  perfectly 
well  performed.  The  wound  in  the  thigh  is  cicatrised,  and  were  it  not  for  the  car- 
diac disease,  this  lad  might  be  considered  in  robust  health.  The  following  is  the 
result  of  a  careful  examination  of  the  chest,  made  December  23d,  1851: — "On  per- 
cussion, shglit  dulness  under  the  right  clavicle.  On  auscultation,  inspiratory  murmur 
somewhat  harsh  under  both  clavicles,  but  most  so  on  right  side.  The  vocal  resonance 
also  is  slightly  exaggerated  over  the  apex  on  right  side.  In  every  other  respect,  the 
lungs  appear  to  be  healthy.  There  is  great  impulse  of  the  heart  stiU,  and  over  the 
apex  there  is  heard,  with  the  second  sound,  a  blowing  murmur,  which  is  very  loud 
at  the  base.  He  remained  in  the  house  until  March  1th,  1852  when  he  was  dis- 
missed in  all  respects  perfectly  well. 


PHTHISIS   PULMONALIS.  661 

August  9ih,  1852. — Presented  himself  at  the  visit  to-day.  Since  his  dismissal  in 
March,  has  been  emploj-ed  by  a  dyer,  and  during  his  occupation  has  been  greatly 
exposed  to  wet  and  cold.  He  has  only  been  able  to  earn  five  shillings  a-week, 
so  that  his  diet  has  been  very  poor,  both  in  quantity  and  quality.  His  health,  not- 
withstanding, has  been  tolerably  good,  although  he  is  now  much  thinner  than  when 
he  left  the  Infirmaiy.  On  percussion  there  is  clear  resonance  under  both  clavicles, 
but  on  the  right  side  very  slight  dulness  with  increased  resistance  is  perceptible. 
On  auscultation,  the  inspiration  under  right  clavicle  is  somewhat  harsh,  but  the  re- 
spiratory murmurs  on  the  whole  are  very  good.  Vocal  resonance  slightly  increased. 
Under  the  left  clavicle  there  is  harshness,  with  fine  sibilation  and  friction  during 
inspiration.  The  expiration  is  prolonged,  and  there  is  also  slight  increase  of  vocal 
resonance.  The  blowing  murmur  at  the  base  of  the  heart  with  the  second  sound 
still  very  distinct.  Otherwise  is  quite  healthy.  He  has  a  sister  settled  at  Piiiladel- 
phia,  and  has  formed  the  intention  of  joining  her  in  the  United  States. 

Ftbruary  6th,  1853 — Presented  himself  at  the  Infirmary  to-daj^,  and  was  carefully 
examined  by  Dr.  Bennett,  Dr.  Christison,  the  various  clerks,  and  students.  The 
physical  signs  are  the  same  as  at  last  report,  the  breath  sounds,  however,  being  more 
soit  and  natural.  He  has  been  prevented  leaving  for  PhiladeliDliia,  as  he  intended 
last  August,  and  since  then  has  been  carrying  on  the  occupation  of  light  porter  to  a 
dyer.  His  general  health  has  been  good,  although  he  has  undergone  much  exposure 
to  cold  and  wet.  He  leaves  for  Philadelpliia  to-morrow,  taking  witli  him  a  letter 
recommending  him  to  the  care  of  Professor  Wood  of  that  city. 

In  a  letter  from  Dr.  "Wood  to  Dr.  Bennett,  dated  March  28ih,  1853,  it  was  stated 
that  Barclay  had  presented  himself  a  week  previously.  "  Being  at  the  time  extremely 
busy,  I  gave  the  boy,  who  told  me  that  he  was  quite  destitute,  a  small  sum  of  money, 
telling  him  to  use  it  for  his  support ;  in  the  meantime  to  look  out  for  employment, 
which  is  not  difficult  to  be  had  in  this  country  for  persons  of  his  class,  and  to  call 
on  me  again  before  long.  He  promised  to  do  so.  I  have  not  seen  him  since."  In 
a  subsequent  letter  (1856)  from  Dr.  Dunglisou,  who  at  Dr.  Bennett's  request  asked 
Dr.  Wood  concerning  him,  it  appeared  that  he  had  not  since  been  heard  of. 

Commentary. — I  am  not  acquainted  with  any  recoi'ded  case,  which, 
throughout  its  progress,  has  been  examined  with  more  cave,  in  wliich 
phthisis,  in  its  last  stage,  was  more  unequivocally  manifested,  and  which 
was  more  decidedly  the  siabject  of  a  complete  cure,  than  the  one  now 
given.  The  lad  was  under  my  observation  from  June  1849  to  February 
1853,  a  period  of  forty-three  months,  and  during  that  time  he  was 
respectively  examined  in  the  clinical  ward  by  four  winter  and  two  sum- 
mer classes  of  students,  as  well  as  by  my  professorial  colleagues.  Of  the 
facts  and  accuracy  of  the  record  in  the  ward  book  there  can  be  no 
doubt;  and  it  is  equally  certain  that  we  watched  the  arrest  of  tubercular 
condensation  at  the  apex  of  the  left  lung,  and  the  cicatrization  of  a  large 
tubercular  excavation  in  the  apex  of  the  right  lung.  Moreover,  a  care- 
ful study  of  this  case  will  show  that  this  result  was  not  bi'ought  alwnt 
by  the  mere  spontaneous  efforts  of  nature.  On  the  contrary,  gTeat  diffi- 
culties had  to  be  surmounted,  numerous  symptoms  removed,  and  most 
important  complications  guarded  against.  Indeed,  the  effects  of  treat- 
ment could  never  be  more  unequivocally  manifested  in  anv  case  than 
they  have  been  in  this.  On  admission,  he  presented  the  wasting  charac- 
ters of  the  disease  in  its  last  stage.  The  emaciation  was  extreme ;  the 
cough  and  sweating  most  distressing;  and  the  physical  signs  demon- 
strated a  cavity  as  large  as  the  fist,  in  the  right  lung.     Under  the  use 


662  DISEASES   OF   THE   EESPIEATORT   SYSTEil, 

of  the  oil  bis  strength  rallied.  After  a  time  it  was  given  up,  on  account 
of  his  becoming  so  fat.  Gurgling  rales,  and  other  signs  of  softened 
exudation,  however,  once  more  became  apparent,  and  again  disappeared 
when  the  use  of  the  oil  was  resumed.  He  continued  to  take  it  from 
time  to  time  afterwards,  and  it  became  appaient  that  the  pulmonary 
signs  varied  according  to  his  ability  of  digesting  the  oil.  The  same  fact 
was  demonstrated  throughout  the  progress  of  the  case,  clearlv  showing 
the  intimate  relation  which  exists  between  the  local  disease  and  the 
general  nutritive  powers  of  the  economy. 

During  no  part  of  the  time  this  boy  was  under  treatment  did  he 
experience  any  difficulty  in  taking  the  oil.  On  the  contrary,  it  occa- 
sioned no  uneasiness  in  the  stomach,  and  was  readily  digested,  and  this, 
although  the  food  was  at  one  period  frequently  vomited,  owing  appa- 
rently to  the  violence  of  the  cough.  Its  influence  on  his  general  health 
was  most  remarkable,  as  well  as  upon  the  local  disease  in  the  lungs. 
From  a  state  of  extreme  eiliaciation  he  became  so  stout  that  it  was 
feared  the  oil  would  occasion  obesity  ;  and  was  therefore,  for  a  time, 
discontinued.  His  appetite  was  always  good — a  circumstance  I  have 
noticed  as  being  very  favourable,  not  only  for  the  beneficial  action  of 
cod-liver  oil,  but  for  the  successful  treatment  of  phthisis  generally. 
Indeed,  it  is  the  anorexia,  nausea,  and  dyspeptic  symptoms  which  con- 
stitute the  great  difficulty  the  phvsician  has  to  overcome  in  the  manage- 
ment of  the  disease,  as  is  well  illustrated  in  the  following  case  : — 


Case  CXLT.* — Pldhisis  Pulmonalis — Amendment  from  Treatment  and  Disappear- 
ance of  Symptoms — Their  Subsequent  Return — Death. 

History. — Jane  HamOton,  a  dressmaker,  set.  IS — admitted  September  12,  1849. 
She  stated  that  last  April  her  general  health  began  to  fail ;  the  appetite  was  bad  ; 
cough  with  expectoration  came  on ;  cold  sweats  appeared  on  the  face,  hands,  and 
feet ;  the  catamenia,  which  had  never  been  very  regular,  were  suppressed ;  and  she 
became  so  weak  that  she  could  not  stand.  Since  then  there  has  been  a  temporary 
improvement ;  but  for  some  time  back  she  has  become  worse. 

Stmptoms  ox  Adsiissiox. — On  admission  she  was  pale  and  emaciated,  and  so 
weak  that  she  was  unable  to  sit  up  above  a  few  minutes  at  a  time.  There  was 
copious  perspiration  during  sleep,  a  severe  cough,  with  abundant  yellowish  viscid 
sputa — no  pain  in  the  chest,  which  was  well  formed  externally.  The  tongue  was 
covered  with  a  brown  fur ;  appetite  capricious  and  bad ;  bowels  open  every  second 
day.  The  treatment  consisted  of  tonics,  expectorants,  and  counter-irritation  to  the 
chest,  which  produced  considerable  amendment.  I  took  charge  of  the  case  in  the 
middle  of  October,  and  found,  on  careful  percussion,  dulness  below  the  right  clavicle, 
with  loud  mucous  rale  over  the  upper  third  of  right  chest.  There  were  also  sonorous 
and  sibilant  rales  over  the  greater  part  of  both  lungs,  anteriorly  and  posteriorly.  By 
means  of  expectorants  and  counter-irritants,  the  bronchitic  symptoms  and  signs  were 
subdued  by  the  Isi  of  Xovemier ;  but  the  dulness  and  moist  rales  under  the  right 
clavicle  stiU  continued.  A  taUe-spoonful  of  cod  live)-  oil  icas  then  ordered  to  he  taken 
three  times  a  day. 

Progress  of  the  Case. — The  remedy  was  suspended  on  the  Sth,  on  account  of 
a  febrile  attack  she  then  experienced,  which  was  ushered  in  with  headache  and 

*  Reported  by  ilr.  Alexander  Struthers,  Clinical  Clerk. 


PHTHISIS   rULMONALIS.  663 

rigors,  and  accompanied  witli  accelerated  but  soft  pulse,  heat  of  skin,  loss  of  appetite, 
frequent  nausea  and  vomiting,  and  considerable  spinal  irritation.  It  was  not  until 
November  30th  that  these  symptoms  were  so  far  removed,  and  the  tone  of  the 
stomach  augmented — by  means,  first,  of  antimonials,  and  subsequently  of  naphtha, 
alkalies,  vegetable  bitters,  and  stimulants — that  the  oil  was  again  ordered.  It  pro- 
duced considerable  nausea,  however,  so  that,  after  persevering  in  its  use  for  ten  days, 
it  was  again  suspended.  It  was  once  more  had  recourse  to  on  the  lAih  of  December, 
and  was  readily  i-etained  on  the  stomach.  A  few  days  subsequently,  the  dose  was 
increased  to  four  table-spoonfuls  daily.  December  30th. — There  is  now  a  very  evi- 
dent improvement  in  the  general  liealth.  Her  strength  is  so  for  increased  that  she 
sits  up  a  considerable  portion  of  the  day.  The  perspirations  have  nearly  disappeared. 
The  expectoration  is  still  thick  and  purulent,  but  not  so  copious.  She  is  evidently 
much  stouter,  and  the  skin  is  of  a  more  healthy  colour.  The  catamenia  have  also 
reappeared.  There  is  still  dulness  under  the  right  clavicle  on  percussion.  The 
coarse  moist  rale  has  disappeared,  and  a  fine  crepitating  murmur  only  is  heard  wjth 
the  inspiration  towards  the  acromial  end  of  the  clavicle. — There  is  prolonged  expira- 
tion, and  increased  vocal  resonance.  From  this  time  she  continued  to  improve.  On 
the  1st  of  January  the  oil  was  reduced  to  three  table-spoonfuls  daily.  A  small 
blister  was  occasionally  applied  to  the  upper  part  of  the  right  chest  anteriorly,  and 
an  expectorant  mixture  given  to  facilitate  the  expectoration,  which,  though  dimi- 
nished in  quantity,  retained  its  viscid  and  purulent  character.  On  the  30th  of  Janu- 
ary the  inspiratory  murmur  had  acquired  a  certain  degree  of  harshness,  but  here  and 
there  very  fine  crepitation  could  still  be  detected.  She  left  the  Infirmary  on  the  2Uh 
of  February. 

I  examined  the  chest  carefully  on  the  "ith  of  March.  There  was  still  dulness,  but 
not  so  marked  as  formerly,  under  the  right  clavicle  ;  no  crepitation  on  auscultation, 
but  harshness  of  the  inspiratory  murmur,  prolonged  expiration,  some  friction  noises, 
and  increased  vocal  resonance.  She  was  stout,  of  healthy  appearance,  and  expressed 
herself  as  being  quite  well ;  but  the  expectoration  of  purulent  matter  still  continued 
to  a  slight  degree,  with  occasional  cougli.  Shortly  afterwards  she  went  to  Dundee 
to  carry  on  her  occupation  as  a  milliner,  when  the  confinement,  late  hours,  and  irre- 
gular food,  soon  caused  a  return  of  her  more  urgent  symptoms.  She  again  entered 
the  Infirmary,  and  once  more,  after  a  few  months,  was  dismissed  relieved.  On  the 
last  occasion,  she  was  admitted  under  another  physician.  August  I9th,  3  852,  the  dis- 
ease having  progressed  to  its  last  stage  during  the  interval.  She  died  September  8th. 
No  examination  of  the  hody  could  be  obtained. 

Commentary. — In  this  case,  the  local  disease  had  not,  on  admission, 
proceeded  to  the  advanced  stage  observable  in  the  former  one,  for  the 
phvsical  signs  in  the  girl  exhibited  at  most  bronchitis,  with  softening  of 
the  tubercular  exudation  at  the  apex  of  the  right  hing,  whereas  in  the 
boy  they  demonstrated  that  a  large  cavity  existed  in  one  lung,  whilst  the 
other  was  also  affected.  There  was  the  same  general  prostration,  how- 
ever, and  the  same  emaciation,  excessive  weakness,  profuse  perspiration, 
purulent  expectoration,  and  distressing  cough.  But  there  was  this  dif- 
ference in  the  antecedent  circumstances  of  the  two  cases — namely,  that 
the  bov  liad  a  good  appetite,  but  had  been  subjected  to  an  insufficient 
diet,  whilst  the  girl  had  no  appetite,  although  she  possessed  the  means 
of  gratifying  it.  In  the  first  case  nutrition  was  imperfect  from  deficient 
quantity  of  food,  the  digestive  organs  being  tolerably  healthy  ;  in  the 
second,  it  was  imperfect  on  account  of  the  dyspepsia  and  disordered 
state  of  the  stomach  rendering  it  impossible  that  a  sufficient  quantity 


664:  DISEASES   OF   THE   EESPIEATORY   SYSTEM. 

could  be  consumed.  The  result  in  both  was  the  same, — namely,  im- 
poverishment of  the  blood,  and  tubercular  exudation  into  the  pulmonary 
organs. 

The  practical  management  of  these  two  cases  Avas  considerably  modi- 
fied by  the  circumstances  to  which  I  have  just  alluded.  In  the  boy, 
there  was  no  difKculty  in  overcoming  the  imperfect  nutrition.  We  have 
seen  that  he  took  the  cod-liver  oil,  and  digested  it  and  his  food  with  the 
greatest  facility.  In  the  girl,  all  thoughts  of  food  caused  disgust,  and 
the  cod-liver  oil  produced  nausea,  and  for  some  time  could  not  be  tole- 
rated. For  a  considerable  period,  therefore,  the  treatment  of  this  case 
was  preparatory,  and  directed  to  the  diminution  of  the  dyspeptic  symp- 
toms, and  removal  of  those  complications  which  prevented  any  success- 
ful attack  on  the  more  important  disease. 

Thus  my  first  eiforts  were  directed  to  alleviating  the  bronchitis,  which 
wias  accomplished  by  means  of  expectorants  and  counter-irritants.  Cod- 
liver  oil  was  then  ordered,  but  it  occasioned  nausea,  and  was  suspended 
on  account  of  a  febrile  attack  she  now  experienced.  On  her  recovery 
from  this,  the  nausea,  vomiting,  and  dyspeptic  symptoms  were  treated 
by  means  of  naphtha,  alkalies,  vegetable  bitters,  and  carminatives,  with 
apparent  benefit;  but,  on  recurring  to  the  oil,  the}'  again  returned  ;  so 
that,  after  persevering  for  ten  days,  it  became  again  necessary  to  a-ive  up 
its  employment.  In  a  few  days,  however,  it  was  once  more  tried,  and  on 
this  occasion  with  success.  It  was  then  taken  readily  ;  a  marked  amend- 
ment followed ;  the  dose  was  increased  to  four  table-spoonfuls  daily,  and 
it  was  astonishing  to  see  how  rapidly  she  improved.  Her  streno-th 
increased,  the  emaciation  and  cachectic  look  dit^appeared,  the  skin 
assumed  a  healthy  colour,  and  she  became  positively  stout  and  fat,  so 
that  she  was  scarcely  recognisable.  The  cough  almost  ceased,  the  expec- 
toration greatly  diminished,  the  perspirations  did  not  appear  at  nioht,  the 
catamenia  returned,  she  sat  up  the  entire  day,  and  at  length  considered 
herself  so  well,  that,  on  being  allowed  to  leave  the  hospital  for  a  day,  she 
did  not  return.  She  called  on  me  a  few  days  afterwai'ds,  Avhen  I  found 
that,  although  the  constitutional  symptoms  had  almost  entirely  disap- 
peared, and  her  general  health  might  be  called  good,  traces  of  the  local 
disease  were  still  apparent,  as  stated  in  the  report.  This  case,  therefore 
exhibits  the  obstacles  which  the  physician  has  not  unfrequently  to  over- 
come before  he  can  carry  out  that  line  of  treatment  bv  means  of  which 
the  abnormal  nutrition  is  to  be  obviated,  and  the  tubercular  exudation 
checked ;  but  it  also  inculcates  the  importance  of  perseverance,  and 
exhibits  the  good  etfects  which  may  result  from  persisting  in  a  treatment 
dictated  by  cocrect  pathological  principles. 

Notwithstanding  the  great  benefit  produced  in  this  case,  a  return  to 
imperfect  diet  and  a  sedentary  employment  once  more  induced  all  the 
symptoms  and  dangerous  etfects  which  in  the  hospital  were  removed  with 
so  much  trouble.  Nor,  unless  we  could  convert  such  institutions  into 
establishments  for  the  permanent  support  and  surveillance  of  phthisical 
cases,  is  it  easy  to  see  how  this  can  be  prevented.  Certain  it  is,  that  we 
are  very  seldom  enabled  to  retain  a  case  so  long  under  treatment,  as  we 
did  that  of  Barclay.  Although,  by  means  of  judicious  treatment,  we 
frequently  check  the  progress  of  phthisis,  and  restore  the  patient  to  a 
good  state  of  health,  it  most  commonly  happens  that  the  patient,  if  he 


PHTHISIS   PULMONALIS.  665 

be  in  a  public  hospital,  insists  on  going  out,  and,  if  a  private  case,  he 
abandons  those  remedies  and  precautions  which  are  absolutely  necessary 
to  his  existence.  Hence  it  too  frequently  happens,  that,  even  after  such 
considerable  amendment  as  we  have  seen  take  place — after  restoration 
from  a  state  of  the  most  complete  prostration  to  one  of  almost  vigorous 
health — the  causes  which  originated  the  disease  induce  its  return,  and 
the  patient  sinks,  after  one  or  more  relapses.  It  is  of  all  things  most 
important,  thei-efore,  to  keep  a  careful  watch  over  phthisical  cases  long 
after  the  constitutional  symptoms  have  disappeared,  and,  in  fact,  so  long 
as  the  physical  signs  indicate  any  traces  of  the  disease.  This,  for  obvi- 
ous reasons,  can  be  accomplished  much  better  in  private  than  in  hospital 
practice. 

Case  CXLYI.*— Phthisis  Puhnonalis— Large  Vomica  on  Left  Side— Caries  of  Left 
Wrist  Joint — Febricula —  Variola — Scrofuhixs  Nephritis. 

History. — John  Fiiilay,  set.  19 — admitted  into  the  dinical  ward  December  20th, 
1850.  Says  that  he  has  been  troubled  with  cough  and  expectoration,  more  or  less, 
for  the  last  six  years,  accompanied  by  occasional  diarrhoea.  For  the  last  three 
weeks  he  has  been  in  the  surgical  clinical  ward,  under  Mr.  Syme,  for  scrofulous  caries 
of  the  left  wrist  joint.     He  has  spat  blood  now  and  then,  but  to  no  great  extent. 

SYiiPTOMS  ON  Aujiissiox. — On  percussion,  the  right  chest  is  everywhere  resonant ; 
but  there  is  marked  dulness  over  the  whole  of  left  chest,  most  complete  in  the  sub- 
clavicular and  supra-scapular  regions.  On  auscultation,  loud  mucous  rales  are  heard 
over  the  whole  of  left  chest  anteriorly,  with  gTirgling  and  pectoriloquy  under  the 
clavicle.  Posteriorly  and  inferiorly  on  this  side,  tliere  is  a  harsh  tubular  breathing? 
with  prolongation  of  the  expiration.  There  is  puerile  respiration  on  the  right  side, 
but  otherwise  nothing  abnormal.  His  external  appearance  is  pale,  presenting  all 
the  so-called  characters  of  the  scrofulous  diathesis.  There  is  great  emaciation,  and 
development  seems  to  have  been  arrested,  as  he  does  not  look  above  12  years  of  age. 
The  left  wrist-joint  is  immovable,  considerably  swollen,  with  several  carious  open- 
ings discharging  pus.  Frequent  cough,  with  copious  muco-purulent  expectoration. 
Pulse  80,  feeble.  Tongue  clean.  Considerable  nausea,  and  total  loss  of  appetite. 
His  diarrhoea  has  recently  been  checked  by  lead  and  opium  pills.  (For  treatment, 
see  Commentary.) 

Progress  of  the  Case. — For  the  next  three  months  the  loss  of  appetite,  sickness, 
and  vomiting  occurred  at  intervals,  and  the  i^liysical  signs  remained  the  same. 
From  this  period,  however,  his  general  health  underwent  gradual  improvement,  the 
cough  was  not  so  severe,  and  the  expectoration  became  more  mucous.  The  sweating 
greatly  dmiinished,  and  he  took  food  more  readily.  Towards  the  end  of  Maj^,  he  had 
evidently  gained  much  in  flesh,  and  the  discharge  from  the  scrofulous  sores  in  the 
wrist  was  trifling.  The  physical  signs  were  so  far  altered,  that  the  mucous  rales 
over  greater  part  of  left  side  were  not  so  coarse  or  diflused,  and  the  gurgling  under 
the  clavicle  was  now  of  a  splashing  character,  and  more  limited.  Pectoriloquy  in 
this  situation  was  complete,  and  there  was  absence  of  expansion  during  respiration. 
There  could  now  also  be  heard  harsh  inspiration,  with  prolonged  expiration  under 
the  riglit  clavicle ;  the  resonance  on  percussion  also  was  here  slightly  impaired. 
During  June,  he  was  much  troubled  with  nausea  and  vomiting.  On  tlie  21st  he 
was  attacked  with  rigors,  followed  by  all  the  symptoms  of  continued  fever,  which 
terminated  by  diaphoresis  on  the  seventh  day.     Shortly  after,  he  was  attacked  with 

*  Reported  by  Messrs.  Sanderson  and  Dewar,  Clinical  Clerks. 


666  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

variola,  wliicli  ran  its  usual  course.  During  July  and  August,  there  was  gradual 
but  marked  improvement  of  his  general  health.  At  the  end  of  the  last-named 
month,  the  left  wrist-joint  was  firmly  anchylosed,  and  all  the  carious  openings  had 
closed  up.  He  still  had  occasional  diarrhoea.  There  was  still  duluess  on  left  side, 
but  the  mucous  rales  were  not  heard  so  low  down  anteriorly.  Fine  crepitation 
with  increased  vocal  resonance  was  now  audible  under  the  right  clavicle.  Up  to  the 
middle  of  October  he  continued  .slowly  to  improve ;  the  sweatings  aud  diarrhoea  had 
ceased,  aud  the  cough  was  much  less  severe.  He  now  complained  of  considerable 
pain  during  micturition,  and  on  examining  the  urine  it  was  found  to  contain  nume- 
rous pus-corpuscles,  and  to  be  coagulable  by  heat  and  nitric  acid.  He  continued  to 
feel  pain  on  urinating,  and  to  pass  pus  bj'  the  urethra  during  the  month  of  October. 
On  the  3d  of  November  the  report  is : — "  Marked  dulness  on  percussion  over  the 
left  chest  anteriorly,  and  under  the  clavicle  cracked-pot  sound.  Posteriorly  it  is 
resonant.  On  auscultation,  loud  friction  is  heard  from  below  up  to  the  level  of  the 
nipple,  and  above  this,  loud  mucous  rattles  passing  into  gurgling  under  the  clavicle. 
Perfect  pectoriloquy  in  this  situation.  On  right  side,  puerile  respiration ;  and  pos- 
teriorly sibilant  rale  at  the  termination  of  the  inspiration.  Xo  sweating  or  diarrhoea. 
Still  occasional  nausea  and  vomiting.  General  strength  much  improved,  and  now 
walks  about  the  ward,  sitting  up  a  great  portion  of  the  day."'  The  report  on  the 
2lst  of  December  IS : — "Still  marked  dulness  over  the  whole  of  left  side,  except 
under  the  clavicle,  where  it  is  tj-mpanitic,  with  cracked-pot  sound.  Resonance  on 
right  side  good.  Under  acromial  end  of  left  clavicle  feeble,  and  distant  gurgling  is 
heard — the  respiration  having  more  of  a  blowing  character  than  formerly,  with 
perfect  pectoriloquy.  The  moist  rales  over  the  other  parts  of  this  side  have  disap- 
peared. On  right  side,  puerile  respiration  is  heard  over  the  inferior  half  of  lung ; 
otherwise,  the  breath-sounds  are  normal  Posteriorly  dulness  of  the  whole  of  left 
side,  but  there  is  no  cracked-pot  sound.  On  auscultation,  the  signs  are  the  same  as 
are  heard  anteriorly.  His  general  health  has  much  improved.  Still  complains  of 
occasional  nausea  and  vomiting,  but  on  the  whole  takes  his  food  well.  Urine  limpid, 
containing  small  shreds,  wliich,  on  examination  with  the  microscope,  are  seen  to  be 
composed  of  numerous  pus-corpuscles  embedded  in  mucus ;  slightly  coagulable  on 
the  addition  of  heat  and  nitric  acid.  Pain  on  micturition  diminished."  From  this 
time  he  continued,  on  the  whole,  to  impi'ove  steadily,  and  was  so  well  during  the 
summer  of  1852,  as  to  walk  about  constantly  in  the  open  air,  aud  went  out  of  the 
house,  by  his  own  desire,  on  the  1st  of  the  following  August.  About  the  middle 
of  October,  however,  having  been  well  in  the  interval,  he  fell  down  and  injured  his 
back.  On  the  following  day,  he  experienced  rigors,  followed  by  febrile  symptoms, 
total  loss  of  appetite,  and  hematuria.  He  was  re-admitted  November  1,  when 
it  was  ascertained  that  considerable  quantities  of  pus  were  passed  with  the  urine, 
which,  he  says,  had  also  been  occasionally  tinged  with  blood.  There  was  pain  on 
micturition,  but  none  in  the  lumbar  region.  On  examining  the  left  lung,  loud 
gurgling  was  heard  both  with  inspiration  and  expiration,  extending  from  the 
clavicle  down  to  the  upper  margin  of  the  third  rib.  There  was  great  dulness  on 
percussion.  Below  the  clavicle,  loud  pectoriloquy,  and  lower  down,  cegophony. 
Under  the  right  clavicle  there  was  fine  moist  rale  on  inspiration,  and  increased  vocal 
resonance,  but  tlie  chest  expanded  well  on  this  side,  and  was  otherwise  normal. 
The  fever,  prostration,  and  discharge  of  pus  by  urine  continued  without  intermis- 
sion, and  he  died  December  4,  1852. 

Sectio  Cadet veris. — Forty  hours  after  death. 

Body  greatly  emaciated ;  the  right  carpal  bones  anchylosed,  with  marks  of  nume- 
rous old  sinuses  on  the  skin  in  their  neighbourhood. 


PHTHISIS   PULMOXALIS,  667 

Chest.— Plcui-fe  on  the  right  side  adherent  at  the  apex,  by  loose  bands  of  chronic 
lymph.  The  right  lung  indurated  at  the  apex  over  an  extent  the  size  of  a  lien's 
egg,  and  strongly  puckered  externally.  On  section,  this  hidurated  portion  was  seen 
to  contain  several  encysted  cretaceous  concretions,  with  the  intervening  pulmonary 
substance  condensed,  hard,  and  fibrous.  A  few  chronic  mOiary  tubercles  were  also 
scattered  through  the  upper  lobe ;  but  the  rest  of  the  lung  was  spongy,  crepitant, 
and  healthy.  The  pleura  on  the  left  side  were  everywhere  Bi-mly  adherent,  and 
over  the  superior  half  of  the  lung,  which  was  much  atrophied,  they  were  converted 
into  a  dense  white  librous  mass,  three-fourths  of  an  mch  thick,  which  gradually 
diminished  m  thickness  inferiorly.  The  left  lung  was  not  the  volume  of  the  closed 
fist ;  it  was  non-crepitant,  felt  indurated,  but  at  the  same  time  flaccid,  evidently 
from  mternal  cavities.  On  section,  the  entke  mass  was  riddled  with  cavities  more 
or  less  communicating  with  each  other,  containing  purulent  matter,  and  having  a 
smooth  lining  membrane.  Many  of  them  presented  a  pouch-like  form,  and  were 
identical  with  what  have  been  described  as  dilatations  of  the  bronchi  At  the  apex 
were  two  encysted  calcareous  concretions,  of  the  size  of  millet  seeds,  but  there  were 
no  other  traces  of  tubercular  deposits.  The  fibrous  structure  between  the  cavities 
consisted  of  a  close  dense  fibrous  texture,  of  bluish  colour,  from  pigmentary  deposits, 
in  which  no  remams  of  pulmonary  structure  could  be  found.  Tlie  bronchi  contained 
a  considerable  quantity  of  viscid,  muco-purulent  matter.  Heart,  larynx,  and  trachea 
healthy. 

Abuojiex. — The  large  intestines,  especially  tlie  coecum,  were  congested,  exhi- 
biting here  and  there  patches  of  slate-coloured  pigment,  with  traces  of  cicatrised 
ulcerations,  together  with  one  superficial  chronic  erosion  about  half  an  inch  in  dia- 
meter, of  irregular  form.  The  kidneys  were  of  natural  size,  and  on  section  displayed 
dilatation  of  the  pelves,  with  pouch-like  enlargements,  the  result  of  scrofulous 
abscesses,  filled  with  pus.  The  secreting  substance  was  everywhere  atrophied,  and 
the  tubular  substance  in  many  places  obliterated.  Mesenteric  glands  and  other 
organs  healthy. 

Microscopic  Ex.\iiiXATiox. — A  careful  microscopic  examination  of  the  luiing 
membrane  of  tlie  pulmonary  abscesses  exhibited  nothing  but  fibrous  tissue,  desti- 
tute of  epithelium.     There  was  nowhere  any  trace  of  a  mucous  surface. 

Commentary. — The  treatmeut  of  tliis  case  was  conducted  on  tlie  prin- 
ciples, and  according  to  the  rules  afterwards  to  be  detailed.  It  was 
directed  principally  to  improve  the  appetite,  diminish  the  nausea,  vomit- 
ino;,  and  diarrhoea,  and  support  the  streiigth  by  means  of  cod-liver  oil 
an"d  o-enerons  diet.  E.vternally,  repeated  blisters  were  applied.  During 
the  aUaek  of  febricula  and  variola,  antimonials  were  given  in  small  doses. 
Latterly  numerous  remedies  were  administered  to  lessen  the  pains  dur- 
ing micturition,  such  as  anodynes ;  uva  ursae  ;  bals.  copaiba? ;  diuretics, 
etc. ;  but  an  enema  of  starch  and  solution  of  morphia  succeeded  better 
than  anvthino-  else.  It  was  always  observed  that  in  proportion  as  the 
dyspeptic  svraptoms  were  relieved,  and  the  assimilation  of  cod-liver  oil 
aiid  food  took  place,  so  his  health  improved ;  and  by  great  care  he  Avas 
not  onlv  kept  alive  for  two  years,  but  I  had  sanguine  expectation  of  an 
ultimate  recovery,  when  he  met  with  the  accident  which,  by  e.vcitiug 
acute  disease  in  the  kidneys,  caused  his  death. 

This  case  presented  many  points  of  resemblance  to  that  of  Barclay 
(Case  CXLIV.),  especially  in  the  scrofulous  diathesis  and  scrofulous  caries 
of  the  bones,  and  the  cavity  under  one  clavicle  on  admission.  The  dis- 
eased lung  was  more  extensively  affected,  however,  and  the  derangement 


668  DISEASES   OF   THE   RESPIRATORY    SYSTEil, 

of  the  stomach  more  violent  and  persistent.  Indeed,  throughout  the  pro- 
gress of  his  case,  the  cliief  difficulty  in  the  treatment  was  the  management 
of  the  stomach  and  bowels.  The  cod-liver  oil  and  diet  did  not  pi'oduce 
the  same  marked  effect  as  in  the  case  of  Barclay,  but  their  operation, 
though  slow,  was  still  very  decided  ;  and  for  a  longtime  I  considered  that 
the  pulmonary  k^sion  in  this  lad  was  in  progress  of  cure,  exactly  in  the 
same  manner  as  took  place  in  Case  CXLIV.  The  dissection  alter  death 
demonstrated  that  in  fact  the  lung  was  undergoing  contraction,  and  that 
the  tubercular  disease  was  being  arrested.  It  presented  a  remarkable 
specimen  of  one  of  the  modes  in  which  this  is.  occasionally  accom- 
plished, namely,  by  the  formation  of  pouches  or  cavities,  the  lining  mem- 
branes of  which  become  smooth,  and  cease  to  exude  tubercle.  This  con- 
dition of  the  lung  has  been  described  by  morbid  anatomists  under  the 
name  of  dilated  bronchi,  and  by  Dr.  Corrigan,  as  cirrhosis  of  the  lung.* 
In  the  first  case  it  has  been  imagined  to  result  from  chronic  bronchitis, 
whereby  the  bronchi  are  dilated  from  within  ;  f  and  in  the  second,  from 
the  formation  of  fibrous  matters,  the  contraction  of  which  causes  this 
enlargement  from  without.  A  consideration  of  the  details  of  this  case, 
however,  must  convince  every  physician  that  we  had  here  to  do  with  large 
tubercular  excavations,  which,  by  compressing  the  lung,  had  obliterated  the 
Avhole  of  its  texture,  and  converted  it  into  a  contracted  fibrous  envelope 
of  these  excavations.  All  trace  of  tubercular  matter  had  disappeared, 
with  the  exception  of  two  small  cretaceous  concretions,  and  the  respira- 
tory function  was  entirely  carried  on  by  means  of  the  opposite  lung,  in 
which  chronic  tubercle  to  a  limited  extent,  and  very  latent,  was  found. 
"Whether,  under  such  circumstances,  the  pulmonary  lesion  would  ulti- 
matelv  have  healed,  it  is  difficult  to  say ;  but  there  can  be  no  doubt  he 
mioht  have  lived  a  long  time  in  this  condition  had  he  not  met  with  the 
accident  which  caused  his  death.  But  that  many  such  lesions  may  be 
arrested,  and  life  continue,  is  proved  by  the  observations  of  Reynaud,  who 
has  given  figures  of  what  he  calls  dilatations  of  the  bronchi,  many  of 
which  were  evidently  the  result  of  tubercular  ulceration.];  Cruveilhier  § 
has  also  figured  a  lung  presenting  similar  appearances. 

In  the  case  of  another  man,  called  Joseph  Finnic,  which  closely  resem- 
bled that  of  Finlay,  I  diagnosed,  during  life,  the  same  contraction  of  the 
hmg  from  tubercular  excavations,  and  the  same  chronic  dilatations  in 
connection  with  the  bronchi.  This  man  died  of  Bright's  disease  in  the 
Roval  Infirmary,  January,  1853  ;  and  on  dissection  a  similar  state  of  the 
pulmonary  texture  was  discovered,  with  the  exception  that  the  atrophy 
of  the  organ  was  not  so  great,  whilst  traces  of  tubercular  infiltration  were 
more  evident. 


Case  CXLTII.]! — Phthisis   Pulmonalis — Vomica  on   Right  Side — Death  from 

Hmnoptysis. 

HiSTOKY. — Walter  Cairns,  £et.  3.5,  stone-cutter — admitted  into  the  clinical  ward 

*  Dublin  Medical  Journal,  vol.  xiii.     1838.  f  Laennec,  vol.  i.  p.  201. 

X  Memoires  de  I'Academie  Royale  de  Medicine,  tome  4'"«,  Plate  4,  Fig.  1 ;  Plate 
5,  Fig.  1 ;  Plate  7,  Fig.  2. 

§  Anatomie  Pathologique,  Livraison  32,  Plate  5,  Fig.  3. 

II  Reported  by  Messrs.  Cunningham  and  Calder,  Clinical  Clerks. 


PHTHISIS  pul:moxalis.  669 

February  10,  1851.  On  the  25th  of  last  July  he  was  discharged  from  the  corps  of 
Sappers  and  Miners  at  Gibraltar,  in  consequence  of  chest  complaint.  Shortly  after, 
he  was  admitted  into  tlie  hospital  at  Woohvich  for  a  fistula  in  ano.  He  was  dis- 
charged in  March,  and  commenced  work  as  a  stone-cutter.  In  September,  cough  and 
expectoration  came  on — symptoms  which  have  been  gradually  increasing  until  now. 
Symptoms  ox  Admission*. — On  percussion,  tliere  is  complete  dulness  under  the 
right  clavicle,  extending  three  inches  downwards.  On  auscultation,  a  loud  mucous 
rale  is  lieard  in  this  situation,  with  bronchophony.  On  the  left  side,  inspiration  under 
clavicle  harsh,  and  expiration  prolonged.  Frequent  and  severe  cough,  with  purulent 
expectoration;  constant  pain  in  right  side  of  chest;  pulse  120,  small  and  weak; 
tongue  slightly  farred;  appetite  greatly  impaired;  vomiting  during  severe  fits  of 
coughing;  diarrhoea;  profuse  sweating  at  night.  He  is  thin,  but  not  emaciated. 
Fistula  in  ano  still  present. 

Progress  of  the  Case. — Towards  the  latter  part  of  February,  the  mucous  rale 
under  right  clavicle  was  changed  into  loud  gurgling,  and  the  bronchophony  into 
loud  pectoriloquy.  All  the  other  symptoms  continued.  During  March,  the  diarrhoea 
considerably  diminished,  but  the  cough  and  expectoration  increased  so  as  to  destroy 
rest  at  night.  During  April  and  May,  tlie  symptoms  were  stationary ;  towards  the 
end  of  the  latter  month,  it  was  observed  that  the  cough  was  not  so  severe,  but  that 
the  breathing  was  more  difficult.  The  dulness  on  percussion  had  extended  inferiorly, 
and  moist  rales  could  be  heard  over  the  whole  right  side,  increasing  in  coarseness 
from  below  upwards.  Increased  vocal  resonance  also  was  more  diflused,  with  strong 
fremitus.  On  the  oth  of  June,  diarrhoea  returned,  and  the  sputa  were  streaked  with 
blood.  On  the  ITth,  the  diarrhoea  had  abated,  but  he  experienced  great  pain  and 
annoyance  from  the  fistula  in  ano,  which  poured  forth  a  profuse  discharge.  On  the 
25th  three  or  four  ounces  of  pure  blood  were  expectorated.  Cracked-pot  sound  is 
distinctly  elicited  on  percussion  below  the  right  clavicle.  Fine  crepitation  may  also 
be  heard  during  inspiration,  under  left  clavicle,  with  increased  dulness  on  percussion. 
Choking  sensation  in  the  throat;  pain  in  epigastrium;  no  diarrhoea.  June  2Sth. — 
The  sputa  have  continued  to  be  mingled  with  blood,  and  occasionallj-  mouthfuls  of 
this  fluid,  quite  pure,  have  been  expectorated.  At  four  o'clock  this  morning,  he 
brought  up  10  oz.  of  blood,  mingled  with  a  matter  resembling  coffee  grounds,  appa- 
rently from  the  stomach.  Shortly  after,  about  16  oz.  of  florid  blood  gushed  from  his 
mouth,  when  he  sank  back  in  the  bed  and  expired. 

Cod-liver  oil  and  nutritious  diet  were  given  during  the  first  few  days,  but  the 
stomach  was  intolerant  of  it.  Afterwards,  the  diarrhoea  was  combated  by  various 
astringents,  such  as  opium,  acetate  of  lead,  tannin,  and  gallic  acid.  He  also  took,  at 
intervals,  quinine,  sulphuric  and  nitric  acids,  and  bitter  infusions.  In  May,  the  suf- 
focative cough  was  much  relieved  by  an  emetic  of  ipecacuanha  and  sulphate  of  zinc. 
The  local  pams  in  the  chest  were  greath^  relieved  by  the  occasional  application  of  a 
few  leeches  and  blisters.  During  the  two  first  attacks  of  hasmoptysis,  gallic  acid 
was  given  in  two  grain  doses  every  hour,  with  cold  a&usion  on  the  chest.  Latterly, 
the  vomiting  was  checked  by  a  mixture  of  naphtha,  Tr.  of  Cardamoms,  and  Inf. 
Calumbse. 

Sectlo  Cadaveris. — Thirty-two  hours  after  death. 

The  body,  though  thin,  was  not  greatly  emaciated,  there  being  three-eighths  of 
an  inch  of  fat  between  the  abdominal  integuments.  Lips  and  nostrils  stained  with 
blood  which  had  issued  from  the  nose. 

Thorax — Right  pleural  cavity  contained  about  six  oz.  of  fluid,  and  its  serous 
walls  were  united  by  strong  and  close  adhesions  over  the  upper  lobe  of  the  lung. 
The  left  pleurae  are  adherent  by  a  few  easily  torn  adliesions.     Both  lungs  present 


670  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

anteriorly  extensive  emphysema,  with  considerable  but  uniform  dilatation  of  the  air 
vesicles.  The  bronchi  on  both  sides  contained  bloody  frothy  fluid,  the  blood  pre- 
dominating on  the  right  side.  Right  Lung. — The  upper  and  a  considerable  part  of 
middle  lobe  much  diminished  in  volume  posteriorly  by  compression.  There  are 
several  irregular  cavities  in  the  summit,  the  largest  not  exceeding  the  size  of  a  wal- 
nut, with  indurated  walls.  The  lower  lobe  consists  of  emphysematous  and  con- 
densed tissue,  the  latter  containing  more  or  less  miliary  and  encysted  tubercles,  some 
of  the  latter  as  large  as  a  pea.  Scattered  throughout  the  inferior  lobe,  were  nume- 
rous extravasated  patches  of  blood,  varying  in  size  from  a  pin's  head  to  that  of  a  cot- 
fee-bean,  but  not  interfering  with  the  crepitation  of  the  lung.  Left  Lung. — Below 
the  pleura-costalis  were  numerous  miliary  tubercles,  scattered  over  the  whole  surfoce, 
but  aggregated  more  densely  towards  tlie  apex.  Here  and  there  were  some  yellow 
tubercular  masses  the  size  of  a  pea,  witli  pucl\erings  corresponding  to  them  on  the 
pleural  surface.  On  section  the  summit  of  tlie  organ  contained  small  miliary  tuber- 
cles. The  substance  of  the  inferior  lobe  contained  very  few  tubercles,  but  was  dense, 
less  crepitant  than  usual,  and  contained  some  of  the  sanguineous  patches  observed 
in  the  opposite  lung. 
Other  organs  healthy. 

Commentary. — This  was  a  case  of  chronic  phthisis,  whicli  on  dissec- 
tion presented  old  ulceration  on  one  side,  and  recent  tubercular  deposits 
on  the  other.  It  proved  latal  Ity  extensive  hemorrhage,  which  caused 
sinking  in  a  previously  debilitated  person.  The  fistula  in  ano  may  have 
contributed  to  the  weakness,  for  the  surgeons  who  were  consulted  refused 
to  interfere,  on  the  ground  that  the  operation  was  not  likely  to  be  suc- 
cessful in  a  phthisical  individual.  Death  from  htemoptysis  is  on  the 
whole  a  rare  termination  of  phthisis.  l)r.  Walshe  only  met  with  two 
in  131  cases,  and  I  believe  the  proportion  to  be  even  much  smaller  than 
this.  He  observes,  that  ^^  a  first  hemorrhage  having  been  severe,  \t  is 
unlikely  that  a  subsequent  one  will  kill  directly."  But  Cairns  had  three 
distinct  attacks  of  hemorrhage,  the  last  of  which  ims  directly  fatal. 

The  treatment  of  this  case  was  conducted  by  my  colleagues  for  four 
months  before  I  .saw  him,  on  the  palliative  plan ;  and  I  may  appeal  to 
the  facts  it  presents,  in  proof  that  such  treatment  produced  no  etfect  in 
any  way  checking  the  progress  of  the  disease.  In  this  respect  it  ofters  a 
marked  contrast  to  the  preceding  cases,  in  which  the  treatment  was 
directed  by  the  pathological  principles  to  be  afterwards  detailed,  and 
had  for  its  object  increasing  the  nutritive  jmivers  throiKjh  tlie  primoi  vice. 

Case  CXLVIIL* — Phthisis  Pulmonalis — Tivo  Vomicce  on  Bight  Side — Small  Cavi- 
ties on  Left  Side — Death  from  Exhaustion. 

History. — ilargaret  Moffat,  £et.  40,  a  washerwoman — was  admitted  into  the 
clinical  ward,  April  5th,  1851.  For  upwards  of  three  years  she  has  been  subject  to 
cough,  expectoration,  and  dyspnoea.  Three  weeks  ago,  after  exposure  to  wet  and 
cold,  she  was  attacked  with  severe  pain  in  the  right  side,  and  the  other  symptoms 
became  aggravated.     In  this  state  she  has  continued  until  admission. 

Symptoms  on  Admission. — The  report  say.s,  there  was  "  little  or  no  alteration  on 
percussion."  Over  the  part  complained  of  in  the  infra-mammary  region  there  were 
loud  friction  noises,  which  were  also  diffused  posteriorly  over  the  inferior  third  of 

*  Reported  by  Messrs.  Pearse  and  Hoile,  Clinical  Clerks. 


PHTHISIS   PULMOXALIS.  671 

right  lung.  Over  the  upper  portion  of  the  lung,  anteriorly,  were  dry  blowing  sounds, 
with  harsh  inspiration;  but  posteriorly,  crepitation  was  heard  over  the  apex.  Over 
the  left  back,  tine  moist  rattles  were  heard.  Sharp  acute  pain,  increased  on  inspira- 
tion, below  right  mamma ;  cough  troublesome,  witii  copious  expectoration  of  muco- 
purulent matter,  here  and  there  streaked  with  blood ;  considerable  dyspnoea.  Pulse 
frequent  and  soft ;  tongue  covered  with  a  brown  fur ;  loss  of  appetite ;  thirst ;  skin 
moist. 

Progress  of  the  Case. — The  pain  in  the  side  subsided  on  the  following  day,  after 
the  application  of  six  leeches;  but  she  complained,  during  April  and  May,  of  occa- 
sional return  of  the  pain,  and  was  particularly  distressed,  in  addition  to  her  other 
symptoms,  by  attacks  of  dyspnoea.  I  took  charge  of  this  case  in  the  middle  of  June, 
when  marked  dulness  was  ascertained  to  exist  over  the  upper  third  of  the  right  lung, 
both  anteriorly  and  posteriorly,  with  mucous  rale  and  increased  vocal  resonance ; 
and  on  tlie  left  side,  posteriorly,  there  was  still  crepitation.  Sputum  continued 
abundant,  consisting  of  purulent  matter  of  gelatinous  consistence.  Appetite  bad. 
Profuse  sweating  at  night.  These  signs  and  symptoms  underwent  veiy  little  varia- 
tion until  her  death,  on  the  30th  of  July.  The  treatment  consisted  at  first  of  leeches 
to  the  side,  expectorant  and  anodyne  mixtures,  with  an  aether  draught  at  night.  In 
May  she  was  ordered  |  ^'j.  of  wine  daily,  decoction  of  senega,  with  3  ss.  doses  of  Tr. 
lobel.  inflat.  Towards  the  end  of  the  month,  blisters  were  applied  externally,  and 
dilute  sulphuric  acid  given  internally,  in  doses  of  ten  drops.  In  the  middle  of  June, 
chalybeate  and  tonic  mixtures  were  ordered,  with  cod-liver  oil,  without  any  efiect  in 
restoring  the  appetite  or  renovating  the  nutritive  process. 

Sectio   Cadaveris. — Forty  hours  after  death. 

Body  greatly  emaciated. 

Thorax. — There  were  three  or  four  ounces  of  fluid  in  the  left  pleura.  Every- 
where firm  adhesions  between  the  pleurae  on  the  right  side.  At  the  apex  of  the 
rigiit  lung,  the  pleurfe  were  thickened  to  the  extent  of  an  inch,  by  the  formation  of 
a  dense,  white,  fibrous  structure.  Right  Lung.— There  were  two  cavities  at  the 
apex,  of  irregular  shape,  and  the  size  of  hens'  eggs.  Numerous  smaller  ones  ex- 
isted, scattered  throughout  the  lung.  The  pulmonary  tissue  was  almost  entirely 
non-crepitant,  dark  coloured,  atrophied,  and  indurated.  Inferiorly  there  were 
nodules  of  a  pink  fleshy  material,  which,  on  microscopic  examination,  were  found 
to  consist  of  fatty  degeneration,  and  were  composed  of  a  multitude  of  fatty  mole- 
cules and  granules,  with  compound  granular  corpuscles.  The  bronchial  glands  were 
much  enlarged,  several  of  them  indurated,  and  the  size  of  a  walnut.  Left  Lung 
was  mostly  crepitant,  but  contained  some  indurated  tissue,  surrounding  small 
cavities  at  the  apex,  the  largest  the  size  of  a  hazel-nut.  In  the  lower  lobe  pos- 
teriorly, there  was  some  oedematous  and  non-crepitant  tissue.  Bronchial  glands 
also  enlarged,  but  less  than  on  the  other  side. 

All  the  other  organs  health}'. 

Commentary. — This  must  have  been  a  very  chronic  case  of  phthisis, 
probably  of  much  longer  standing  than  she  stated  on  coming  into  the 
house.  '  The  rio-ht  hmg  was  universally  condensed,  contracted,  and 
nodules  of  the  tubercular  matter  itself,  mingled,  perliaps,  with  pneu- 
monic exudations,  had  passed  into  fatty  degeneration,  and  presented  a 
vcllow  pinkish  colour.  There  were  none  of  the  more  violent  symptoms 
of  derano-ed  digestive  action  in  this  case,  such  as  vomiting  or  diarrhoea; 
and  I  wo°uld  ag^iin  point  to  the  fact,  that  the  palliative  treatment  entirely 
failed  to  makeauy  impression  on  the  malady. 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


Case  CXLIX.^— Phthisic  PuhnonaUs— Large    Vomica  ivith  rneumo-Thorax{?)  on 
Left  Side— Softened  Tubercle  on  Eight  Side— Bright s  Disease. 

History.— James  Hutchison,  tet.  26,  a  stone-mason — admitted  into  the  cUnical 
ward  June  16th,  1851.  Last  September,  after  unusual  exposure  to  wet  and  stormy 
weather  while  prosecuting  his  occupation,  was  seized  with  distinct  rigors,  followed 
by  severe  pain  in  the  chest,  dyspnoea,  and  cough.  The  cough  and  pain  left  him  in 
Januar^v,  but  the  dyspnoea  has  continued.  About  the  end  of  last  March,  he  ob- 
served "oedema  of  the  legs,  and  tliat  the  urine  was  diminished  in  quantity,  and  was 
occasionally  high  coloured.     Tiiese  symptoms  have  continued  since. 

Symptoms  ox  Admission. — There  is  marked  dulness  on  percussion  over  the  left 
side  of  chest  anteriorly  and  posteriorly,  most  complete  inferiorly.  On  auscultation, 
the  respiratory  murmurs  are  absent  at  the  lower  two-thirds  of  left  lung ;  but  over 
the  superior  third  there  is  loud  gurgling,  both  anteriorly  and  posteriorly.  Tocal 
resonance  is  everywhere  increased,  but  over  the  apex  there  is  a  harsh,  braz.en, 
almost  metallic  sound,  on  coughing.  Posteriorly  and  inferiorly,  there  is  cegopliony. 
On  the  right  side,  there  is  dulness  in  the  subclavicular  and  supra-scapular  regions, 
with  crepitation  and  increased  vocal  resonance.  The  rest  of  the  lung  is  resonant, 
with  harsh  and  puerUe  respiration.  Cough  prolonged  and  reverberating ;  sputum 
scanty;  muco-purulent ;  pulse  72,  soft;  urine  diminished  in  quantit}-,  of  deep  red 
colour  sp.  gr.  1020,  highly  coagulable  by  heat,  and  on  the  addition  of  nitric  acid; 
great 'debility,  with  a  feeling  of  weakness  in  the  lumbar  region;  appetite  bad; 
thirst-  acid  taste  in  the  mouth;  nausea  after  taking  food;  bowels  loose,  but  no 
diarrhoea;  considerable  emaciation;  skuiantemic;  inferior  extremities  cedematous ; 
prepuce  and  scrotum  much  distended;  general  anasarca,  but  not  to  so  great  an 
extent  as  has  previously  existed. 

Progress  of  the  Case.— The  pulmonary  signs  and  symptoms  remained  the 
same,  but  under  the  action  of  the  digitalis  and  squill  pills,  and  a  chalybeate  mixture, 
with 'tonics  and  carminatives,  the  anasarca  greatly  diminished  in  ten  days.  The 
urine  also  became  clear,  but  retained  its  coagulability.  Vomiting,  however,  ap- 
peared ;  he  could  take  no  food,  and  the  general  weakness  increased.  He  insisted 
on  going  out,  though  in  a  dying  condition,  on  the  30//i  oj  June,  and  expued  a  few 
days  afterwards. 

Commentcmj. — The  extent  of  the  disease  in  this  case,  involving  the 
whole  of  one  Inng,  and  part  of  the  other,  together  with  the  extensive 
disoro-anization  which  induced  pneumo-thorax,  etc.,  was  in  itself  of  fatal 
auo-urv.  But  when  to  this  is  superadded  the  most  complete  prostra- 
tion derano-ement  of  the  digestive  system,  and  extensive  degeneration 
of  t'he  kidneys,  with  oedema  of  the  lower  extremities,  it  may  well  be 
supposed  that  the  case  admitted  of  nothing  but  palliatives.  These 
were  applied  to  the  relief  of  the  renal  symptoms,  and  had  partially 
succeeded  when  he  left  the  house. 

Case  Ch.\— Chronic  Phthisis— Enlarged  Liver — Albuminuria— Large  Excavation 
in  Left  Lung — Cicatrices  and  Induration  of  Bight  Lung — Waxy  Liver  and 
Kidneys — Tubercular  Ulceration  of  Intestines. 

History. — Margaret  Clark,  tet.  39— admitted  November  12th,  1844.     Slie  says 

*  Reported  by  Mr.  ^Y.  M.  Calder,  Clinical  Clerk. 
f  Reported  by  Mr.  Bum  Murdoch,  CUnical  Clerk. 


PHTHISIS   PULMONALIS.  673 

that  for  two  years  previous  to  admission  slie  was  labouring  under  frequent  attacks 
of  cough,  with  profuse  expectoration  and  spitting  of  blood.  During  this  period  she 
has  become  greatly  emaciated  and  very  wealv,  sweating  at  night,  with  occasional 
diarrhoea.     Catamenia  have  been  absent  during  the  last  three  months. 

Symptoms  0>f  Admissiox. — There  is  frequent  prolonged  cough,  often  causing 
vomiting,  with  copious  purulent  expectoration.  Marked  dulness  on  left  side  of 
chest,  with  loud  cracked-pot  resonance,  and  flattening  of  ribs  under  the  clavicle. 
Under  right  clavicle  dulness  also  evident,  but  resonance  good  over  the  rest  of  the 
lung.  On  auscultation  over  left  side,  loud  gurgling  is  audible,  with  pectoriloquy, 
extending  over  the  whole  anterior  surface,  but  diminishing  somewliat  towards  the 
base.  Under  right  clavicle  there  is  loud  mucous  rale  on  inspiration,  with  broncho- 
phony. Breath  sounds  inferiorly  normal.  Posteriorly,  the  physical  signs  are 
similar  to  those  in  front.  There  is  considerable  dyspnoea  on  exertion.  Heart 
sounds  normal.  Pulse  110,  feeble.  Total  loss  of  appetite  with  anorexia  and 
vomiting  after  taking  food.  Tongue  slightly  furred.  No  diarrhoea  at  present,  but 
says  she  is  very  subject  to  attacks  of  it.  Body  greatly  emaciated,  and  copious 
sweating  at  night.  Other  functions  normal.  $  Naphthce  Medicin.  3  j ;  Tr.  Card, 
comp.  5  j ;  Mist.  Camph.  f  v.  M.  A  sixth  part  to  be  taken  three  times  a  day.  Milk 
mixed  luith  an  equal  part  of  lime  tvater,  and  strong  beef  tea  ivith  toast,  to  be  taken 
frequently  in  small  quantities. 

Progress  of  the  Case — April  \&th. — From  the  time  of  her  admission  until  now 
the  physical  signs  have  remained  the  same,  with  the  exception  that  the  moist  rattles 
at  the  apex  of  right  lung  have  gradually  diminished,  and  have  now  nearly  disap- 
peared. At  each  catamenial  period  there  has  been  considerable  haemoptysis  con- 
tinuing several  days,  and  amounting  often  to  several  ounces  per  day.  Shortly  after 
admission  the  appetite  improved,  she  took  nutrients  with  §  iij  of  wine,  and  two 
and  sometimes  three  table-spoonfuls  of  cod-liver  oil  daily.  From  time  to  time  the 
latter  remedy  was  suspended,  and  bitter  vegetable  infusions  and  tinctures  adminis- 
tered, occasionally  mixed  with  chalybeates.  Every  now  and  then  an  attack  of 
diarrhoea  has  come  on,  which  has  been  restrained  by  chalk  mixture  and  astringents. 
Hence  she  has  been  alternately  better  and  worse  as  to  symptoms,  but  at  present  she 
is  decidedly  better  than  when  she  entered  the  house.  July  1th. — Since  last  report 
the  liver  has  been  observed  to  have  gradually  enlarged.  It  can  now  be  felt  extend- 
ing below  the  level  of  the  umbilicus  on  the  right  side,  presenting  a  rounded  margin 
and  forming  a  distinct  abdominal  tumour.  The  emaciation  is  extreme,  and  latterly 
there  has  been  considerable  vomiting  and  diarrhoea.  There  is  a  hectic  flush  on  the 
cheeks.  The  skin  is  warm ;  pulse  120,  feeble;  jarofuse  sweating  at  niglat ;  loud  gur- 
gling rales  still  audible  on  left  side  of  chest,  with  cracked-pot  sound  on  percussion, 
and  pectoriloquy.  On  right  side  there  is  loud  vocal  resonance  under  clavicle,  slight 
dulness  on  percussion,  and  dry  cavernous  or  hoarse  tubular  breathing.  Cough  still 
troublesome,  especially  at  night.  Sputum  purulent  and  copious,  occasionally  tinged 
with  blood.  For  the  last  few  days  has  passed  little  urine,  which  Is  albuminous,  and 
the  feet  are  slightly  oedematous.  To  have  §  ij  of  gin  instead  of  wine.  5  "Si?',  ^ther. 
Nit.  §ss;  Tr.  Digitalis  3ij;  Mist.  Scilloe  c.  ad  ?vj.  M.  One  table-spoonfid  to  be 
taken  three  times  a  day.  July  2Uh. — Urine  still  highly  albuminous  and  scanty, 
though  diuretics  have  been  freely  given,  including  supertartrate  of  potass.  Liver 
now  much  larger,  and  extends  down  to  Poupart's  ligament  when  she  sits  up. 
(Edema  has  extended  above  the  knee.  AYeakness  has  increased.  August  IQth  — 
Has  continued  in  the  same  exhausted  condition,  every  care  having  been  taken  to 
support  her  strength  by  small  quantities  of  nutritious  food.  She  has  experienced 
little  pain,  and  latterly  obtained  sleep  at  night  by  tether  and  morphia  draughts.  At 
4  am.  this  morning,  respiration  became  very  ditKcult,  and  shortly  after  she  died. 

43 


674:  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Sectio  Cadaveris. —  Thirty-one  hours  after  death. 

Body  greatly  emaciated. 

Thorax. — Both  pleurae  strongly  adherent  throughout  by  chronic  adiiesions. 
Apices  of  both  lungs  much  puckered  externally.  The  whole  of  the  superior  lobe  of 
left  lung  hollowed  out  so  as  to  form  a  cavern  the"  size  of  a  large  cocoa-nut,  contain- 
ing foetid  air  and  about  four  ounces  of  dirty  pus.  Its  walls  were  lined  by  a  distinct 
pyogenic  membrane,  and  consisted  externally  only  of  thickened  pleura,  and  inter- 
nally of  a  layer  of  indurated  lung  about  half  an  inch  in  thickness.  In  the  inferior 
lobe  were  several  masses  of  infiltrated  tubercle,  which  in  some  places  were  softened, 
forming  small  purulent  collections,  varying  in  size  from  a  pea  to  that  of  a  hazel  nut. 
Throughout  the  upper  lobe  of  right  lung  there  were  a  few  excavations,  quite  drj% 
varying  in  size  from  a  millet  seed  to  that  of  a  small  nut.  The  parenchyma  between 
these  was  much  indurated  by  chronic  pneumonia,  and  of  an  iron-grey  colour  from 
pigmentary  deposits.  At  the  apex  were  several  cretaceous  concretions  about  the 
size  of  peas.  One  of  these  was  the  size  of  an  almond  nut,  and  elongated  in  form, 
and  all  were  enclosed  in  indurated  capsules.  The  two  inferior  lobes  were  emphyse- 
matous anteriorl3^  In  the  centre  of  the  lowest  one  was  an  indurated  white  patch, 
the  size  of  half-a-crown,  with  radii  stretching  from  it  in  all  directions.  On  cutting 
through  it,  it  was  seen  to  consist  externally  of  dense  white  fibrous  tissue,  an  eighth 
of  an  inch  in  thickness,  and  immediatel}-  below  it  was  a  mass  of  indurated  tubercle, 
the  size  of  a  hazel  nut,  of  iron-gre}-  colour,  containing  gritty  points  of  cretaceous 
matter.  Other  similar  masses  of  varying  size,  but  widely  .scattered,  gave  a  nodulated 
feel  to  the  two  inferior  lobes  on  this  side.     Heart  healthy. 

Abdomex. — The  liver  was  not  only  enlarged,  but  altered  greatly  in  shape.  The 
right  lobe  was  so  elongated  as  to  extend  down  to  the  crest  of  the  ilium.  The 
length  from  above  downwards  was  12  inches ;  breadth,  8  inches.  Length  of  left  lobe 
was  8  inches ;  breadth,  5  inches.  Its  entire  weight  was  Tibs.  9  oz.  The  greatest 
thickness  of  the  organ  from  behind  forwards  was  four  inches.  In  texture  it  was  of 
waxj'  consistence  and  appearance,  of  a  dirty  yellow  colour,  dense  feel,  smooth  sec- 
tion, presenting  semi-translucent  edges.  The  s/^fceft  weighed  7oz.  odr.,  and  was 
healthy.  The  mucous  membrane  of  the  coecum  was  of  a  black  tint,  which  extended 
up  the  ascending  and  half  way  across  the  transverse  colon,  gradually  diminishing  in 
intensity.  This  discoloured  portion  of  the  membrane  was  studded  over  with  chronic 
tubercular  ulcers  in  various  stages  of  healing,  mingled  with  numerous  cicatrices  and  . 
puckerings.  The  largest  of  the  open  ulcers  were  the  size  of  a  siiilling,  with  irregular 
raised  edges,  and  dirty  yellowish  base.  Mesenteric  glands  everywhere  enlarged,  of  a 
wliite  colour  and  indurated ;  some  contained  tubercular  deposits.  Both  kidneys 
waxy ;  externally  pale,  indurated,  and  rough ;  internally,  cortical  substance  atro- 
phied, pale,  and  on  section  having  translucent  edges.  The  uterus  contained  in  its 
inferior  wall  a  fibrous  tumour  the  size  of  a  walnut.  Three  others  the  size  of  peas 
were  on  its  anterior  surface ;  ovaries  contracted,  rugose,  and  of  semi-cartilaginous 
consi.?tence.     Other  organs  healthy. 

Microscopic  Ex.\iiiN"ATiox. — The  tubercle  everywhere  presented  its  usual  cha- 
racters. The  cells  of  the  liver  had  undergone  a  remai'kable  change,  being  colourless, 
refracting  light,  deprived  of  nuclei,  and  forming,  when  compressed  together,  a  trans- 
lucent, amorphous  mas.s.  The  black  matter  in  the  coecum  was  composed  of  mole- 
cules and  irregular  masses  of  black  pigment. 

Commentary. — This  case  of  chronic  phthisis,  which  we  watched  for 
nine  months,  appeared  to  be  on  the  point  of  death  when  she  entered  the 
Tiifinnarv.     The  prostration  was  extreme,  and  an  enormous  excavation 


PHTHISIS   PULMONALIS.  675 

even  then  existed  in  the  left,  with  smaller  ones  in  the  right  Inng,  Care- 
ful treatment  directed  to  restore  the  tone  of  the  stomach,  nutrients 
administered  in  small  quantities,  with  wine  and  cod-liver  oil,  caused  a 
gradual  restoration,  and  my  opinion  is,  that  from  that  time  tlie  pulmo- 
nary disease  continued  to  diminish.  The  cavities  on  the  right  side 
became  dry,  cicatrices  and  ci'etaceous  transformations  of  tlie  tubercular 
matter  proceeded,  and  the  large  excavation  on  the  left  side  became 
smaller  and  more  circumscribed.  The  liver  first,  and  then  the  kidneys, 
next  underwent  the  waxy  transformation  ;  oedema  came  on  and  she  sunk. 
I  have  already  alluded  to  the  peculiar  character  of  this  degeneration  of 
the  liver  and  kidney  (p.  214).  It  is  exceedingly  common  in  phthisical 
cases,  and  in  this  instance  was  recognised  and  examined  histologically 
with  great  care  in  1845.  Formerly  it  was  confounded  with  fatty  dege- 
neration, and  it  has  been  supposed  that  cod-liver  oil  tends  to  its  produc- 
tion. But  a  knowledge  of  the  true  nature  of  the  waxy  degeneration  nmst 
negative  such  a  supposition,  as  the  liver  is  altogether  free  from  fat.  The 
interruption  to  the  portal  and  renal  circulations,  and  the  diminished  flow 
of  urine,  produced  more  or  less  anasarca,  a  complication  which  sooner  or 
later  is  uniformly  fatal. 

The  foregoing  series  of  cases  illustrate  tolerably  well  the  advantages 
which  attend  what  may  be  denominated  a  curative,  as  distinguished 
from  a  palliative,  treatment  of  phthisis.  It  is  exceedingly  rare,  however, 
that  we  can  demonstrate  among  hospital  cases  a  complete  cure  of  the 
disease  in  its  advanced  stage,  such  as  took  place  in  Barclay.  (Case 
CXLIV.)  In  the  majority  of  instances,  no  sooner  is  amendment  effected, 
than  they  insist  on  going-  out.  A  few  return  with  the  disease  advanced, 
again  get  better,  and  so  on,  until  at  length  they  die.  Many  others,  I  am 
satisfied,  get  permanently  well.  In  private  cases,  however,  recovery  is 
much  more  frequently  observed ;  and  now  that  physical  diagnosis  has 
enabled  us  with  great  certainty  to  recognise  the  disease  and  follow  its 
progress,  we  can  have  no  doubt  of  the  superior  advantages  of  a  curative 
over  a  palliative  practice.  To  carry  out  the  former,  however,  upon  cor- 
rect principles,  it  is  proper  to.  have  a  knowledge — 1st,  Of  the  natural 
progress  of  the  disease  ;  2d,  Of  its  pathology  and  general  treatment;  and 
3d,  Of  the  special  treatment,  in  reference  to  symptoms  and  complica- 
tions. It  may  be  well  to  make  a  few  observations  on  each  of  these 
heads. 


I. —  On  the  Natural  Progress  of  Phthisis  Puhnonalis — The  Tendency  to 
Ulceration — The  Modes  of  Arrestment. 

At  first  tubercle  is  deposited  in  the  state  of  a  fluid  exudation  from  the 
capillaries  in  the  same  manner  that  lymph  is.  In  this  condition  it 
insinuates  itself  into  the  interstices  of  the  pulmonary  parenchyma,  passes 
through  the  lining  membrane  of  the  air  vesicles,  and  fills  their  interior. 
Numerous  successful  injections  of  pneumonic,  tubercular,  and  cancerous 
lungs,  in  my  possession,  demonstrate  that  the  exudation  in  all  is  poured 
out  in  the  same  manner,,  and  occupies  the  same  position  in  the  pul- 
monary texture.     A  miliary  tubtn-cle  may,  in  this  manner,   block  up 


676 


DISEASES  OF   THE   RESPIRATORY  SYSTEM. 


from  three  to  twent}^  of  these  air  vesicles,  (Figs,  135,  130.)  It  now 
coagulates  and  constitutes  a  foi'cig-n  soli<l  body,  which  can  only  be 
removed  by  being  again  broken  down   and  rendered  capable  of  being 


l/jg.} 


either  absorbed  or  excreted.  Thus  the  miliary  or  infiltrated  forms, 
■whether  grey  or  yellow,  after  a  time  soften, — a  process  wbicli  may  com- 
mence at  any  part  of  the  mass  and  gradually  affect  the  whole.     This 


Fig.  433.  Section  of  a  lung  in  the  first  stage  of  Phthisis  Pulmonalis.     Ulcerative 
softening  is  commencing  at  the  apex.  Two-tldrds  the  real  size. 


PHTHISIS   PULMONALIS. 


677 


softeniniTf  is  a  disinteGfration  or  slow  death  of  the  tubercular  exudation, 
coustituting-  true  ulceration,  which  is  more  or  less  extensive  according  to 
the  amount  and  extent  of  the  morbid  deposit.     (Figs,  433,  434,  and 


Fi2.  434. 


435.)      "When   recent,   the  pulmonary  parenchyma   in   the   immediate 
neighbourhood  is  more   or  less  congested ;    and  when    chronic,   it  is 


Fig.  434.  Section  of  a  lung  in  the  second  stage  of  Phthisis  Pulmonahs.     Tubercle 
is  extensively  infiltrated  in  the  upper  lobe,  and  a  considerable  cavity  has  formed. 

Two-thirds  the  real  size. 


678 


DISEASES   OF   THE   RESPIRATORY   SYSTEM, 


thickened  and  indurated,  often  forming  a  capsule  which  surrounds  the 
tubercular  deposit.  The  pleura  also  is  very  liable  to  be  afiected  ;  when 
recently  so,  presenting  soft  fibrinous  exudations  with  more  or  less  adhe- 


Fig.  435. 


sion  ;  whereas  when  chronic,  these  become  fibrous  and  reach  a  thickness 
and  density  seldom  seen  in  other  diseases.     The  bronchi  are  necessarily 


Fig.  435.  Section  of  a  lung  in  the  third  stage  of  Phthisis  Pulmonalis.  A  cavity 
occupies  the  superior  half  of  the  organ,  and  another  smaller  one  has  formed  in  the 
inferior  lobe.  Two-thirds  the  real  size. 


PHTHISIS   PULMOXALIS.  679 

involved  ;  their  terniinal  extremities  are  among  the  first  structures 
aflFected ;  and  as  the  tuberculosis  proceeds,  all  the  appearances  charac- 
teristic of  chronic  broncliitis  are  produced.  As  tlie  ulcerative  process 
extends,  the  hing  is  more  and  more  destroyed,  the  excavations  become 
larger  and  more  numerous  (Figs.  434,  435),  until  at  length  it  can  no 
lono-er  carry  on  its  iu)portant  functions,  and  the  patient  dies,  or  the  fatal 
resuh,  as  very  commonly  happens,  is  hastened  by  disease  in  other 
organs. 

The  ulcerative  or  destructive  tendency  of  the  tubercular  exudation 
has  generally  been  supposed  to  be  its  chief  chaiacteristic  ;  but  thei-e  are 
verv  few  cases  in  which  its  progress  is  uniform.  It  is  continually 
checked,  and  for  a  time  slumbers ;  and  all  morbid  anatomists  have  recog- 
nised, even  in  the  worst  specimens  of  tubercular  lungs,  numerous  cica- 
trices and  evidences  of  attempts  to  heal.  These  attempts  are  more  or 
less  perfect,  and  when  ineffectual,  it  is  owing  to  the  circumstance  that  as 
one  portion  of  lung  cicatrizes,  another  becomes  the  seat  of  recent 
tubercle. 

Cicatrices  present  different  appearances,  according  as  the  cavities 
from  which  they  wei-e  formed  have  been  superficial  or  deep  seated.  In 
the  first  case  it  will  generally  be  observed  that  the  pleurse  are  more  or 
less  adherent  and  thickened,  and  this  frequently  forms  an  external  boun- 
daiy  to  the  tubercular  cavity.  As  the  matters  which  the  cavity  contains 
are  expectorated  or  transformed,  the  lymph  gradually  contracts,  and  draws 
the  lung  closely  to  the  thoracic  walls,  from  which  it  cannot  be  sepai-ated 
without  great  violence.  Sometimes,  however,  it  is  deeper,  and  the  adhe- 
sion is  very  slight  or  does  not  exist.  In  this  case,  when  the  walls  of  the 
cavern  contract,  the  pleui-al  surface  of  the  lung  is  drawn  inwards,  and  in 
this  way  the  irregular  puckerings  visible  on  the  suiface  are  produced. 

Occasionally  no  traces  of  tubercular  matter  are  discovered  either 
within  or  in  the  vicinity  of  these  cicatrices.  Under  such  circumstances 
thev  appear  to  be  formed  of  dense  fibrous  tissue,  and  the  paienchy- 
matous  substance  in  their  vicinity  is  of  a  bluish-black  colour,  trom 
increased  pigmentary  deposit,  and  of  peculiar  induration  and  density, 
owing  to  chronic  exudation.  More  generally,  however,  the  contraction 
and  puckering  will  be  found  to  have  occui-i-ed  around  tubercle  which  has 
uudero-one  various  ti'ansformations.  Occasionally  there  are  round 
masses  of  crude  tubercle  surrounded  by  a  cyst.  They  are  of  unusual 
densitv,  still  of  a  yellowish  colour ;  but  contain  granules  of  earthy  salts 
more  or  less  numerous.  Often  they  are  white  and  friable,  resembling 
chalky  matter.  In  this  state  the  soft  portions  have  been  apparently 
absorbed,  and  the  whole  consists,  under  the  microscope,  of  irregular 
masses  of  earthy  matter,  mixed  with  numerous  granules  and  crystals  of 
cholesterine.  At  other  times  the  whole  has  been  converted  into  a  solid 
calcareous  mass,  frequently  round,  or  occasionally  with  numerous  pro- 
lonoations  and  irregularities,  Avhich  accurately  fit  the  surface  and  bronchi 
with  which  they  are  in  contact.  These  cretaceous  and  calcareous  con- 
cretions may  remain  an  indefinite  time  in  the  parenchymatous  substance 
of  the  lungs,  or  they  may  be  evacuated  through  the  bronchi  with  the 
sputa.     The  cyst  which  incloses  them  then  forms  a  dense  linear  cicatrix. 

Such  appear  to  be  the  usual  modes  in  which  tubercular  ulcers  heal. 
They  occur  in  exactly  the  same  manner  as  abscesses  in  other  parenchy- 


680 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


matous  tissues,  the  result  of  simple  exudation  ;  and  that  the  process  in 
both  is  identical,  is  proved  by  the  frequency  with  which  in  the  latter 
calcareous  deposits  also  take  place.  If,  then,  the  further  deposition  of 
tubercle  could  be  arrested,  there  seems  no  reason  why  cavities  in  the 
lung  should  not  heal  with  the  same  frequency  as  ulcerations  or  abscesses 
in  other  internal  organs.  Indeed,  the  careful  dissections  of  morbid 
anatomists  have  recently  shown  that  this  arrestment,  instead  of  being  a 
rare  or  occasional  occurrence,  really  happens  with  extreme  frequency. 
In  1845,  I  made  a  series  of  observations  with  reference  to  the  cretaceous 
masses  and  puckerings  so  frequently  observed  at  the  apices  of  the  lungs 
in  persons  advanced  in  life.  The  conclusion  arrived  at  was,  that  the 
spontaneous  arrestment  of  tubercle  in  its  early  stage  occurred  in  the 
proportion  of  from  one-third  to  one-half  of  all  the  individuals  who  die 
after  the  age  of  forty.  The  observations  of  Rogee  and  Boudet,  made  at 
the  Satpetriere  Hospital  in  Paris,  amongst  individuals  generally  above 
the  age  of  seventy,  showed  the  proportion  in  such  persons  to  be  respec- 
tively one-half  and  four-fifths. 

That  the  cretaceous  and  calcareous  concretions,  accompanied  with 
puckerings,  are  really  evidences  of  abortive  tubercles,  is  established  by 
the  following  facts  : — 

1.  A  form  of  indurated  and  circumscribed  tubercle  is  frequently  met 


Fig.  486. 

with,  gritty  to  the  feel,  wliich,  on  being  dried,  closely  resembles  creta- 
ceous concretions. 

Fig.  436.  Section  of  the  summit  of  the  right  lung,  exhibiting  the  cretaceous 
masses,  more  or  less  loaded  with  and  surrounded  by  carbonaceous  deposit.  Many 
air  vesicles  are  enlarged,  constituting  incipient  emphysema.  The  preparation  now  in 
my  possession  exhibits  a  characteristic  specimen  of  the  mode  in  whicii  a  considerable 
amount  of  tubercular  exudation  is  arrested  by  calcareous  degeneration. 

Natural  size. 


PHTHISIS   PULMOXALIS.  681 

2.  These  concretions  are  found  exactly  in  the  same  situations  as 
tubercle.  Thus  they  are  most  common  in  the  apex,  and  in  both  lungs. 
They  tVcquentlv  occur  in  the  bronchial,  mesenteric,  and  other  lymphatic 
glands,  and  in  the  psoas  muscles,  or  other  textures  which  have  been  the 
seat  of  tubercular  depositions,  or  scrofulous  abscesses. 

3.  When  a  lung  is  the  seat  of  tubercular  infiltration  throughout, 
whilst  recent  tubercle  occupies  the  inferior  portion,  and  older  tubercle, 
and  perhaps  caverns,  the  superior,  the  cretaceous  and  calcareous  concre- 
tions will  be  found  at  the  apex. 

4.  A  comparison  of  the  opposite  lungs  will  frequently  show,  that 
whilst  on  one  side  there  is  firm  encysted  tubercle,  partly  transformed 
into  cretaceous  matter,  on  the  other  the  transformation  is  perfect,  and 
has  occasionally  even  passed  into  a  calcareous  substance  of  stony  hard- 
ness. 

5.  The  seat  of  cicatrices  admits  of  the  same  exceptions  as  the  seat  of 
tubercles.  In  one  case,  I  have  found  the  puckering  and  cicatrix  in  the 
inferior  lobe  only  ;  and  have  met  with  three  cases  where  the  inferior 
lobe  was  throughout  densely  infiltrated  with  tubercle,  whilst  the  superior 
was  onlv  slightly  atfected. 

It  has  indeed  been  argued,  that  occasionally  these  cretaceous  masses 
may  be  the  result  of  a  simple  exudation.  "When  they  are  found  isolated 
in  the  middle  or  base  of  the  organ,  such  certainly  may  be  the  case,  and 
consequently  the  fifth  argument  may  be  atfected.  But  this  is  rare,  and 
can  scarcely  make  any  alteration  in  the  vast  proportion  of  those  concre- 
tions and  puckerings  which  are  undoubtedly  the  result  of  abortive 
tubercles.  With  these  facts  before  us,  and  with  the  knowledge  that 
there  is  nothing  in  the  nature  of  tubercle  itself  which  is  opposed  to  the 
evidence  of  these  anatomical  facts,  the  frequent  spontaneous  cuie  of 
tubercle  may  now  be  considered  established. 

Since  these  observations,  however,  have  become  known,  it  has  been 
stated  that  after  all,  practically  speaking,  phthisis  pulmonalis  docs  not 
mean  the  existence  of  a  few  isolated  tubercles  scattered  through  the 
hmfj,  and  that  what  is  really  meant,  is  that  advanced  stage  in  which 
the  lung  is  affected  with  ulceration,  and  in  which  the  bodily  powders  are 
so  lowered  that  perfect  recovery  seldom  or  never  takes  place.  But  here 
again  a  careful  examination  of  the  records  of  medicine  will  show  that 
many  even  of  these  advanced  cases  have  recovered.  Laennec,  Andral, 
Cruveilhier,  Kingston,  Pressat,  Rogee,  Boudet,  and  others,  have  pub- 
lished cases  where  all  the  functional  symptoms  and  physical  signs  of  the 
disease,  even  in  its  most  advanced  stage,  were  present,  and  yet  where  the 
individual  survived  many  years,  ultimately  died  of  some  other  disorder, 
and  on  dissection  cicatrices  and  concretions  were  found  in  the  lungs. 

I  here  show  you  a  preparation,  exhibiting  a  remarkable  cicatrix  in  the 
luno-,  which  I  described  and  figured  in  the  "Monthly  Journal''  for 
March  1850.     As  it  is  short,  I  may  quote  it : — 


682 


DISEASES    OF   THE   KESPIEATORY   SYSTEM. 


Case  CLI. — Advanced  Phthisis — ReMoration  to  Health — Death  many  years  afterivards 
from  Delirium  Tremens — On  Dissection,  a  Cicatrix,  three  inches  long,  in  A2}ex  of 
Right  Lung,  and  Cretaceous  Concretions,  with  puckering  at  the  Summit  of  Left 
Lung. 

"John  Keith,  set.  50,  a  teacher  of  languages,  was  admitted  into  the  Eoyal  Infir- 
mary, February  8,  1844,  in  a  state  of  coma,  and  died  an  hour  afterwards.  On  exa- 
mination, the  membranes  of  the  brain,  at  the  base,  were  unusually  congested,  and 


covered  with  a  considerable  exudation  of  recently  coagulated  l.ymph,  here  and  there 
mingled  with  bloody  extravasation.  The  apex  of  the  right  lung  presented  a 
remarkable  cicatrix,  consisting  of  dense  white  fibrous  tissue,  varying  in  breadth 

Fig.  437.  The  section  of  the  upper  portion  of  lung  in  Keith's  case  seen  from  within, 
the  apex  having  been  left  entire  to  sliow  the  deep  puckerings  which  covered  its  sur- 
face. The  line  of  the  healed  cavity  is  densely  loaded  with  black  carbonaceous  depo- 
sit, in  which  are  seen  five  cretaceous  concretions,  three  of  them  encysted.  This  pre- 
par-Ttion,  now  in  my  possession,  is  perhaps  a  unique  specimen,  proving  the  healing, 
by  cicatrization,  of  an  enormous  tubercular  excavation  in  the  lung.  Natural  size. 


PHTHISIS   PULMOXALIS.  683 

from  one-fourth  to  three-fourths  of  an  inch,  and  measuring  about  three  inches  in 
length.  The  pleural  surface  in  its  neighbourhood  was  considerably  puckered.  On 
making  a  section  through  the  lung,  parallel  with  the  external  cicatrix,  tlie  siibstance 
immediately  below  presented  linear  indurations,  of  a  black  colour,  together  with  five 
cretaceous  concretions,  varying  in  size  from  a  pin's  head  to  that  of  a  large  pea. 
The  surrounding  pulmonary  substance  was  healthy  (Fig.  437).  The  apex  of  the 
left  lung  was  also  strongly  puckered,  and  contained  six  or  seven  cretaceous  concre- 
tions each  surrounded  by  a  black,  dense,  fibrous  cyst. 

"  A  very  respectable-looking  and  intelligent  man,  who  attended  the  post-mortem 
examination,  informed  me  that  Keith,  in  early  life,  was  in  very  indifferent  ch-cum- 
stances,  and  had  supported  himself  as  a  writer's  clerk.  At  the  age  of  two-and- 
twenty  or  three-and-twenty,  he  laboured  under  all  the  symptoms  of  a  deep  decliue, 
and  his  life  was  despaired  of  About  this  time,  however,  he  was  lost  sight  of  by 
his  friends ;  but  it  was  afterwards  ascertained  that  he  had  become  a  parish  school- 
master in  the  west  of  Scotland,  and  that  his  health  had  been  re-established.  He 
returned  to  Edinburgh  six  years  before  his  death,  and  endeavoured  to  gain  a  liveli- 
hood by  teaching  Latin  and  French.  He  succeeded  but  very  imperfectly,  and  fell 
into  dissipated  habits.  Latterly  he  had  become  subject  to  attacks  of  mania,  appa- 
rently the  result  of  drink.  It  was  after  an  unusually  severe  attack  of  this  kind 
that  he  was  brought  into  the  Infirmary,  where  he  died  in  the  manner  previously 
described." 

This  case  points  otit  tl;e  following  important  facts, — 1st,  That,  at  the 
ao-e  of  twentv-two  or  twenty-three,  the  patient  had  had  a  tubercular 
uTcer  in  the  right  lung,  the  size  of  which  must  have  been  very  consider- 
able when  the  contracted  cicatrix  alone  was  three  inches  long.  2d, 
That  tubercular  exudations  existed  in  the  apex  of  the  left  lung.  It  is, 
therefore,  very  probable  that  the  statement  made  by  his  friend  at  the 
examination  was  correct — namely,  that,  when  young,  he  laboured  under 
all  the  symptoms  of  advanced  phthisis  pulmonalis.  It  is  shown,  3dly, 
That  after  receiving  the  appointment  of  a  parish  schoolmaster,  after 
changing  his  residtmce  and  occupation,  while  his  social  condition  was 
greatTy  miproved,  these  symptoms  disappeared.  We  may  consequently 
^nfer,  that  it  was  about  this  period  that  the  excavation  on  the  right  side 
healed  and  cicatrized,  while  the  tubercular  exudations  on  the  left  side 
Avere  converted  into  cretaceous  masses,  and  so  rendered  abortive.  It 
demonstrates,  4thly,  That  when,  at  a  more  advanced  age,  he  again  fell 
into  bad  circumstances,  and  even  became  a  drunkard,  tubercular  exuda- 
tions did  not  return,  but  that  delirium  tremens  was  induced,  with  simple 
exudation  on  the  membranes  of  the  brain,  of  which  he  died. 

Although  the  curability  of  phthisis  pulmonalis,  even  in  its  most 
advanced  "stage,  can  now  no  longer  be  denied,  it  has  been  argued  that 
this  is  entirely  owing  to  the  operations  of  nature,  and  that  the  physician 
can  lav  little  claim  to  the  result.  Andral,  who  early  admitted  the  occa- 
sional" citatrization  of  caverns,  states  this  in  the  following  words:— 
"Xo  fact,"  he  says,  "demonstrates  that  phthisis  has  been  ever  cured, 
for  it  is  not  art  which  operates  in  the  cicatrization  of  caverns ;  it  can  at 
most  onlv  favour  this,  by  not  opposing  the  operations  of  nature.  For 
ages  remedies  have  been  sought  either  to  combat  the  disposition  to 
tiTbercles,  or  to  destroy  them  when  formed,  and  thus  innumerable  spe- 
cifics have  been   employed   and  abandoned  in  turn,  and  chosen  from 


684  DISEASES  OF  THE   EESPIRATORY   SYSTEM. 

every  class  of  medicaments."*  But  if  it  he  true,  according  to  Hoffman, 
that  '■'■  Medicns  naturce  minister  non  macjister  est,''^  it  follows  that  by  care- 
fully observing-  the  operations  of  nature,  learning  her  method  of  cure, 
imitating  it  as  closely  as  possible,  avoiding  what  she  points  out  to  be 
injurious,  and  furnishing  what  she  evidently  requires,  we  may  at  length 
arrive  at  rational  indications  of  treatment.  The  cases  both  of  Keith  and 
Barclay,  in  mv  opinion,  furnish  evidence  that  we  have  in  a  great 
measure  attained  this  end ;  and  this  leads  me  to  speak,  in  the  second 
place,  of 

II. —  The  Paiholony  and  General  Treaiment  of  Phthisis  Pulmoncdis. 

Many  observant  physicians  have  not  failed  to  notice,  that  phthisis 
pulmonalis  is  ushered  in  with  a  bad  and  capricious  appetite,  a  furred  or 
morbidly  clean  tongue,  unusual  acidity  of  the  stomach  and  alimentary 
canal,  anorexia,  constipation  altei'nating  with  diarrhoea,  and  a  variety  of 
symptoms  denominated  dyspeptic,  or  referable  to  a  deranged  state  of  the 
primtTe  vise.  Moreover,  it  can  scarcely  be  denied  that,  in  the  great  major- 
ity of  cases,  these  are  the  symptoms  which  accompany  phthisis  through- 
out its  progress,  becoming  more  and  more  violent  towards  its  termination. 
Xow,  as  the  nutritive  properties  of  the  blood  are  entirely  dependent  on 
a  proper  assimilation  of  food,  and  as  this  assimilation  must  be  interfered 
with  in  the  morbid  conditions  of  the  alimentary  canal,  the  continuance 
of  such  conditions  necessarily  induces  an  impoverished  state  of  that  fluid, 
and  imperfect  growth  of  the  tissues.  Moreover,  when,  under  such 
circumstances,  exudations  occur,  it  has  been  shown  by  the  histologist 
that  they  do  not  exhibit  any  tendency  to  perfect  cell  formations,  but  that 
corpuscles  are  produced,  which  form  slowly,  and,  slowly  breaking  down, 
cause  softening  and  ulceration,  which  becomes  more  and  more  extensive 
as  the  amount  of  the  exudation  increases. 

An  observation  of  the  circumstances  which  precede  the  disease,  or  its 
so-called  causes,  clearly  indicates  imperfect  digestion  and  assimilation  as 
its  true  origin.  Thus  phthisis  is  essentially  a  disorder  of  childhood  and 
youth — that  is,  the  period  of  life  when  nutrition  is  directed  to  building- 
up  the  tissues  of  the  body.  Diminish  the  proper  quantity  of  food  taken 
by  a  healthy  adult,  and  tubercular  diseases  are  not  induced  ;  but  if  this 
be  attempted  with  children  or  young  persons,  they  are  a  most  common 
result.  It  has  been  supposed  that  hereditary  predisposition,  a  vitiated 
atmosphere,  changeable  temperature,  certain  unhealthy  occupations, 
humidity,  particular  localities,  absence  of  light,  and  so  on,  predispose  to 
phthisis.  \'ery  frequently  several  of  these  are  found  united,  so  that  it  is 
difficult  to  ascertain  the  influence  of  each.  When  they  so  operate,  how- 
ever, they  invariably  produce,  in  the  first  place,  more  or  less  disorder  of 
the  nutritive  functions,  and  are  associated  with  dyspepsia,  or  other  signs 
of  mal-assirailation  of  food. 

From  a  study  of  the  symptoms,  causes,  morbid  anatomy,  and  histology 
of  phthisis  pulmonalis,  we  are  therefore  led  to  the  conclusion,  that  it  is  a 
disease  of  the  primary  digestion,  causing, — 1st,  Impoverishment  of  the 
blood  ;  2d,  Local  exudations  into  the  lung,  which  present  the  characters  of 

*  Diet,  de  Med.     1st  Edit.     Phthisie. 


PHTHISIS  PULMOXALIS.  685 

tubercular  exudation ;  and,  3d,  Owing  to  tlie  successive  formation  and 
softenino;  of  these,  and  the  ulcerations  which  follow  in  the  pulmonary  or 
other  tissues,  the  destructive  results  which  distinguish  the  disease.  Fur- 
ther observation  shows,  that  circumstances  which  remove  the  mal-assimi- 
lation  of  food  frequently  check  further  tubercular  exudations,  while  those 
which  previouslv  existed  become  abortive,  and  that  occasionally  very 
extensive  excavations  in  the  pulmonary  tissue  may,  owing  to  like  circum- 
stances, heal  up  and  cicatrize.  The  curative  treatment  of  this  disease 
must  therefore  be  directed, — 1st,  To  restoring  the  healthy  nutrition  of 
the  economy  ;  2d,  To  subduing  local  irritation  ;  and,  3d,  To  the  avoidance 
of  those  circumstances  which  are  likely  to  deteriorate  the  constitution  on 
the  one  hand,  or  induce  pulmonary  symptoms  on  the  other. 

1,  A  healthy  condition  of  the  body  cannot  proceed  without  a  proper 
admixture  of  mineral,  albuminous,  and  oleaginous  elements.  This  may 
be  inferred  from  the  physiological  experiments  of  Tiedemann  and  Gmelin, 
Leuret  and  Lassaigne,  Magendie,  and  others;  from  an  observation  of  the 
constituents  of  milk,  the  ^jatural  food  of  young  mammiferous  animals; 
from  a  knowledge  of  the  contents  of  tlie  egg,  which  constitute  the  source 
from  which  the  tissues  of  oviparous  animals  are  formed  before  the  shell 
is  broken  ;  and  from  all  that  we  know  of  the  principles  contained  in  the 
food  of  adult  animals.  The  researches  of  chemists,  r.s  of  Trout,  Liebig, 
and  others,  point  to  the  same  generalization,  when  they  assert  that  car- 
bonised and  uitrogenised,  or,  as  they  have  been  called,  respiratory  and 
sano-nio-enons  food,  are  necessary  to  carry  on  nutrition,  inasmuch  as  oil  is 
rt  tvpe  of  the  one,  and  albumen  of  the  other.  The  chemical  theory  is 
imperfect,  however,  because  it  does  not  point  out  how  these  elements  form 
the  tissues ;  for  it  is  not  every  form  of  carbonised  or  of  albuminous  food 
that  is  nutritious,  but  only  such  kinds  of  them  as  are  convertible  into  oil 
and  albumen. 

The  reason  of  this  was  first  pointed  out  by  Dr.  Asclierson  of  Berlin, 
in  1840,  and  made  known  by  me  to  the  profession  in  this  country  in 
1841.  I  have  since  endeavoured  to  show,  that  the  elementary  molecules 
formed  of  a  particle  of  oil,  surrounded  by  a  layer  of  albumen,  which  are 
produced,  as  he  described,  by  rubbing  oil  and  albumen  together,  are  not 
developed  directly  into  blood-globules  and  other  tissues,  as  he  supposed, 
but  must  first  pass  through  a  series  of  transformations — a  knowledge  of 
which  is  highly  important,  not  only  to  a  comprehension  of  nutrition 
generally,  but  especially  to  that  abnormal  condition  of  it  which  occurs 
m  phthisis.  Thus  the  successive  changes  which  occur  for  the  purposes 
of  assimilation  in  the  healthy  economy  may  be  shortly  enumerated  as 
follows: — 1st,  Introduction  into  the  stomach  and  alimentary  canal  of 
oriTanic  matter.  2d,  Its  transformation  by  the  process  of  digestion  into 
albuminous  and  oily  compounds  :  this  process  is  chemical.  3d,  The  imbi- 
bition of  these  through  the  mucous  membrane  in  a  fluid  state,  and  their 
union  in  the  termini  of  the  villi  and  lacteals  to  form  eleujentary  granules 
and  nuclei :  this  pi-ocess  is  physical.  4th,  The  transformation  of  these, 
first,  into  chvle  corpuscles,  and,  secondly,  into  those  of  blood  :  which  is 
a  vital  process.  It  is  from  this  fluid,  still  further  elaborated  in  numerous 
wavs,  that  the  nutritive  materials  of  the  tissues  are  derived,  so  that  it 
must  be  evident,  if  the  first  steps  of  the  process  are  improperly  performed, 


686  DISEASES   OF   THE   EESPIRATORY   SYSTEil. 

the  subsequent  ones  must  also  be  interfered  with.  Hence  we  can  readily 
comprehend  how  an  improper  quantity  or  quality  of  food,  by  diminishing 
the  number  of  the  elementary  nutritive  molecules,  must  impede  nutrition. 
When  we  examine  with  a  magnifying  power  of  250  diameters  a  drop 
of  chvle  taken  from  the  thoracic  duct  of  an  animal,  three  hours  after  it 
has  eaten  a  raeal,  we  observe  that  it  contains,  first,  a  molecular  basis 
(Gulliver)  of  incalculably  minute  particles;  and  secondly,  numerous  cor- 
puscles in  different  stages  of  development  into  blood  globules.  This 
molecular  basis  has  been  proved  by  numerous  chemical  analyses  to  con- 
sist principally  of  fat,  eraulsionised  by  its  admixture  with  albumen.  In 
short,  these  two  important  principles,  fat  and  albumen,  constitute  essen- 
.  tial  elements  of  the  nutritive  chyme;  and 

„  ..-^---.irs^  't^^  former  divided  into  exceedingly  minute 
^^'  P''-  '•  ^'  =-^'''  particles  by  the  latter,  pass  through  the 
-   ;  "       villi  and  form  the  milky  fluid  called  chyle. 

^        It  is  unnecessary  for  me  to  trace  the  subse- 
/  '^       quent  changes  this  chyle  undergoes  by  its 

/  .  passage  through  the  mesenteric  glands,  and 

^/i-  the   successive   stages   of  elaboration    pro- 

"'e'-^v^ '•'" ''    -'      -        -  duced  in  it  by  the  operation  of  the  blood 

'-  /^/-^^^^  glands  and  the  lungs.     No  one  can  doubt 

■^'^'  ^^"'  that  the  oil  and  albumen  so  derived  from 

the  food,  and  so  altered  chemicallv  and  mechanically  in  the  body,  con- 
stitute the  material  from  which  blood  is  formed ;  neitlier  can  there  be 
any  question  that  the  presence  and  emulsionising  of  these  elements  in 
proper  proportions,  are  absolutelv  necessary  to  supply  and  keep  up  the 
vital  properties  of  the  blood. 

Tlie  peculiarity  of  phthisis,  however,  is,  that  an  excess  of  acidity  exists 
in  the  alimentary  canal,  whereby  the  albuminous  constituents  of  the 
food  are  rendered  easily  soluble,  whilst  the  alkaline  secretions  of  the 
saliva  and  of  the  pancreatic  juice  are  more  than  neutralized,  and  rendered 
incapable  either  of  transforming  the  carbonaceous  constituents  of  vegeta- 
ble food  into  oil,  or  of  so  preparing  fatty  matters  introduced  into  the 
system,  as  will  render  them  easily  assimilable.  Hence  an  increased 
amount  of  albumen  enters  the  blood,  and  has  been  found  to  exist  there 
by  all  chemical  analysis,  while  fat  is  largely  supplied  by  tlie  absorption 
of  the  adipose  tissues  of  the  bodv,  causing  the  emaciation  which  charac- 
terises the  disease.  In  the  meanwhile,  the  lungs  become  especially 
liable  to  local  congestions,  leading  to  exudation  of  an  albuminous  kind  : 
which  is  tubercle.  This,  in  its  turn,  being  deficient  in  the  necessary 
proportion  of  fatty  matter,  elementary  molecules  are  not  formed  so  as  to 
constitute  nuclei  capable  of  further  development  into  cells  ;  they  there- 
fore remain  abortive,  and  constitute  tubercle  corpuscles.  Thus  a  local 
disease  is  added  to  the  constitutional  disorder,  and  that  compound  aflec- 
tion  is  induced  which  we  call  phthisis  pulraonalis,  consisting  of  symptoms 


Fig.  438.  Cliyle  from  the  thoracic  duct  of  a  dog,  three  hours  after  eating  a  meal. 
a,  Fluid  chyle  showing  its  molecular  basis  and  corpuscles  in  various  stages  of  deve- 
lopment into  those  of  blood,  b,  Corpuscles  of  chyle  embedded  in  fibrOlated  fibrin. 
They  are  round  in  the  centre,  but  more  or  less  compressed  and  elongated  towards 
the  margin.  250  diani. 


PHTHISIS   PULMOXALIS.  687 

atti-ibutable  partly  to  tlie  alimentiiry  canal,  and  partly  to  tlie  pulmonary 
organs. 

To  improve  the  faulty  nutrition  whicli  originates  and  keeps  up  the 
disease,  it  is  of  all  things"important,  therefore,  to  cause  a  larger  quantity 
of  fatty  matter  to  be  assimilated.  A  mere  increase  in  the  amount,  or 
even  qualitv,of  the  food,  will  often  accomplish  this,  as  in  the  case  of  Keith. 
The  treatn"ient  practised  some  years  ago  by  Dr.  Stewart  of  Erskine, 
which  consisted  in  freely  administering  beef-steaks  and  porter,  and  caus- 
ing exercise  to  be  taken  in  the  open  air,  excited  considerable  attention 
from  its  success.  I  have  been  informed,  that  in  some  parts  of  America 
the  cure  consists  in  living  on  the  bone  marrow  of  the  butfalo,  and  that  the 
consumptive  patient  gets  so  strong  in  this  way,  that  he  is  at  length  able 
to  hunt  down  the  annual  in  the  prairies.  All  kinds  of  food  rich  in  fat, 
will  not  unfrequently  produce  the  same  effects,  and  hence  the  value  long 
attributed  to  milk,' especially  ass's  milk,  the  produce  of  the  dairy,  as 
cream  and  butter,  fat  bacon,  caviar,  etc. 

But  in  order  that  such  substances  should  be  digested  and  assimilated, 
the  powers  of  the  stomach  and  alimentary  canal  must  not  have  under- 
gone anv  (Treat  dimmution.  In  most  cases  it  will  be  found  that  the 
patient  is  unable  to  tolerate  such  kind  of  food,  and  that  it  either  lies 
undigested  in  the  stomach,  or  is  sooner  or  later  vomited.  Under  these 
circmnstances,  the  animal  oils  themselves  are  du-ectly  indicated,  by  giving 
which  we  save  the  digestive  apparatus,  as  it  were,  the  trouble  of  manufac- 
turing or  separating  them  from  the  food.  By  giving  considerable  quan- 
tities of  oil  directly,  a  large  proportion  of  it  is  at  once  assimilated,  and  is 
rendered  capable  "of  entering  into  combination  with  the  albumen,  and 
thereby  forming  those  elementary  molecules  so  necessary  for  the  forma- 
tion of  a  healthy  chyle.  Such,  it  appears  to  me,  is  the  rationale  of 
the  good  effects  of  cod-liver  oil. 

Since  I  introduced  this  substance  to  the  notice  of  the  profession  in  this 
country  as  a  remedy  for  phthisis,  in  1841,  I  have  continually  prescribed 
it  in  hospital,  dispensary,  and  private  practice.  I  need  not  perhaps  say, 
that  I  have  given  it  in  a  very  large  number  of  cases,  and  have  observed 
its  effects  in  all  the  stages  of  the  disease,  and  under  almost  every  circum- 
stance of  age,  sex,  and  condition.  I  have  had  the  most  extensive  oppor- 
tunities of  examining  the  bodies  of  those  wdio  have  died  after  taking  it  in 
considerable  quantities,  and  am  still  observing  the  cases  of  many  persons 
who  mav  be  said  to  have  owed  their  lives  to  its  employment.  Further,  I 
have  carefully  watched  the  progress  it  has  made  in  the  good  opinion  of  the 
professional  public,  and  perused  all  that  has  been  published  regarding  it 
in  the  literature  of  this  and  other  countries.  It  were  certainly  easy  for 
me,  therefore,  to  write  at  great  length  on  this  subject ;  but  I  do  not  see 
that  anything  of  utility  could  be  added  to  what  I  have  already  published. 
The  following  is  a  summary  of  my  views  regarding  cod-liver  oil  as  a 
remedy  for  phthisis  : — 

1.  Cod-liver  oil  is,  as  M.  Taufflied  pointed  out,  an  analeptic  (dvaXafi,/3avw, 
to  repair),  and  is  indicated  in  all  cases  of  abnormal  nutrition  dependent 
on  want  of  assimilation  of  fatty  matter, 

2.  It  is  readily  digestible  under  circumstances  where  no  other  kind  of 
animal  food  can  be  taken  in  sutRcient  quantity  to  furnish  the  tissues  with 
a  proper  amount  of  fatty  material. 


688  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

3.  It  operates  by  combining  with  tlie  excess  of  albuminous  consti- 
tuents of  the  chyme,  and  forming  in  the  villi  and  terminal  lacteals  those 
elementary  molecules  of  which  the  chyle  is  originally  composed. 

4.  Its  eftects  in  phthisis  are  to  nourish  the  body,  which  increases  in 
bulk  and  in  vigour ;  to  check  fresh  exudations  of  tubercular  matter,  and 
to  diminish  the  cough,  expectoration,  and  perspiration. 

5.  The  common  dose  for  an  adult  is  a  table-spoonful  three  times  a-day, 
which  may  often  be  increased  to  four,  or  even  six,  Avith  advantage. 
When  the  stomach  is  irritable,  liowever,  the  dose  to  commence  with 
should  be  a  tea  or  dessert-spoonful. 

6.  The  kind  of  oil  is  of  little  importance  therapeutically.  The  pure 
kinds  are  most  agreeable  to  the  palate ;  but  the  brown  coai'ser  kinds 
have  long  been  used  with  advantage,  and  may  still  be  employed  with 
confidence  whenever  cheapness  is  an  object. 

7.  I  have  never  observed  its  employment  to  induce  pneumonia,  or 
fatty  disease  of  the  liver  or  kidney,  however  long  continued,  although 
such  complications  of  phthisis  are  also  exceedingly  frequent. 

But  in  some  rare  cases  the  oil  cannot,  even  under  the  best  7nanage- 
ment,  be  retained  on  the  stomach,  and  eftbrts  have  been  made  to  intro- 
duce fat  into  the  economy  by  some  other  channel,  such  as  by  the  skin 
and  rectum.  The  former  plan  was  first  tried  by  Dr.  Baur  of  Tubingen, 
Avho  rubbed  various  kinds  of  oil  into  the  skin,  and  even  recommended 
oil  baths.  Persons  occasionally  get  better  under  this  as  they  do  under 
every  other  kind  of  treatment,  but  the  excessive  trouble,  and  sense  of 
micleanliness  which  greasy  fiictions  occasion,  are  sti'ong  objections  to  its 
use.  Its  costliness  also  renders  it  inapplicable  to  the  poor.  Oily  ene- 
mata  were  recommended  by  Dr.  Buist  of  Aberdeen.  But  it  must  be 
evident  that  as  nature  never  intended  mankind  to  be  permanently  nou- 
rished either  by  the  skin  or  by  the  rectum,  so,  in  imitation  of  her 
processes,  the  object  of  an  analeptic  treatment  in  pulmonary  tuberculosis 
must  be  to  cause  the  elements  of  the  food  to  be  taken  by  the  mouth  ;  to 
diminish  the  dyspeptic  symptoms,  and  induce  assimilation  by  the  lacteal 
rather  than  by  the  lymphatic  vessels. 

2.  The  second  indication — namely,  to  subdue  local  irritation — is  only 
to  be  followed  out  in  acute  cases  by  much  the  same  practice  as  guides  us 
in  the  treatment  of  pneumonia,  which  is  the  general  cause  of  such  irri- 
tation. From  what  has  been  previously  said  on  that  subject,  it  must  be 
evident  that,  however  practitioners  may  flatter  themselves  that  by 
bleeding  or  mercury  they  have  checked  inflammation,  these  remedies 
in  plithisis,  so  far  from  arresting  the  local  lesion,  have  only  accele- 
rated it. 

In  the  chronic  forms  of  the  disease  this  indication  is  only  to  be  met 
by  topical  counter-irritation.  Hence  a  seton  or  issue,  a  succession  of 
blisters,  tartar-emetic  ointment,  and  croton  oil,  are  all  beneficial,  and  may 
be  used  according  to  circumstances.  Cold  sponging,  employed  with 
great  precaution,  so  as  not  to  produce  a  chill,  but  rather  a  glow  of  heat 
afterwards,  is  also  beneficial.  Such  are  the  only  means  in  our  power  to 
meet  this  impoitant  indication,  because,  combined  with  this  local  lower- 
ing treatment,  the  general  system  must  be  invigorated  to  the  utmost. 
Tliis   is   the  diflicult  problem  to  be  worked  out  in  the  treatment  of 


PHTHISIS   PULMONALIS.  689 

phthisis,  and  in  doing  so  we  shall  be  much  assisted  by  paying  pavticular 
attention  to  the  third  indication. 

3.  The  avoidance  of  those  circumstances  likely  to  deteriorate  the  con- 
stitution on  the  one  hand,  or  induce  pulmonary  symptoms  on  the  other, 
otfei-s  a  wide  field  for  the  judicious  practitioner,  especially  in  his  charac- 
ter as  a  watchful  guardian  over  his  patient's  health.  One  of  the  great 
difficulties  we  have  to  overcome  in  this  climate,  is  the  frequent  varia- 
tions of  temperature,  and  the  sudden  changes  from  fervent  heat  to  chilling 
cold.  Supposing  that  you  have  the  means  of  supporting  nutrition  and 
keeping  down  local  irritation,  it  is  by  no  means  certain  that  good  will  be 
accomplished,  from  the  impossibility  of  securing  those  hygienic  regula- 
tions and  that  equable  climate,  which  are  necessary  to  carry  out  the 
third  indication.  In  the  first  place,  nutrition  itself  is  more  connected 
with  proper  exercise  and  breathing  fresh  air  than  many  people  imagine. 
It  does  not  merely  consist  in  stimulating  the  appetite  and  giving  good 
things  to  eat.  It  requires — 1st,  Food  in  proper  quantity  and  quality; 
2d,  Proper  digestion  ;  3d,  Healthy  formation  of  blood ;  4th,  A  certain 
exchange  between  the  blood  and  the  external  air  on  the  one  hand,  and 
between  the  blood  and  the  tissues  on  the  other;  and  5th,  It  requires 
that  there  should  be  proper  excretion,  that  is,  separation  of  what  has 
performed  its  allotted  function  and  become  useless.  All  these  processes 
are  necessary  for  nutrition,  and  not  merely  one  or  two  of  them,  for  they 
are  all  essentially  connected  with,  and  dependent  on,  one  another.  Hence 
the  means  of  prevention  consist  in  carrying  out  those  hygienic  regula- 
tions which  secure  the  performance  of  these  ditferent  nutritive  acts,  the 
most  important  of  which  are  attention  to  climate,  exercise,  and  diet. 

Much  has  been  written  on  climate,  but  the  one  which  appears  to  me 
best  is  that  which  will  enable  the  phthisical  patient  to  pass  a  few  hours 
every  day  in  the  open  air,  without  exposure  to  cold  or  vicissitudes  of 
temperature  on  the  one  hand,  or  excessive  heat  on  the  other.  Whenever 
such  a  favoured  locality  mav  be  found  during  the  winter  and  spring 
months,  its  advantages  should  be  considered  as  dependent  on  exercise, 
and  on  the  stimulus  given  to  the  nutritive  functions,  rather  than  to  its 
influence  on  the  lungs  directly. 

The  great  mass  of  those  affected  with  phthisis,  however,  have  not  the 
means  of  searching  out  a  favourable  climate  on  the  Continent,  or  even 
of  maintaining  themselves  in  a  sheltered  nook  on  the  western  or  south- 
western coasts  of  this  country.  It  has,  therefore,  been  proposed  that 
such  buildings  as  the  Crystal  Palace  should  be  converted  into  winter 
gardens  and  public  promenades.  Not  to  speak  of  the  intellectual  and 
recreative  purposes  that  such  a  plan  would  subserve,  it  is  worthy  of  our 
consideration  how  far  it  would  tend  to  promote  health  in  general,  but 
especially,  how  it  would  conduce  to  the  cure  of  phthisis.  Its  great  advan- 
tage would  be  offering  the  means  of  exercise  in  a  pure  atmosphere,  at  an 
equable  temperature.  It  is  easy  for  us,  by  confining  patients  in  a  suite 
of  rooms  in  which  the  heat  is  regulated,  to  secure  immunity  from  cold 
and  change  of  air;  but  such  a  contrivance  is  most  intolerable  to  the 
patient;  the  mind  becomes  peevish,  which  in  itself  is  a  powerful  obstacle 
to  the  proper  performance  of  the  digestive  functions.  But  above  all,  the 
body  is  deprived  of  exercise — that  necessary  stimulus  to  the  appetite, 

44 


690  DISEASES   OF  THE   EESPIRATORY   STSTEiT, 

respiration,  and  other  functions.  Some  years  ago,  I  succeeded  in  con- 
fining a  consumptive  patient  to  his  room  for  an  entire  Avinter.  His  spirits 
suflfered  gi-eatly  ;  but  on  the  whole  he  supported  the  imprisonment  with 
resolution.  Next  winter,  however,  nothing  could  induce  him  to  remain 
at  home,  and  one  dav  he  rushed  out  of  the  house,  ascended  Arthui-'s 
Seat,  and  was  much  better  in  consequence.  Since  then  I  have  been 
convinced  that,  although  by  confinement  you  may  gain  some  advantages, 
on  the  whole  it  is  a  prejudicial  practice  if  rigorously  carried  out. 

What  is  required,  in  these  cases  is  the  means  of  exercise,  whether  on 
foot,  on  horseback,  or  in  a  carriage,  where  the  patient  is  protected  from 
cold  winds,  and  where  the  mind  can  be  amused  by  pleasant  sights  and 
cheerful  conversation.  Such  is  the  case  in  all  those  favoured  localities 
considered  best  for  consumptive  people,  and  such  would  be  the  advan- 
tages derived  from  resorting  to  the  Crystal  Palace  as  a  winter  garden 
and  promenade.  Delicate  individuals  could  be  transported  there  by 
means  of  a  close  carriage,  in  the  worst  seasons,  without  difficulty,  and  on 
entering  it  could  breathe  for  hours  a  pure,  balmy  air,  and  meet  their 
friends,  take  exercise  in  various  ways,  read,  work,  or  otherwise  amuse 
themselves.  Such  an  out-door  means  of  recreation,  combined  with  care- 
ful hvo-ienic  regulations  at  home,  would  go  fi^r  to  remove  many  of  the 
difficulties  which  we  have  to  encounter  in  the  ordinary  treatment  of 
consumption. 

"With  regard  to  diet,  it  may  be  said,  in  general  terms,  that  one  of  a 
nutritious  kind,  consisting  of  a  good  proportion  of  animal  food  abound- 
ing; in  fat,  is  best  adapted  for  phthisical  cases,  whilst  everything  that 
induces  acidity  should  be  avoided.  But,  as  previously  stated,  the  diffi- 
culty consists  in  causing  such  diet  to  be  taken,  on  account  of  the  bad 
appetite  and  dyspeptic  or  febrile  symptoms  which  prevail.  Xo  e2"ort, 
therefore,  should  be  spared  to  overcome  the  obstacles  which  prevent  food 
of  sufficient  quality  and  quantity  from  being  digested,  the  appropriate 
means  for  doing  which  must  vary  according  to  the  circumstances  of  the 
case,  and  will  be  treated  of  immediately.  The  strongest  stinmlus  to  the 
appetite,  however,  is  exercise,  and  hence  the  importance  of  the  conside- 
rations already  entered  into,  with  reference  to  securing  what  is  essential 
in  the  treatment  of  the  disease,  namely,  good  digestion  and  proper 
assimilation. 

If  the  pathology  of  pulmonary  tuberculosis  fonnerly  described  be  cor- 
rect, it  indicates  what  are  the  means  best  adapted  for  preventing,  as 
well  as  arresting,  the  disease  when  it  has  already  commenced.  These 
are,  for  the  infant,  a  healthy  nurse,  cleanliness,  and  careful  attention  to 
all  those  circumstances  which  tend  to  increase  the  bodily  vigour  and  to 
secure  good  digestion.  At  the  time  of  weaning  and  of  teething,  the 
most  watchful  care  becomes  necessary,  so  that  local  irritation  and  its 
effects  may  be  prevented  as  much  as  possible,  and  a  proper  diet,  con- 
taining a  sufficient  amount  of  the  fatty  principles,  be  taken.  During 
adolescence,  indulgence  in  indigestible  articles  of  food  should  be  avoided, 
especially  pastry,  unripe  fruit,  salted  provisions,  and  acid  drinks,  while 
the  habit  of  eating  a  certain  quantity  of  fat  should  be  encouraged,  and, 
if  necessary,  rendered  imperative.  The  same  precautions,  conjoined  with 
proper  bodily  and  mental  exercise,  avoiding  exhausting  and  too  fatigu- 
ino-   occupations,  should  subsequently  be   maintained  until  the  prodis- 


PHTHISIS  PULMOXALIS.  691 

position  to  tubercular  disease  lias  been  completely  overcome.  In  short, 
everything  that  can  support  and  invigorate  should  be. adopted,  and  every- 
thing that  can  exhaust  and  depress  should  be  shunned.  .  As  vitiation  of 
the  chyle  and  blood  precedes  the  local  deposition  of  a  tubercular  exuda- 
tion, it  necessarily  follows  that  that  numerous  class  of  delicate  invalids, 
whose  chief  complaint  is  derangement  of  the  digestive  process,  with 
languor  and  debility,  may,  by  the  hygienic  means  now  indicated,  and 
proper  treatment  of  the  dyspepsia,  be  restored  to  health. 

Were  it  possible  in  all  cases  for  these  three  indications  to  be  carried 
out,  I  feel  satisfied  the  cure  of  phthisis  would  be  more  frequent;  but  in 
the  treatment  of  this  disease,  the  physician  has  to  struggle  not  onlv  with 
the  deadly  nature  of  the  disorder,  but  with  numerous  difficulties  over 
which  he  has  no  control,  such  as,  among  the  poorer  classes,  the  impos- 
sibility of  procuring  good  diet,  and  the  thousand  imprudences  not  only 
they,  but  the  majority  of  invalids,  are  continually  committing.  Then 
another  great  difficulty  is,  to  convince  the  patient  that,  notwithstanding 
the  I'emoval  of  his  urgent  symptoms,  the  disease  is  not  cured,  and  that 
these  will  return,  if  the  causes  which  originally  produced  them  are  ao-ain 
allowed  to  operate.  Sometimes  I  have  found  it  difficult  to  keep  hospital 
patients  in  the  house  when  they  are  doing  well,  at  other  times  thev  are 
sent  out  in  accordance  with  certain  regulations,  which  oblige  the  admis- 
sion of  more  acute  cases.  This  was  the  case  with  Barclay.  (Case 
CXLIV.)  So  long  as  he  was  under  treatment,  or  rather  enjoyed  the 
comtbrts  and  good  diet  of  the  Infirmary,  so  long  was  he  well ;  but  sent 
out,  exposed  to  misery,  to  insufficient  food,  and  work,  he  becaine  woi-se. 
Lastly,  the  attempt  to  relieve  distressing  symptoms  interferes  much  more 
than  is  generally  supposed  with  the  curative  treatment.  This  leads  me 
to  speak  of  the 


III. — Sjiecial   Treatment  of  Phthisis  Pulmonalis. 

Under  the  head  of  General  Treatment  of  Phthisis  Pulmonalis,  I  have 
pointed  out  the  means  of  meeting  the  three  indications  which  should 
never  be  lost  sight  of  in  this  dist^ase.  But  every  case  requires  a  special 
treatment  in  addition,  which  will  depend  on  the  unusual  severity  of  this 
or  that  symptom,  or  the  existence  of  peculiar  complications.  It  is  to 
the  undue  importance  given  to  this  special,  as  distinguished  from  the 
general  treatment,  that  I  attribute  much  of  that  want  of  success  experi- 
enced by  practitioners.  Thus  it  is  by  no  means  uncommon  to  meet 
with  patients  who  are  taking  at  the  same  time  a  mixture  containing 
squills  and  ipecacuanha  to  relieve  the  cough;  an  anodyne  draught  to 
cause  sleep  and  diminish  irritability ;  a  mixture  containing  catechu,  gal- 
lic acid,  tannin,  or  other  astringents,  to  check  diarrhoea;  acetate  of  lead 
and  opium  pills  to  diminish  haemoptysis;  sulphuric  acid  drops  to  relieve 
the  sweating;  and  cod-liver  oil  in  addition.  I  have  seen  many  persons 
taking  all  these  medicines  and  several  others  at  one  time,  with  a  mass  of 
bottles  and  boxes  at  the  bedside  sufficient  to  furnish  an  apothecary's 
shop,  without  its  ever  suggesting  itself  apparently  to  the  practitioner, 
that  the  stomach  drenched  with  so  many  nauseating  things  is  thereby 


692  DISEASES   OF   THE   RESPIKATORY   SYSTEM. 

prevented  from  performing  its  healthy  functions.  In  many  cases  there 
can  be  little  doubt  tliat  this  treatmen't  of  symptoms,  with  a  view  to  their 
palliation,  whilst  it  destroys  all  hope  of  cure,  ultimately  fails  even  to 
relieve  the  particular  functional  derangement  to  which  it  is  directed. 
Still  these  symptoms  require  attention;  but  their  causes,  and  the  means 
required  for" their  relief,  will  be  best  understood  by  speaking  of  each  in 
succession. 

Couyh  and  Exj^ectoration. — At  first  the  cough  in  phthisis  is  dry  and 
hacking.  "When  tubercle  softens  or  bronchitis  is  present,  it  becomes 
moist  and  more  prolonged.  ^Vhen  excavations  exist,  it  is  hollow  and 
reverberating.  In  every  case  cough  is  a  spasmodic  action,  occasioned  by 
exciting  the  branches  of  the  pneumogastric  nerves,  and  causing  simul- 
taneous retlex  movements  in  the  bronchial  tubes  and  muscles  of  the  chest. 
The  expectoration  following  dry  cough  is  at  first  scanty  and  muco-puru- 
lent,  and  afterwards  copious  and  purulent.  When  it  assumes  the  num- 
mular form, — that  is,  occurs  in  viscid  rounded  masses,  swimming  in  a 
fluid  clear  mucus,  it  is  generally  brought  np  from  pulmonary  excava- 
tions. The  accumulation  of  the  sputum  in  the  bronchial  tubes  is  an 
excitor  of  cough ;  and  hence  the  latter  symptom  is  often  best  combated 
by  those  means  Avhich  diminish  the  amount  of  sputum.  When,  on  the 
other  hand,  the  cough  is  dry,  those  remedies  should  be  used  which 
diminish  the  sensibility  of  the  nerves.  In  the  first  case,  the  amount  of 
mucus  and  pus  formed  will  materially  depend  on  the  w^eakness  of  the 
body,  and  the  onward  progress  of  the  tubercle.  Hence  good  nourish- 
ment and  attention  to  the  digestive  functions  are  the  best  means  of  check- 
ing both  the  cough  and  expectoration ;  whereas  giving  nauseating  mix- 
tures of  ipecacuanha  and  squills  is  perhaps  the  worst  treatment  that  can 
be  employed.  There  is  no  point  which  experience  has  rendered  me 
more  certain  of  than  that,  however  these  symptoms  may  be  palliated  by 
couo-h  and  anodyne  remedies,  the  stomach  is  thereby  rendered  intolerant 
of  food,  and  the' curative  tendency  of  the  disease  is  impeded.  On  the 
other  hand,  notliing  is  more  remarkable  than  the  spontaneous  cessation 
of  the  cough  and  expectoration  on  the  restoration  of  the  digestive  func- 
tions and  improvement  in  nutrition.  Wlien  the  cough  is  dry,  as  may 
occur  in  the  first  stage,  with  crude  tubercle,  and  in  the  last  stage  with 
dry  cavities,  counter-irritation  is  the  best  remedy,  employed  in  various 
forms.  Opium  may  relieve,  but  it  never  cures.  The  occasional  use  of 
the  sponge  saturated  in  a  solution  of  nitrate  of  silver,  is  frequently  of  the 
greatest  service.      (See  Laryngitis.) 

Loss  of  u\2)]jetife. — This  is  the  most  constant  and  important  symptom 
of  phthisis,  inasmuch  as  it  interferes  more  than  any  other  with  the  nutri- 
tive processes.  If  food,  or  the  analeptic,  cod-liver  oil,  cannot  be  taken 
and  digested,  it  is  vain  to  hope  for  amelioration  in  any  of  the  essential 
symptoms  of  the  disease.  Here  we  should  avoid  a  mistake,  into  which 
the  inexperienced  are  very  liable  to  fall.  Nothing  is  more  common 
tlian  for  phthisical  patients  to  tell  their  medical  attendants  that  their 
appetite  is  good,  and  that  they  eat  plentifully,  wlien  more  careful  inquiry 
proves  that  the  consumption  of  food  is  altogether  inadequate,  and  that 
they  loathe  every  kind  of  animal  diet.  In  the  same  manner,  they  say 
they  are  quite  well,  or  better,  when  they  are  evidently  sinking.  We 
should  never  be  satisfied  with  general   statements,  but  determine  the 


PHTHISIS   PULMOXALIS.  693 

kind  and  amount  of  food  taken,  when  sufficient  proof  will  be  discovered, 
in  the  vast  majority  of  cases,  of  the  derangement,  formerly  alluded  to,  of 
the  appetite  and  digestive  powers.  Very  commonly  also,  there  will  be  acid 
and  other  unpleasant  tastes  in  the  mouth.  In  all  such  cases,  especially 
if  too  much  medicine  has  been  already  given,  the  stomach  should  be 
allowed  to  repose  itself  before  anything  be  administered,  even  cod-liver 
oil.  Sweet  milk,  with  toasted  bread,  and  small  portions  of  meat  nicely 
cooked,  so  as  to  tempt  the  capricious  appetite,  should  be  tried.  Then 
ten  drops  of  the  Sp.  Amnion.  Aromat.,  given  every  four  hours  in  a  wine- 
glassful  of  some  bitter  infusion,  such  as  that  of  Calumba  or  Gentian,  with 
a  little  Tr.  Aurantii,  Tr.  Cardainomi,  or  other  carminative.  In  this  way 
the  stomach  often  regains  its  tone,  food  is  taken  better,  and  then  cod- 
liver  oil  may  be  tried,  first  in  tea-spoonful  doses,  cautiously  increased. 
Should  this  plan  succeed,  amelioration  in  the  symptoms  will  be  almost 
certainly  observed. 

^'^ausea  and  Vomitinr/. — Xot  unfrequently  the  stomach  is  still  more 
deranged;  there  is  a  feeling  of  nausea  and  even  vomiting  on  taking 
food.  In  the  latter  stages  of  phthisis,  vomiting  is  also  sometimes  occa- 
sioned by  violence  of  the  cough,  and  the  propagation  of  reflex  actions, 
by  means  of  the  par  vagum,  to  the  stomach.  In  the  former  case,  the 
sickness  is  to  be  alleviated  by  carefully  avoiding  all  those  substances 
which  are  likely  to  occasion  a  nauseating  effect,  by  not  overloading  the 
stomach,  but  allowing  it  to  have  repose.  In  cases  where  too  much 
medicine  has  been  administered,  a  suspension  of  all  medicaments  for  a 
few  days  will  frequently  enable  the  practitioner  to  introduce  nourishment 
cautiously  with  the  best  effect.  I  have  found  the  following  mixture  very 
effectual  in  checking  the  vomiting  in  phthisis.  I^  Xaphthce  Medkinalis, 
3);  Tr.  Cardamomi  comp.,  3J;  Mist.  Camphorce,  3  vij.  M.  ft.  mist. 
Of  which  a  sixth  part  may  be  taken  every  four  hours.  When  it  depends 
on  the  cough,  those  remedies  advised  for  that  symptom  should  be  given. 
I  have  tried  emetics  for  the  relief  of  nausea  and  vomiting,  but  with  no 
good  result. 

Diarrhoea. — This  is  a  very  common  symptom  throughout  the  whole 
progress  of  phthisis,  at  first  depending  on  the  excess  of  acidity  in  the 
alimentary  canal,  to  which  we  have  alluded,  but  in  advanced  cases  con- 
nected with  tubercular  deposit  and  ulceration  in  the  intestinal  gland. 
The  best  method  of  checking  this  troublesome  symptom,  is  by  improv- 
\nv  the  quality  and  amount  of  the  food.  The  moment  the  digestive 
processes  are  renovated,  this,  with  the  other  functional  derangements  of 
the  alimentarv  canal,  will  disappear.  Hence  at  an  early  period  we 
should  avoid  large  doses  of  opium,  gallic  acid,  tannin,  and  other  power- 
ful astrincrents,  and  depend  upon  the  mildest  remedies  of  this  class,  such 
as  chalk  with  aromatic  confection,  or  an  antacid,  such  as  a  few  grains  of 
carbonate  of  potash.  When,  on  the  other  hand,  in  advanced  phthisis, 
continued  diarrhoea  appears,  and  is  obstinate  under  such  treatment,  then 
it  mav  be  presumed  that  tubercular  disease  of  the  intestine  is  present, 
and  the  stronger  astringents  with  opium  may  be  given  as  palliatives. 

Hie  mo  [Ay  His. — This  symptom  sometimes  appears  suddenly  in  indi- 
viduals in  whom  there  has  been  no  previous  suspicion  of  phthisis,  and 
in  whom,  on  careful  examination,  no  physical  signs  of  the  disease  can  be 
detected.     On  other  occasions,  the  sputum  may  be  more  or  less  streaked 


694  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

with  blood ;  and  lastly,  it  may  occur  in  tlie  advanced  stage  of  the  dis- 
ease, apparently  fi'oni  ulceration  of  a  tolerably  large  vessel.  In  all  these 
cases  the  best  remedy  is  perfect  quietude,  and  avoidance  of  every  kind 
of  excitement,  bodily  and  mental.  Astringents  have  been  recommended, 
especially  acetate  of  lead  and  opium ;  but  how  these  remedies  can  ope- 
rate, I  am  at  a  loss  to  understand ;  and  I  have  never  seen  a  case  in 
which  their  administration  was  unequivocally  useful,  I  have  now  met 
with  several  cases  where  supposed  pulmonary  haimoi-rliage  really  origi- 
nated in  follicular  disease  of  the  pharynx  or  larynx,  and,  with  the  sup- 
posed phthisical  symptoms,  was  removed  by  the  use  of  the  probang  and 
nitrate  of  silver  solution, 

Stoeatinr/  I  regard  as  a  symptom  of  weakness,  and  therefore  as  a 
common,  though  by  no  means  a  special  one  in  phthisis.  Here,  again, 
the  truly  curative  ti-eatment  will  consist  in  renovating  the  nutritive 
processes,  and  adding  strength  to  the  economy.  It  will  always  be 
observed  that,  if  cod-liver  oil  and  good  diet  produce  their  beneficial 
effect,  the  sweating,  together  with  the  cough  and  expectoration,  ceases. 
On  the  other  hand,  giving  acid  drops  to  relieve  this  symptom,  as  is  the 
common  practice,  by  adding  to  the  already  acid  state  of  the  alimentary 
canal,  is  directly  opposed  to  the  digestion  of  the  fatty  principles,  which 
require  assimilation. 

It  should  not  be  forgotten  that  consumptive  patients,  and  all  those 
suffering  from  pulmonary  diseases,  are  especially  sensitive  to  cold.  The 
impeded  respii'ation  from  the  lungs  in  such  cases,  is  counterbalanced  by 
increased  action  of  the  skin,  which  becomes  unusually  liable  to  the  in- 
fluence of  diminished  temperature.  Again,  cold  applied  to  the  surface 
immediately  produces,  by  reflex  action,  spasmodic  cough  and  excitation 
of  the  luno-s.  Every  observant  person  must  have  noticed  how  cough  is 
induced  by  crossing  a  lobby,  going  out  into  the  open  air,  a  draught  of 
wind  entering  the  room,  getting  into  a  cold  bed,  etc,  etc.  The  mere 
exposure  of  the  face  to  the  air  on  a  cold  day,  takes  away  the  breath, 
induces  cough,  and  obliges  the  patient  instinctively  to  muliie  up  the 
month.  The  mimerous  precautions,  therefore,  that  ought  to  be  taken 
bv  the  phthisical  individual,  should  be  pointed  out,  especially  the  neces- 
sity of  warm  clothing,  to  which  large  additions  should  be  made  on 
going  out  into  the  air.  Thus,  covering  the  lowei-  part  of  the  face  is  im- 
portant as  a  means  of  extra  clothing,  and  not  as  a  means  of  breathing 
warm  air,  as  the  favourers  of  respirators  imagine.  The  patient  should 
always  sit  with  his  back  to  the  horses  or  to  a  steam-engine,  and  if  by 
accident  his  shoes  or  clothes  become  wet,  they  should  be  changed  as 
soon  as  possible.  In  the  house,  ladies  should  have  a  shawl  near  them, 
to  put  on  in  going  from  one  room  to  another,  in  descending  a  stair  to 
dinner,  etc.  By  attention  to  these  rainutiie,  much  suffering  and  cough 
may  be  avoided. 

Febrile  Si/mptoms. — The  quick  pulse,  general  excitement,  loss  of 
appetite,  and  tliirst,  which  are  so  common  in  the  progress  of  phthisical 
cases,  are  dependent  on  the  same  causes  as  those  which  induce  symp- 
tomatic fever  in  general.  Vascular  distension,  resulting  in  exudation  and 
its  absorption,  is  proceeding  with  greater  or  less  intensity  in  the  lungs, 
and  frequently  in  other  organs.  This  leads  to  nervous  irritation  and  in- 
crease of  fibrin  in  the  blood,  accompanied  by  febrile  phenomena.     The 


PHTHISIS   PULMOXALIS.  695 

intensity  of  these  is  always  in  proportion  to  the  activity  of  local  disease, 
or  to  the  amount  of  secondary  absorption  going  on  from  the  tissues,  or 
from  morbid  deposits.  Nothing  is  more  common  than  attacks  of  so- 
called  local  iniiammations  in  phthisis,  and  the  careful  physician  may 
often  determine  by  physical  signs  the  supervention  of  pleurisy,  pneu- 
monia, or  bronchitis  on  the  previously  observed  lesion,  and  not  unfre- 
quentlv  larvn^itis,  enteritis,  or  other  disorders.  In  such  cases,  nature 
herself  dictate's  that  the  analeptic  treatment,  otherwise  appropriate,  is 
no  loncrer  applicable— food  disgusts,  and  fluids  are  eageriy  demanded. 
Under  these  circumstances,  it  has  been  common  to  apply  leeches  to  the 
inflamed  part,  and  extract  blood  by  cupping,  measures  which  undoubt- 
edlv  cause  temporary  relief,  but  which  are  wholly  opposed  to  the  plan 
of  general  treatment  formerly  recommended,  and  to  what  we  know  of 
the'pathology  of  the  disease. '  Every  attack  of  febrile  excitement  is  fol- 
lowed bv  a  corresponding  collapse,  and  it  should  never  be  forgotten  that, 
in  a  disease  which  is  essentially  one  of  weakness,  the  patient's  strength 
should  be  husbanded  as  much  as  possible.  Hence  the  treatment  I 
depend  on  in  such  circumstances,  consists  of  at  first  the  internal  adminis- 
tration of  the  neutral  salts,  especially  of  tartar  emetic  in  small  doses, 
combined  with  diuretics,  in  order  to  favour  crisis  by  the  urine.  Sub- 
sequently quinine  is  undoubtedly  advantageous.  I  have  satisfied  myself 
that  such  attacks  are  not  to  be  cut  short  by  leeches  or  cupping,  and 
although  in  many  cases,  as  previously  stated,  temporary  relief  is 
produc'ed,  the  exposure  of  the  person,  and  unpleasant  character  of 
the  applications,  the  trickling  of  blood,  and  wet  sponges,  as  often 
irritate,  and  give  rise  to  unnecessary  risk.  Still  there  are  cases  where 
topical  blood-letting,  if  it  camtot  be  shown  to  have  advanced  the  cure, 
cannot  be  proved"  to  have  done  harm,  but  these  cases,  as  far  as  my 
observation  goes,  are  very  few  in  number.  In  the  rapidly  febrile  cases, 
or  the  so-called  instances  of  acute  phthisis,  mercury  has  been  recom- 
mended ;  but  I  have  never  seen  it  produce  the  slightest  benefit.^ 

Debility. — This  is  a  very  common  symptom  of  phthisis  from  the 
first,  and  frequently  leads  the  patient  into  indolence  both  of  mind 
and  body,  a  condition  very  unfavourable  for  the  nutritive  functions,  upon 
the  successful  accomplishment  of  which  its  removal^  depends.  It  is  to 
remove  the  weakness  that  tonics  have  been  administered,  but  I  have 
never  seen  quinine,  bitter  infusions,  or  even  chalybeates,  of  much  service 
alone,  while  the  continual  use  of  nauseous  medicine  disgusts  the 
patient,  and  interferes  with  the  functions  of  the  stomach.  Here  again 
the  great  indication  is  to  remove  the  dyspeptic  symptoms,  give  cod-liver 
oil,  an  animal  diet,  and  improve  the  appetite  by  gentle  exercise  and 
chanrje  of  scene.  Should  the  practitioner  succeed  in  renovating  the 
nutritive  functions,  it  is  often  surprising  how  the  strength  increases,  in 
itself  a  suflScient  proof  as  to  what  ought  to  be  the  method  of  removing 
the  debilitv.  I  have  frequently  seen  patients  who  have  been  so  weak 
that  thev  could  not  sit  up  in  bed  without  assistance,  so  strengthened  by 
the  analepdc  treatment,  that  they  have  subsequently  walked  about  and 
taken  horse  exercise  without  fatigue,  and  this  after  all  the  vegetable, 
mineral,  and  acid  tonics  had  been  tried  in  vain. 

Despondency  and  Anxiety. — It  is  impossible  for  the  careful  practitioner 
to  avoid  noticing  the  injurious  influence  of  depressing  mental  emotions 


696  DISEASES  OF   THE   EESPIRATORY   SYSTEiL 

on  the  progress  of  phthisis.  Indeed  the  worst  cases  are  those  of  indivi- 
duals Avith  raild,  placid,  and  iinimpassioned  characters,  Avho  give  way  to 
the  feelings  of  languor  and  debility  which  oppress  them.  Such  persons 
are  most  amiable  patients — they  give  no  trouble — anything  will  do  for 
them — they  resign  themselves  to  circumstances,  and  state  that  they  are 
eating  well  and  getting  better  up  to  tlie  last.  These  are  cases  of  bad 
augury,  for  it  is  exceedingly  difficult  to  inspire  them  with  sufficient 
energy  to  take  exercise,  or  to  carry  out  those  regulations  which  are 
absolutely  essential  to  renovate  the  appetite  and  the  nutritive  functions. 
Such  persons  are  benefited  by  slow  travelling,  cheerful  society,  and  every- 
thing that  can  elevate  the  spirits,  and,  insensibly  to  themselves,  com- 
municate a  stimulant  to  the  mental  and  bodily  powers.  Anxiety,  on  the 
other  hand,  though  it  may  sometimes  depress  and  interfere  with  the 
digestive  functions,  is  often  a  most  useful  adjunct  to  the  phvsician. 
Those  who  experience  it  are  most  careful  of  their  health,  sometimes 
indeed  too  much  so,  but,  if  once  satisfied  of  the  benefit  of  any  particular 
line  of  treatment,  tliey  pursue  it  with  energy.  These  are  cases  of  good 
augury,  and  most  of  the  permanent  cures  I  have  witnessed  have  been  in 
such  persons — medical  men,  and  others  acquainted  with  the  nature  of 
their  disease,  who  have  exhibited  resolution,  and  a  noble  fortitude,  and 
have  bravely  struggled  against  local  pain,  general  debility,  and  nervous 
fear.* 


CANCER  OF  THE  LUXG. 

Case  CLII.f — Cancer  of  the  Lung,   Thyroid  Body,  and  Lymphatic   Glands  of  the 
Neck- — Bronchitis — Leucocythemia. 

History. — Margaret  Stewart,  a  cook,  set.  60 — admitted  into  the  clinical  ward 
July  16,  1851.  For  some  years  back  she  has  been  subject  to  a  short  dry  cough, 
which  has  never  been  troublesome  except  after  cooking  a  larger  dinner  than  usual. 
With  the  exception  of  an  attack  of  diarrhoea  when  the  cholera  was  prevalent,  she 
has  been  more  or  less  constipated.  Has  never  suffered  from  epistaxis  or  otlier  foi'ni 
of  haemorrhage.  Four  weeks  ago  she  first  perceived  a  swelling  in  the  neck,  which, 
commencing  in  front,  has  gradually  spread  towards  the  right  side.  Latterly  her 
breathing  has  become  short  and  hurried ;  her  strength  has  decreased,  and  the  cough 
has  been  accompanied  by  considerable  expectoration. 

Symptoms  ox  Admissiox. — On  admission,  the  neck  presents  a  prominent  indu- 
rated swelling,  anteriorly,  measuring  about  four  inches  in  diameter,  evidently  owing 
to  enlargement  of  the  thyroid  body.  A  chain  of  enlarged  glands  extends  from  the 
anterior  swelling  round  the  right  side  of  the  neck,  a  little  beyond  the  ear.  She  com- 
plains of  great  weakness,  constant  sweating  at  night,  and  cough  with  copious  frothy 
expectoration.  The  chest  is  everywhere  resonant  on  percussion.  Tliere  are  loud 
sonorous  and  moist  rales  heard  over  the  whole  chest,  especially  posteriorly  and 
inferiorly.  The  vocal  resonance  is  also  unusually  loud,  but  equal  on  both  sides. 
The  tongue  is  furred,  dark  brown  in  the  centre ;  deglutition  is  difficult,  apparently 
from  pressure  of  the  enlarged  cervical  glands.  The  appetite  is  bad,  with  an  acid 
taste  in  the  mouth.     Other  functions  properly  performed. 

*  For  numerous  other  facts  and  observations  connected  with  the  pathology  and 
treatment  of  phthisis,  see  the  Author's  work  on  Pulmonary  Tuberculosis  8vo.  Edin- 
buro'h.  \  Reported  by  ilr.  D.  0.  Hoile,  Clinical  Clerk. 


CANCER  OF  THE   LUNG.  697 

Progress  of  the  Case. — She  continued  in  this  condition  for  several  days,  during 
which  iodine  and  counter-irritants  were  apphed  to  the  neck,  and  expectorants  and 
antispasmodics  taken  internall}^  to  reheve  the  cough.  The  dyspncea,  liowever, 
gradually  increased;  deglutition  became  more  difficult,  and  her  strength  diminished. 
On  the  30th  of  July  tlie  urine  was  ascertained  to  contain  albumen,  whicli  had  pre- 
viously not  existed.  She  died  without  a  struggle,  August  5th. 
Sectio  Cadaveris. — Foi-ty  hours  after  death. 

Xeck. — On  dissecting  the  integuments  from  the  neck  on  the  right  side,  a  con- 
siderable number  of  glands,  about  the  size  of  a  barley-corn  and  small  pea,  were 
observed  in  clusters  between  the  platysma  myoides  and  the  sterno-mastoid  muscle. 
A  hard  tumour  existed  in  front  of  the  neck,  stretching  along  the  whole  front  of  the 
trachea,  and  over  the  great  vessels  on  either  side  beneath  the  sterno-mastoid  muscles, 
and  posteriorly  on  the  right  side,  as  far  back  as  the  transverse  processes  of  the 
vertebrae,  and  down  beneath  the  clavicle  to  the  anterior  surfoce  of  the  first  rib,  where 
it  was  firmly  adherent  to  the  periosteum.  A  prolongation  of  the  tumour,  about  the 
size  of  two  walnuts,  passed  beneath  the  sternum  at  its  upper  end,  being  attached  to 
its  periosteum.  This  prolongation  on  section  presented  the  outline  of  a  congeries  of 
enlarged  lymphatic  glands,  having  a  white  appearance,  in  some  places  soft,  and  even 
diffluent,  and  yielding  on  pressure  a  copious  milky  cancerous  juice.   ■ 

Thorax. — There  were  lax  adhesions  at  various  points  on  the  pleurae  on  both  sides. 
The  pleural  cavities  contained  a  little  fluid  on  the  right  side,  amounting  to  about  five 
ounces.  At  the  lower  part  of  the  left  lung,  and  also  at  the  back  part  of  right  lung, 
there  was  a  small  amount  of  recent  membranous  exudation.  A  multitude  of  small 
cancerous  nodules  were  scattered  throughout  the  whole  of  both  lungs.  Some  were 
mnnediately  below  the  pleurpe,  and  some  in  the  substance  of  the  organs.  For  the 
most  part  these  masses  were  scattered  pretty  equally,  being  as  numerous  at  the  base 
as  at  the  apex,  and  varying  from  the  size  of  a  millet  seed  to  tliat  of  a  small  walnut. 
Some  were  of  firm  consistence,  and  others  soft  and  friable,  presenting  various  degrees 
of  induration.  Tliey  all  on  pressure  yielded  a  copious  milky  juice.  The  mucous 
membrane  of  the  bronchi  was  of  a  mahogany  colour,  and  the  tubes  were  more  or  less 
filled  with  muco-purulent  matter. 

Abdomex. — Abdominal  organs  healthy. 

Microscopic  Exajiinatiox. — The  cancerous  juice  squeezed  from  the  cervical 
glands,  and  the  nodules  scattered  throughout  the  lungs,  contained  numerous  cancer- 
cells,  which  it  is  unnecessary  to  describe  minutely  here.  (See  p.  128.)  Associated 
with  these  were  a  considera-  -.  »  -e,  .. 

ble  number  of  round  colour-  ^"•^^l  j-.  '    *  "       'a' 

less    corpuscles,    varying     in  -     \'-  /'  "•  (&j     '(ZS         '  '.^ 

diameter  from  the    150th    to  °       °  •    #    V  ^^  --^  ''<3>  ^ 

the    100th    of    a    millimetre  "  "''?\"'  -?     ^-■^'  -^     ' 

in    diameter.       An     unusual  ^  =j 

number   of   these    cells    also   '-' 
existed  in  the  blood,  as  was      C!'  „"  %    ,-  '?..•' 


determined  both  before  and 
after  death.  (See  Leucoey- 
themia.) 


^(^- 


•-     ^ 

FiL'   440 


Commentary. — In    tlie    case  before    ns,    the    chest    was    frequently 

Fig.  439.  Corpuscles  in  cancerous  juice  squeezed  from  the  thyroid  body. 

Fig.  440.  The  same,  after  the  addition  of  acetic  acid,  showing  the  cancer  cells,  and 
those  peculiar  to  the  gland,  which  were  found  in  large  numbers  in  the  blood. 
250  diam. 


698  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

examined  ■with  great  care,  and  was  ascertained  to  be  everywhere 
resonant  on  percussion.  Loud  sonorous  and  moist  rales  were  heard 
on  both  sides,  especially  posteriorly  and  itiferiorly.  Hence  there 
were  all  the  signs  of  bronchitis,  which  was  found  afterwards  to  exist ; 
but  there  was  associated  with  them  unusually  loud  vocal  resonance, 
equal  on  both  sides.  It  occurred  to  me  at  the  time  that  this  latter  sign 
was  merely  indicative  of  diminished  volume  in  the  lungs;  but,  after  the 
dissection,  it  became  manifest  that  it  was  owing  to  increased  density  of 
the  organs,  from  the  disseminated  cancerous  nodules.  AVh ether  the 
conjoined  signs  of  augmented  or  unusual  resonance  of  the  lungs,  bron- 
chitis and  increased  vocal  resonance,  will  prove  diagnostic  in  such  cases, 
further  experience  only  can  determine.  Doubtless,  it  will  be  always 
difficult  to  separate  such  signs,  dependent  on  nodular  cancer,  ft'ora  those 
connected  with  collapse  of  the  lung,  which  is  so  common  a  result  of 
chronic  bronchitis.  In  the  present  case  I  was  in  great  doubts  notwith- 
standing my  acquaintance  with  the  valuable  sign  of  tumour  in  the  neck, 
as  pointed  out  by  Dr.  Kilgour  of  Aberdeen.* 

The  treatment,  it  must  be  obvious,  could  only  be  palliative. 

Cancer  of  the  lung  may  occur  in  two  distinct  forms, — 1st,  That  of 
disseminated  nodules ;  2d,  That  of  infiltrated  masses.  In  the  former 
case  there  are  no  physical  signs,  or  functional  symptoms,  which  indicate 
the  presence  of  cancer ;  in  the  latter  there  are  unusual  dulness,  and 
resistance  on  percussion,  increased  vocal  resonance  and  tubular  breath- 
ing, or  diminished  respiration,  according  to  the  density,  position  and 
extent  of  the  cancerous  infiltration.  If  with  these  signs  there  be  indica- 
tions of  the  existence  of  cancer  in  other  parts  of  the  body,  there  will  be 
little  difficulty  in  forming  the  diagnosis;  and  even  should  this  be  absent, 
the  history  of  the  case,  advanced  period  of  life,  and  the  non-existence  of 
moist  rattles  will  occasionally  be  sufficient.  It  must  be  confessed,  how- 
ever, that  notwithstanding  the  valuable  labours  of  Stokes,  Hughes, 
M'Donnell,  AValshe,  and  Kilgour,  the  means  of  diagnosing  this  lesion 
with  certaintv  are  very  defective.  In  the  present  work,  eight  other  cases 
are  recorded  in  which  cancer  of  the  lung  existed  (Cases  XXIX., 
XXXVII.,  XLIX ,  LXV.,  LXXL,  LXXVI.,^LXXVII.,  and  LXXXV.) 
In  one  of  these  the  pleurte  only  were  aft'ected  (Case  LXXYII.)  With 
the  exception  of  Case  XXXYII.,  in  which  the  posterior  surface  of  the 
lungs  could  not  be  examined,  the  pulmonary  organs  were  carefully  per- 
cussed and  auscultated  in  all.  But  in  none  did  any  combination  or  suc- 
cession of  signs  exist  which  could  induce  any  one  to  pronounce  that  pul- 
monary cancer  was  present.  Case  LXXVI.  alone  presented  the  gelati- 
nous sputum  tinged  with  blood,  or  the  currant  jelly  expectoration 
described  bv  Stokes.  In  Case  XLIX.  there  was  ulceration  and  gangrene 
of  the  fungoid  mass,  with  all  the  signs  of  pneumonia — and  pneumonic 
condensation  was  found  surrounding  the  epithelioma  of  the  lung  after 
death.  In  Case  LXXI.  there  was  thoracic  aneurism,  to  which  all  the 
phvsical  signs  were  attributable.  "When  infiltrated  cancer  exists  to  any 
amount  in  the  apex  of  the  lungs,  associated  with  cancer  in  other  organs, 
or  with  an  evident  tumour  in  the  neck  or  mediastinum,  the  diagnosis  is 
comparatively  easy, 

*  Montbly  Journal  of  Medical  Science,  June  1850, 


CAEBONACEOUS  LUNGS.  699 

Xothing  can  be  more  variable  than  the  minute  strnctiire  of  cancer  in 
the  luno;^  AVhen  recent,  it  may  present  delicate  round  or  oval  cells 
(Fifj.  119).  When  more  advanced,  it  may  exhibit  large  compound  cells 
(FiJ.  126)  as  in  Case  LXXVI.  When  in  the  intiltrated  form  and 
soft'ened  to  any  extent,  I  have  seen  the  whole  reduced  to  a  mass  of  irre- 
jTularlv-formed  nuclei,  as  in  Fig.  325.  On  one  occasion  I  found  a  large 
mass  of  brain-like  looking  cancer  of  the  lung,  somewhat  fibrous,  and 
principally  composed  of  elongated  fusiform  corpuscles. 


CARBONACEOUS  LUNGS. 

Case  CLUl.*— Carbonaceous  Lungs  with  Black  Expectoraiion. 

History.— Thomas  "Wilson,  jet.  38,  collier,  from  the  Oakley  Mines  near  Dunferm- 
line, was  admitted  into  the  clinical  ward  26th  July  1851.  He  states  that  he  has 
been  employed  about  coal  mines  for  the  last  twenty-four  years,  during  the  principal 
part  of  which  time  he  has  been  occupied  in  blasting  rock  for  the  sinking  of  pits,  using 
large  quantities  of  gunpowder  daily.  He  is  much  exposed  to  cold  and  wet  in  this 
occupation,  working  almost  constantly  with  wet  feet,  and  frequently  with  the  whole 
of  his  clothes  drenched.  During  the  laying  open  of  a  new  surfece  for  the  working 
of  coal,  he  has  often  worked  in  an  atmosphere  barely  capable  of  supporting  the  com- 
bustion of  the  miners'  lamps;  he  has  observed  this  particularly  when  working  iron- 
stone. Notwithstanding,  it  was  only  about  seven  months  ago  that  he  began  to  be 
troubled  with  short  dry  cough,  and  difficulty  of  breathing.  He  continued  to  work 
till  about  four  months  ago,  when  the  cough  became  more  severe;  he  had  much  dys- 
pnoea, and  frequent  profuse  perspiration,  especially  at  night.  Two  weeks  after  this 
—that  is,  about  fourteen  weeks  ago — he  was  laid  up  from  work ;  and  about  the 
same  time,  while  under  treatment,  he  began  to  spit  much,  and  observed  that  the 
expectoration  was  of  a  deep  black  colour.  The  change  was  so  sudden  as  to  alarm 
him  considerably. 

Symptoms  on  Admission'. — On  admission,  the  thorax  is  of  large  dimensions  and 
well  formed.  On  percussion,  there  is  slight  comparative  dulness  on  the  left  side  of 
the  chest  over  the  upper  half  in  front ;  and  there  is  also  appreciable  dulness  over 
the  same  extent  on  the  same  side  posteriorly.  There  is  complete  resonance  on  the 
right  side  anteriorly  and  posteriorly.  On  auscultation,  for  some  inches  below  the 
clavicle  on  the  left  side,  the  inspiration  is  rough  and  harsh,  and  there  is  prolongation 
of  the  expiration.  Lower  down  on  the  same  side,  there  is  also  fine  moist  rale,  and  the 
vocal  resonance  is  somewhat  increased.  On  the  right  side  there  is  loud  pealing  vocal 
resonance  both  anteriorly  and  posteriorly ;  it  is  particularly  loud  in  front  immediately 
below  the  clavicle,  but  there  is  nothing  abnormal  to  be  detected  in  the  respiratory 
sounds.  The  expansion  of  the  chest  is  equal  on  both  sides.  Breathing  is  equal  and 
unembarrassed  while  he  is  sitting  or  lying  in  bed,  but  on  using  much  exertion,  it  be- 
comes short  and  difficult.  There  is  some  cough,  but  it  is  not  very  troublesome.  States, 
that  at  the  commencement  of  his  illness,  he  could  not  lie  on  his  left  side;  but  at  pre- 
sent he  can  lie  in  any  position  without  uneasiness.  The  sputum  is  in  considerable 
quantity,  adheres  tenaciously  to  the  bottom  of  the  spit-box,  and  is  of  an  intense  black 
colour.  On  being  placed  in  Avater,  a  small  portion  of  a  lighter  colour  swims  on  the 
surface,  but  the  greater  part  sinks  immediately.     On  being  allowed  to  stand  for  a 

*  Reported  by  Mr.  W.  Calder,  Clinical  Clerk. 


700  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

little,  the  supernatant  water  becomes  nearly  clear,  the  dense  black  mass  remaining 
at  the  bottom  of  the  dish.  Acetic,  sulphuric,  and  nitric  acids  and  also  aq.  potassse, 
though  boiled  with  tlie  sputum,  do  not  in  the  least  affect  its  colour.  The  other  s}-s- 
tenis  are  quite  normal.  Has  good  appetite,  no  sour  or  unpleasant  taste  in  his  mouth. 
Bowels  are  regular  at  present,  and  are  generally  so ;  has  never  had  diarrhoea.  Does 
not  sweat  at  night,  nor  unless  when  employed  at  his  work.  Pulse  during  examina- 
tiou  was  88.  soft  and  full;  during  his  stay  in  the  house  has  averaged  about  76.  He 
was  ordered  an  expectorant  mixture ;  and  during  the  last  fortnight  lie  was  in  the 
house,  he  had  three  table-spoonfuls  of  cod-liver  oil  daily.  He  went  out  by  his  own 
desire  in  August,  the  S3nnptoms  having  undergone  little  change. 

Microscopic  Examination  of  the  Sputum. — On  placing  a  small  portion  of 
the  sputum  below  the  microscope,  many  of  the  epitheUal  cells  are  seen  loaded  with 
the  black  carbonaceous  matter.  In  some  of  them,  the  nuclei  are  evident,  the  matter 
being  deposited  between  them  and  the  cell  walls ;  in  others,  the  nuclei  are  quite 
concealed.  In  other  parts  of  the  field,  all  appearance  of  cells  is  lost,  and  nothing  but 
apparently  homogeneous  black  nia.sses  are  visible.  Some  of  the  cells  ma}'  also  be 
seen  ruptured,  and  tlie  black  contents  poured  out.     (See  Fig.  337.) 

Com/menlary. — The  physical  signs  existinir  in  this  case  leave  ns  in  lit- 
tle doubt  that  there  was  considerable  condensation  at  the  apex  of  both 
Inno's.  Tills  was  indicated  on  one  side  by  considerable  dulness  on  per- 
cussion, and  on  the  other  by  a  pealing-  vocal  resonance.  It  is  true,  the 
resonance  in  this  place  was  unaccompanied  by  any  change  in  tlie  per- 
cussion note,  a  circumstance  that  may  be  caused  by  the  existence  of 
slight  emphysema  counterbalancing  the  increased  density  of  the  puhno- 
nary  tissue.  The  history  of  the  man's  case,  the  nature  of  his  employ- 
ment, and  the  black  sputum,  at  once  indicated  to  us  that  this  condensa- 
tion was  owing  to  accumulation  of  carbonaceous  matter  in  the  lungs,  a 
disease  which  is  peculiarly  apt  to  occur  in  coal-miners,  the  moulders  in 
iron  and  copper,  and  a  few  other  trades. 


Case  CLIV.* — Carhonaceous  Lungs  with  Black  Expectoration  in  a  Female, 

History. — Christina  Nasmyth,  a3t.  42,  tlie  wife  of  a  coal  miner  residing  near  Mus- 
selburgh— admitted  21st  May,  1857.  For  nine  years  previous  to  marriage  she 
worked  in  a  coal  pit,  being  engaged  in  pushing  the  trucks  along  the  tram-ways. 
She  married  at  sixteen  years  of  age,  and  has  never  since  worked  in  the  pit.  She 
has  had  four  children,  all  healthy.  Her  own  health  she  declares  to  have  been  excel- 
lent till  January,  1857.  About  this  time  she  noticed  a  cough  accompanied  by 
sputum  of  inky  black  colour,  and  by  sense  of  pain  over  the  breast  and  between  the 
shoulders.  Her  appetite  failed,  and  she  became  very  weak.  Latterly  her  voice  has 
become  hoarse  and  broken.  Medical  treatment  before  admission  had  not  been 
effectual. 

Symptoms  on  Admission. — No  dyspnoea ;  cougli  is  unfrequent,  short,  and  ratlier 
dry;  sputum  scanty,  consisting  of  frothy  blood  with  tenacious  masses  of  bluish- 
black  mucus;  painful  sense  of  tightness  over  the  breast;  the  voice  is  liarsh  and 
broken.  There  is  sliglit  dulness  under  the  right  clavicle,  with  creaking  sound  during 
inspiration,  prolonged  expiration,  and  some  increase  of  vocal  resonance.  Tliere  is 
crack-pot  soutid  under  left  clavicle,  bronchial  respiration  with  a  few  moist  sounds 
at  close  of  inspiration,  and  increased  vocal  resonance ;  posteriorly,  percussion  seems 

*  Reported  by  S.  de  Melho  Aserappa,  Clinical  Clerk. 


CARBONACEOUS   LUNGS.  701 

unimpaired  ;  no  moist  sounds  are  audible,  but  occasional  sibilant  and  snoring  sounds 
during  expiration  over  middle  of  both  lungs.  The  cardiac  organ  is  normal  in  posi- 
tion and  size ;  the  first  sound  is  rough  at  apex ;  the  pulse  is  80,  and  of  good  strength. 
Appetite  is  defective ;  occasional  thirst  in  the  mornings ;  no  vomiting;  considerable 
flatulence;  bowels  are  open  generally  every  second  day;  menstruation  regular; 
urine  1010  sp.  gr.,  otherwise  normal. 

Progress  of  the  Case. — May  23d. — No  trace  of  blood  in  the  sputum,  which 
consists  of  several  tenacious  masses  of  a  bluish-black  colour,  floating  in  a  slightly 
viscous  mucus.  On  microscopic  examination,  there  are  seen  numerous  molecules  of 
pigment  occasionally  lying  free,  but  sometimes  contained  in  large  cells ;  there  are 
also  visible  a  few  bundles  of  fibrous  and  elastic  tissue.  Ordered  milk  and  steak  diet. 
26th. — Xo  moist  sounds  are  now  audible  under  left  clavicle;  respiration  continues  to 
be  loudly  bronchial  at  left  apex,  and  less  so,  but  still  unusually  loud  over  the  right ; 
hoarseness  of  voice  has  diminished.  27th. —  Ordered  Emplastrum  Picis  (6  by  6)  to 
be  applied  over  the  chest.  28th. — No  change  in  respiratory  murmurs,  nor  in  sputum ; 
some  dyspnoea,  and  considerable  debility.  Is  ordered  a  mixture  of  sweet  spirits  of 
nitre  and  aromatic  spirits  of  ammonia.  29fh. — The  black  masses  are  now  fewer  in 
number.  June  1st. — Hoarseness  of  voice  has  ceased;  sputum  more  scanty,  with 
fewer  black  masses;  appetite  is  improved;  patient  walks  daily  about  the  ward. 
June  Gih. — Has  continued  in  the  same  state  as  in  last  report ;  is  anxious  now  to 
return  to  her  family,  and  is  accordingly  discharged  to-day  relieved. 

Commentary. — It  would  appear  from  the  account  of  this  woman,  that 
from  the  age  of  seven  to  that  of  sixteen  years  she  worked  in  a  coal-pit. 
She  then  married,  ceased  to  work  in  the  pit,  and  continued  healthy  for 
twentv-six  years.  Then  for  the  first  time  cough  came  on  accompanied 
with  black  spit  and  disorganization  of  the  lung.  This  circumstance 
proves  that  the  tendency  to  carbonaceous  formation  may  be  formed 
several  years  before  it  becomes  manifested  in  active  disease,  which  may 
be  induced  subsequently  by  any  of  the  ordinary  causes  which  occasion 
bronchitis  or  pneumonia.  Young  girls  are  not  now  so  much  employed 
in  coal-pits  as  formerly,  and  such  a  case  as  the  above  must  now  be  con- 
sidered, in  many  points  of  view,  as  one  of  great  rarity. 

From  the  circumstance  of  this  disease  being  very  common  among  the 
colliers  in  the  neighbourhood  of  Edinbui-gh,  it  has  been  thoroughly  studied 
here.  In  the  first  case  that  Avas  recorded  by  Dr.  James  Gregory,  the 
black  matter  was  analysed  by  Dr.  Christison,  and  shown  by  him  to  con- 
sist of  pure  carbon  or  lamp  black,  a  result  confirmed  by  every  subsequent 
writer.  The  papers  by  Dr.  William  Thomson,  inserted  in  the  XX.  and 
XXI.  Vols,  of  the  Transactions  of  the  Medico-Chirurgical  Society  of 
London,  contain  a  mass  of  important  information  concerning  this  disease  ; 
and  in  a  series  of  communications  by  the  late  Dr.  Mackellar,  inserted  in 
the  "]\Ionthly  Journal"  for  1845,  you  will  find  numerous  facts  and 
opinions  regarding  it,  the  results  of  long  and  extensive  practice  among 
the  colliers  of  Haddingtonshire. 

On  examining  the  lungs  of  those  who  die  labouring  under  this  disease, 
thev  are  found  to  present  a  deep  black  colour,  which  is  most  intense 
towards  their  apices.  On  section,  the  pulmonary  tissue  yields  on  pressure 
a  copious  black  inky  juice,  which  stains  all  surrounding  objects,  attaches 
itself  to  the  inequalities  on  the  skin  of  the  hands,  and  insinuates  itself 


702  DISEASES    OF   THE    RESPIRATORY   SYSTEM. 

under  the  nails  like  fine  black  paint.  At  tlie  apices  of  tlie  lungs,  the 
pulmonary  tissue  is  generally  more  or  less  condensed,  and  the  black 
matter  thicker,  and  often  of  the  consistence  of  putty.  In  advanced  cases, 
ulcerations  and  cavities  exist,  exactly  resembling  in  all  their  characters 
those  of  phthisis,  with  the  exception  that  no  tubercle  can  be  discovered, 
and  that  the  whole  is  of  an  intense  black  colour.  Occasionally  black 
indurated  and  gritty  masses  can  be  felt  and  dug  out,  which  in  some  rare 
cases  present  a  slight  crystallized  structure,  like  coal  or  crystallized  car- 
bon. The  morbid  anatomy  of  the  disease  will  be  best  understood  by 
carefulh'  examining  the  preparations  which  exist  in  the  University 
Museum. 

On  placing  some  of  the  black  fluid  squeezed  from  the  lung  under  a 
microscope,  and  examining  it  with  a  power  of  250  diameters  linear,  it  is 
seen  to  consist  of  a  multitude  of  black  molecules  of  extreme  minuteness 
floating  in  a  liquid.  Here  and  there  may  be  observed  cells,  similar  to 
those  previously  described  as  existing  in  the  sputum,  more  or  less  loaded 
with  similar  molecules  of  black  matter,  on  which  the  strongest  chemical 
re-agents  produce  no  efl'ect  whatever.  (See  Figs.  56,  57,  and  337.)  I 
have  frequently  examined  the  disease  in  all  its  stages,  and  never  found  it 
to  be  referrable  to  the  changes  occurring  in  blood  after  hemorrhagic 
extravasations,  as  Yirchow  supposes  to  be  the  case. 

When  w^e  endeavour  to  investigate  the  pathology  of  this  disorder,  we 
are  met  with  a  host  of  difliculties.  Does  it  originate  from  the  inhalation 
of  carbonaceous  particles  floating  in  the  atmosphere,  or  is  it  the  result  of 
a  secretion  of  carbon  in  the  pulmonary  system  itself? 

The  principal  fact  on  which  the  first  opinion  rests,  is  the  frequency  of 
the  disease  in  colliers,  and  in  moulders  of  iron  and  copper.  Yet  it  is 
curious,  that  whilst  it  is  common  among  the  workmen  of  some  coal  pits, 
it  is  unknown  among  those  employed  in  others,  although  the  dust  and 
powder  is  as  finely  levigated  in  one  place  as  in  the  other. 

There  is  another  curious  fact  connected  with  the  disease  in  coal  miners, 
viz.,  that  those  engaged  in  working  at  what  is  called  the  coal  wall,  and 
in  sifting  or  transporting  the  coal,  are  little  afi^ected ;  whilst  those  who 
work  at  the  stone  wall  are  peculiarly  liable.  This  working  at  the  stone 
wall,  consists  in  blasting  the  rock  by  means  of  gunpowder.  Hence  the 
prevalence  of  black  deposits  in  the  lungs  has  been  by  some  not  so  much 
attributed  to  the  dust  of  coal,  as  to  the  smoke  of  the  explosions,  or  of  the 
lamps  carried  by  the  miners,  confined  as  it  is  in  narrow  passages,  where 
little  ventilation  exists. 

Even  this  explanation  has  difliculties  ;  for  it  has  been  proved,  that  in 
some  mines,  where  blasting  is  carried  on  very  extensively,  and  where 
there  is  much  coal  dust,  it  does  not  exist  at  all ;  and  hence  it  has  been 
supposed  that  there  are  some  kinds  of  stone  which  disengage  gases,  or  the 
working  among  which  is  much  more  deleterious  than  others.  Thus  Mr. 
Philip  of  Aberdour,  who  has  had  great  experience  in  this  disease,  in  a 
communication  he  made  to  Dr.  Thomson,  savs,  "  In  working  at  stone 
work,  that  is,  in  sinking  pits  and  driving  mines  of  communication,  the 
workmen  are  exposed,  in  an  imminent  degree,  to  the  influence  of  the 
impure  air;  for,  besides  working  in  a  confined  space,  and  in  a  cul-de-sac, 
where  the  ventilation  is  very  impertect,  there  is  also  a  considerable 
exudation  of  the  carbonic  acid  gas  from  the  fresh  cut  surfaces  of  the 


CARBONACEOUS   LUNGS.  703 

minerals.  In  this  impure  air  tliey  continue  to  -work  for  many'  liours 
daily,  for  some  montlis,  their  operations  being  frequently  carried  on 
several  yards  in  advance  of  where  their  lamps  will  burn."  In  another 
place,  he  says,  "Those  pits  and  mines  which  have  been  noted  for  the 
impurity  of  the  air,  have  given  origin  to  the  greatest  number  of  cases." 

Again,  Mr.  Steele  of  Craighall  says,  he  considers  the  disease  to  be 
caused  by  running  mines  in  stone,  and  working  in  impure  air.  He  also 
observes, — "  A  principal  reason  is,  that  the  stone  contains  some  poisonous 
matter,  which  is  probably  of  a  metallic  nature,  as  the  workmen  complain 
of  it  exciting  a  styptic  and  metallic  taste  in  the  mouth.  A  mine  was 
carried  across  the  strata  in  the  Niddrv  estate,  the  finishing  of  which 
required  a  number  of  vears.  Six  or  eight  of  the  miners  employed  in  it 
died ;  several  were  obliged  to  leave  it,  and  only  one  of  those  who  com- 
menced it  was  able  to  work  in  it  throughout,  and  lived  to  see  it  com- 
pleted. There  was  a  particular  stone  in  this  mine,  which  was  repeatedly 
met  with,  and  to  which  the  miners  gave  the  name  of  arsenic,  which  was 
found  highly  pestiferous.  Its  exact  nature  I  am  not  acquainted  with. 
In  a  stone  mine,  run  some  years  ago  in  the  Newbattle  field,  a  great  many 
men  died, — the  average  length  of  time  each  of  the  miners  employed  in  it 
lived  being  about  two  years.  The  mortality  was  ascribed  to  the  nature 
of  the  stone." 

The  facts  connected  with  this  peculiar  black  colouring  of  the  lung 
leave  it  therefore  undecided  whether  it  be  owing  to  the  inhalation  of 
coal  dust,  the  smoke  of  gunpowder  and  oil  lamps,  or  caibonic  acid  gas, 
entering  the  lung.  Is  the  powder  deposited  directly  and  primarily  in 
the  minute  tissue  of  the  organ,  or  is  the  carbon  deposited  secondarily, 
and  by  a  process  of  secretion  from  the  blood  ? 

Before  we  can  answer  these  questions,  there  are  two  other  series  of 
cases,  which  it  is  necessary  to  take  into  consideration.  1st,  Persons  have 
been  known  to  have  the  black  spit,  and  black  infiltrated  appearance  of 
the  lungs,  with  caverns,  without  ever  having  been  in  a  coal  mine,  or 
exjiosed  in  anr  w;iv  to  gunpowder  smoke.  Several  such  cases  are  given 
in  the  paper  of  Dr.  W.  Thomson.  One  of  these  is  by  Dr.  Browne,  now 
Commissioner  of  Lunacy  for  Scotland  ;  another  by  the  late  Dr.  Moir  of 
Musselburgh.  The  subject  of  this  last  case  was  never  exposed  to  noxious 
vapours,  unless  it  might  be  carbonic  acid, — as  he  was  the  proprietor  of 
an  extensive  brewery,  and  in  the  daily  habit  of  inspecting  the  tun-rooms, 
the  large  vats  in  which  overflow  with  that  deleterious  gas.  Another  case 
was  observed  by  the  same  gentleman,  in  the  person  of  a  coachman, 
where,  after  death,  the  lungs  were  found  to  contain  collections  of  an  inky 
or  tarry  fluid,  which  stained  the  fingers,  as  if  with  soot  or  charcoal.  A 
fourth  and  similar  case,  in  a  woman,  is  related  by  Dr.  Ycitch.  In  none 
of  these  cases  were  the  individuals  exposed  to  the  fumes  of  smoke,  or 
coal  dust.  I  have  myself  seen  several  of  such  cases ;  in  one  especially, 
a  cyst  in  the  bronchial  gland  existed,  about  the  size  of  the  human  eye- 
ball, filled  with  a  black  inky  fluid. 

2(7,  M.  Guillot  of  Paris  has  brought  forward  another  scries  of  cases  in 
old  persons.*  He  is  physician  to  the  hospital  for  aged  people,  and  says 
there  is  scarcely^an  individual  of  advanced  life  who  does  not  present  the 

*  Archives  Generales  de  Medecine,  vol.  67. 


704  DISEASES   OF   THE    RESPIRATORY   SYSTEM. 

carbonaceous  deposit  in  the  lung,  generally  most  marked  at  the  apex. 
The  carbon  often  exists  in  crude  masses,  obliterating  the  vessels  and  bron- 
chial tubes.  I  have  also  seen  many  cases  of  this  kind,  and  there  can  be  no 
doubt  that  the  longer  we  live,  the"more  carbon  is  deposited  in  the  lungs. 
In  intants,  as  is  well  known,  those  organs  are  of  a  light  pink  colour,  and 
they  become  more  grav  and  of  a  deep  blue  or  black  tint  as  life  advances. 

What  are  we  to  conclude  from  these  causes  ?  The  black  matter  in  all 
of  them,  when  chemically  examined,  is  undoubtedly  free  carbon,  and  is 
distiniruished  bv  the  action  of  chemical  agents;  hence  it  is  not  likely  to 
be  an  alteration" of  hjematin,  resulting  from  bloody  extravasations  into  the 
pulmonarv  tissue,  as  Virchow  supposes.  It  never  presents  the  brownish 
colour  orstructural  character  we  have  shown  to  be  present  in  coal,*  a 
circumstance  opposed  to  its  being  derived  from  without,  in  the  form  of 
dust.  Dr.  Pearsonf  thought  that  we  are  always  insensibly  breathing 
an  air  more  or  less  loaded  with  smoke,  the  results  of  combustion,  and 
other  impurities ;  and  that  this  of  course  accumulates  the  older  we  get. 
If  this  opinion  were  true,  it  should  be  more  common  in  persons  who 
inhabit  densely  populated  and  manufacturing  towns,  as  London,  Liver- 
pool, Manchester,  or  Glasgow.  Yet  we  do  not  find  this  to  be  the  case. 
The  air  in  Paris  is  remarkably  pure,  the  fires  of  manufactories  are  few, 
and  vet  there,  according  to  (juillot,  it  is  common. 

On  the  other  hand,  should  we  conclude  that  it  is  formed  internally  by 
a  chemical  process  in  all  cases  ?  If  so,  must  we  ascribe  it  to  the  inhala- 
tion of  carbonic  acid  gas,  rather  than  to  carbon  in  a  minutely  divided 
state,  inspired  from  without  ?  In  the  present  state  of  our  knowledge,  we 
cannot  answer  these  questions  with  any  exactitude. 

Another  point  of  great  interest  is  the  apparent  antagonism  of  carbona- 
ceous deposits  with  tubercle. 

We  frequently  find  the  black  lungs  of  colliers  to  contain  small  or  large 
ulcerated  cavities,  with  bands  crossiiig  them;  but  we  rarely  find  tubercle. 
In  one  or  two  cases  chronic  tubercle  has  been  found ;  but  it  does  not 
appear  that  the  caverns  filled  with  black  matter  in  the.  miner  are  owing 
to  tubercle.  Such  is  the  analogy,  however,  existing  between  these  cavi- 
ties, and  the  symptoms  they  occasion,  that  the  disease  has  been  named 
"  black  phthisis"  by  severalpersons.  Some  have  supposed  that  tubercu- 
lar tissue  is  first  set  up,  and  that  the  carbonaceous  deposit  is  then  insinu- 
ated among  the  textures  and  ulcerations.  By  others,  and  especially  l>y 
the  late  Dr.  Mackellar,  it  is  maintaiue'l  that  there  is  never  tubercle  in 
these  cases,  and  that  ulceration  is  entirely  owing  to  the  accumulation  of 
masses  of  carbon  which  are  expectorated.  I  have  carefully  examined 
several  lungs  in  various  stages  of  the  disease,  but  have  never  been  able  to 
satisfv  m  vself  of  the  existence  of  tubercle.  The  difficulty  of  the  investiga- 
tion, however,  is  very  great,  for  it  is  probable  that,  did  a  tubercular  exuda- 
tion exist,  it  would  "be  so  impresrnated  with  the  carbonaceous  matter,  as 
not  to  be  recognisable  even  under  high  powers.  On  the  other  hand,  the 
bronchial  tubes  are  frequently  loaded  with  purulent  matter  of  the  usual 
appearance,  but  which,  instead  of  presenting  pus-corpuscles,  is  loaded 
with  particles  closely  resembling  those  found  in  softened  tubercle. 

*  See  the  Author's  paper  on  the  structure  of  various  kinds  of  coal.     Transaclions 
of  the  Royal  Society  of  Edinburgh,  vol.  xxi.  part  I. 
f  Philosophical  Transactions,  1853. 


CARBONACEOUS   LUNGS,  705 

Giiillot  has  alluded  to  the  well-known  fact,  that  in  old  persons  who  pre- 
sent traces  of  tubercle,  the  cretaceous  conci'Ctions  are  always  surrounded 
by  black  matter.  He  thinks  that  the  carbonaceous  deposit  compresses 
the  capillaries  which  immediately  surround  the  tubercle,  prevents  its 
further  exudation,  and  so  imluces  cure.  But  this  is  by  no  means  invaria- 
ble. Still  it  is  an  undoubted  fact,  that  the  black  matter,  like  tubercle, 
always  exists  in  greater  proportion  at  the  apex  of  the  lung,  and  the 
rarity  of  recent  tubercle  in  combination  with  it,  leads  us  to  suppose  that 
it  exerts  a  peculiar  influence  on  tubercular  deposits.  I  have  also  seen 
black  matter  surrounding  tubercle  of  the  peritoneum,  but  in  this  situation 
it  has  not  been  free  carbon,  for  long  immersion  in  spirit  has  caused  the 
disappearance  of  all  colour.     (See  Fig.  330.) 

So  far  as  my  observations  have  yet  carried  me,  no  difference  is  to  be 
determined  structurally  between  the  pigment  of  melanosis  and  that  of 
the  disease  under  consideration.  Some  cells  spit  up  by  the  miner,  con- 
taining black  granules,  exactly  resemble  those  in  melanic  cancer.  (Com- 
pare Figs.  336  and  337.)  On  the  other  hand,  there  is  a  marked 
ditference  in  the  chemical  constitution  ;  as  in  the  one,  the  black  pigment, 
whatever  be  its  nature,  is  fugitive,  and  removable  by  mineral  acids ;  in 
the  other,  fixed,  and  unchanged  even  under  the  blow-pipe.  Hence  all 
black  deposits  maybe  divided  into  two  classes;  to  distinguish  which  we 
mav  call  one  class  bv  the  name  it  has  so  long  borne,  viz.,  "  melanotic^'' 
and  the  other,  from  its  chemical  composition,  "  carbonaceous.''' 

With  regard  to  the  treatment  of  individual  cases  of  black  phthisis, 
there  is  little  to  be  said.  The  disease,  once  established,  does  not  admit 
of  cure  bv  art ;  and  it  is  a  curious  fact,  that  a  man  may  work  in  a  coal 
mine  for  many  years  without  the  black  spit;  but  when  it  comes  on, 
even  should  he  leave  the  mine  immediately,  he  will  continue  to  expecto- 
rate carbonaceous  matter  for  a  long  time  afterwards.  Of  this  both  the 
cases  before  us  are  corroborative,  and  the  circumstance  is  one  which 
constitutes  a  strong  argument  in  favour  of  those  who  contend  for  the 
disease  being  dependent  upon  a  secretion  rather  than  a  mechanical 
deposition  of  carbon.  A  palliative  treatment,  guided  by  the  nature  of 
the  svmptoras  and  strength  of  the  constitution,  is  all  that  is  admissible. 
The  only  means  of  preventing  the  disease  seems  to  consist  in  ventilating 
the  mines  where  colliers  work,  or  adopting  the  means  of  carrying  off  the 
fumes  to  which  the  moulders  of  iron  and  copper  are  exposed.  Such 
prophylactic  measures  are  equally  called  for,  whatever  theory  of  the 
nature  of  the  disorder  shall  ultimately  be  proved  to  be  correct. 


45 


SECTION  YIII. 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 

In  no  department  of  medicine  lias  our  knowledge  of  the  diagnosis  and 
treatment  of  disease  made  more  rapid  progress  in  recent  times  than  iu 
that  relating  to  disorders  of  the  genito-urinary  system.  Notwithstand- 
ing what  has  been  very  justly  said  as  to  the  impropriety  and  frequent 
danger  of  unnecessary  mechanical  exploration  of  the  uterine  passages 
with  instruments,  it  cannot  be  denied  that,  used  with  judgment  and  dis- 
cretion, they  have  materially  contributed  to  a  recognition  and  successful 
treatment  of  lesions  that  would  otherwise  have  been  unknown  or  misun- 
derstood. The  use  of  the  microscope  in  the  examination  of  the  urine, 
conjoined  with  an  histological  investigation  of  morbid  alterations  in  the 
kidney,  hitherto  grouped  together  under  the  name  of  "  Bright's  Disease," 
has  also  thrown  a  flood  of  light  upon  a  class  of  disorders  formerly 
involved  in  the  greatest  obscurity,  besides  opening  up  a  field  to  the 
chemical  pathologist  in  his  endeavour  to  work  out  the  transformations 
necessarj^  for  the  excretory  processes,  which  cannot  be  too  highly  valued. 
From  these  various  investigations  medicine  has  already  derived  great 
advantage,  and  will  doubtless  obtain  much  more.  The  diseases  of  the 
generative  organs  of  women,  however,  constitute  at  present  so  peculiarly 
a  speciality  of  the  obstetrician,  that  the  only  one  of  them  that  I  shall 
allude  to  is 


OVARIAN  DROPSY. 

Case  CLV.* — Ovarian  Dropsy — Frequent  Paracentesis — Excision  of  both  Ovaries — 
Strangulation  of  the  Intestine — Phlebitis — Death  from  Ileus  the  seventieth  day 
after  the  operation. 

History. — Jessie  Fleming,  unmarried,  set.  20 — admitted  July  5th,  184.5.     She 
states,  that  eighteen  months  ago  slie  first  perceived  a  tumour  in  the  lower  part  of 

*  Reported  by  Mr.  D.  P.  Morris,  Clinical  Clerk. 


OVARIAN   DROPSY.  707 

the  abdomen,  deep  seated  in  the  middle  of  the  hypogastrium.  She  remembers  that 
she  could  push  it  aside  in  various  directions  without  pain,  and  that  at  this  time  it 
was  about  the  size  of  an  orange.  She  can  assign  no  cause  for  its  appearance.  The 
tumour  rapidly  increased  in  bulk,  until  at  the  end  of  ten  months  the  abdomen  was 
greatly  distended — so  much  so,  that  respiration  and  progression  were  rendered 
difiScult.  Paracentesis  was  now  performed,  and  forty  imperial  pints  of  a  viscid 
yellowish-coloured  fluid  were  removed.  The  abdomen,  however,  again  rapidly 
increased  in  size,  and  paracentesis  was  again  had  recourse  to.  The  operation  has 
now  been  performed  six  times,  the  intervals  between  each  becoming  less  and  less 
lengthened,  and  the  amount  of  fluid,  though  always  considerable,  varying  in  amount. 
She  says  that  immediately  after  every  tapping,  a  tumour  can  be  felt  about  the  size 
of  a  child's  head  on  each  side  of  the  abdomen ;  that  these  tumours  (she  thinks  there 
are  two)  are  movable  laterally,  but  seem  to  grow  from  below.  She  thinks  the  one 
on  the  left  side  is  larger  and  higher  up  than  that  on  tlie  right.  Her  general  health 
has  been  little  affected  by  the  disease. 

Symptoms  ox  Admission'. — At  present,  July  6th,  she  complains  of  pain  in  the 
head,  which  is  stated  to  be  dull  and  hea\y,  and  seated  principally  over  tlie  forehead. 
It  comes  on  occasionally,  and  lasts  for  three  or  four  days  at  a  time.  She  has  pain  in 
the  loins  very  frequently,  especially  when  the  dropsy  is  large.  Special  senses  and 
common  sensibility  normal.  Her  sleep  is  much  disturbed  by  breatlilessness.  and  by 
the  semi-erect  posture  the  dropsy  requu-es.  Motion  is  impeded  by  the  size  of  the 
abdomen,  and  from  its  great  weight.  There  is  much  muscular  weakness.  The 
abdomen  measures  48^  inches  at  its  largest  girih,  which  is  just  above  the  navel.  It 
fluctuates  distinctly.  Dulness  of  the  liver  cannot  be  defined  by  percussion.  The 
skin  of  the  abdomen  is  marked  by  transverse  fissures  or  marks  of  a  purplish  colour; 
it  often  feels  very  hot  and  as  if  it  were  bursting ;  tongue  clean ;  appetite  a  little 
impaired ;  no  thirst  or  sickness ;  bowels  regular ;  stools  somewhat  fluid,  but  of 
healthy  a.spect ;  urine  scanty,  thick,  high  coloured,  of  acid  reaction  containing  a 
yellowish  brown  sediment,  but  unaffected  by  heat;  skin  dry,  not  warmer  than  usual. 
She  states  that  she  never  perspires.  Has  no  cough  or  pectoral  complaints  except 
dyspnoea,  which  is  very  severe  at  night.  On  auscultation  the  chest  appears  to  be 
healthy.  Pulse  88,  sharp  and  small ;  heart's  sounds  apparently  abrupt,  but  natural. 
The  cataraenia  have  appeared  at  irregular  intervals,  sometimes  of  three  weeks,  at 
others  five  weeks,  and  when  present  are  profuse. 

Progress  of  the  Case. — From  this  time  she  remained  generally  in  about  the 
same  condition.  The  urine  passed  in  the  twenty-four  hours  never  exceeded  twelve 
ounces,  and  on  one  occasion  was  as  low  as  six  ounces.  The  abdomen  gradually 
became  more  tense  and  the  dyspnoea  more  urgent.  July  \2th. — ilr.  Syme  performed 
the  operation  of  paracentesis  of  the  abdomen.  Tlie  trocar  was  introduced  to  the  left 
of  the  linea  alba,  about  two  inches  above  the  pubic  bone.  Five  imperial  gallons  of 
a  yellow-coloured  transparent  fluid  were  removed.  The  last  four  ounces  which  came 
off  were  viscid  like  white  of  egg,  and  contained  a  few  yellowish  opaque  flocculi. 
The  fluid  was  densely  coagulable  on  application  of  heat  or  nitric  acid.  The  flocculi, 
when  examined  with  the  microscope,  were  found  to  be  composed  not  of  lymph,  as 
was  at  first  supposed,  but  of  numerous  cells,  varying  in  size  from  the  100th  to  tlie 
40th  of  a  millimetre  in  diameter.  The  great  majority  were  about  the  50th  of  a  mil- 
limetre. They  were  slightly  granular,  of  round  and  oval  shape,  unaSected  by  water, 
but  becoming  more  transparent  on  the  addition  of  acetic  acid,  and  exhibiting  a  dis- 
tinct nucleus  about  the  140th  of  a  millimetre  in  diameter.  (See  Fig.  70.)  The 
nucleated  cells  were  imbedded  in  a  granular  matter  which  could  easily  be  broken 
down.  Shortly  after  the  operation,  she  complained  of  considerable  pain  in  the 
abdomen  towards  the  left  side,  which  was  not  increased  on  pressure.      Fifty  minims 


708  DISEASES   OF   THE   GENITO-UPJNARY  SYSTEil. 

of  tincture  of  opium  to  be  takea  immediately.     July  loth. — Has  continued  to  feel 
more  or  less  pain  in  the  abdomen,  wliich  is  not  superficial  or  peritoneal.    The  bowels 
have  been  freely  opened  by  compound  jalap  powder,  and  she  has  passed  from  48  to 
50  oz.  of  urine  daily.    The  puncture  is  now  healed ;  the  abdomen  is  still  voluminous 
but  soft.     On  palpation,  a  tumour  with  distinct  margins,  about  the  size  of  the  adult 
human  head,  may  be  distinctly  felt,  firmly  attached  inferiorly  within  the  pelvis,  but 
its  upper  portion  movable  to  a  considerable  extent  from  side  to  side.      She  describes 
the  pain  as  being  of  a  dull,  gnawing,  and  continued  character ;  not  lancinating  nor 
increased  on  movement.     Pulse  98,  of  natural  strength  ;  tongue  slightly  furred ;  has 
tolerable  appetite ;  no  thirst,  but  says  she  vomits  everything  she  takes.    The  matters 
vomited  are  thrown  up  about  ten  minutes  after  each  meal,  in  successive  mouthfuls, 
accompanied  by  gnawing  pains  at  the  stomach      These  latter  pains  are  felt  under 
the  false  ribs  on  the  right  side.     The  stomach  is  often  felt  to  be  distended,  followed 
by  considerable  eructations  of  gas;  bowels  have  been  open  four  or  five  times;  urine 
much  increased  in  amount   since  the  operation ;    to-day  she    passed    thirty-eight 
ounces.     The  compound  jalap  powder  was  directed  to  be  given  again.     July  18th. — 
To-day  she  was  carefully  examined  by  Professor  Simpson,  who  employed  his  uterine 
bougie.     By  this  means  the  fundus  of  the  uterus  was  raised  above  the  brim  of  the 
pelvis,  where  it  was  distinctly  felt  presenting  its  obtuse,  rounded,  natural  form.    The 
Professor  stated  his  opinion  that  the  tumour  was  connected  to  the  left  ovary  by  a 
narrow  pedicle.     Urine  ten  ounces.     July  19th. — The  examination  of  yesterday  was 
followed  by  great  pain.     She  described  this  as  being  "  tremendous,"  and  seated  ui 
the  back.     The  nurse  said  she  cried  out  as  a  woman  in  labour.     About  two  and  a 
half  hours  afterwards  a  draught  containing  one  drachm  of  solution  of  morphia  was 
given.     It  relieved  the  pain,  but  it  continued  until  11  p.m.     An  anod\-iie  and  ether 
draught  was  then  given,  which  was  immediately  rejected  by  vomiting.     August  7th. 
—Since  last  report  the  vomiting  has  gradually  abated,  under  the  influence  of  opium 
and  creosote  pills.    The  urine,  however,  has  again  diminished  in  amount,  and  for  the 
last  ten  days  has  only  been  from  ten  to  twelve  ounces,  while  the  size  of  the  abdomen 
has  slowly  increased  to  its  former  volume.     To-day,  paracentesis  was  performed  by 
Dr.  James  Duncan,  and  five  and  a  half  gallons  of  fluid  removed,  presenting  the  same 
characters  as  that  described  July  12th.     Soon  after  the  operation,  she  experienced 
considerable  pain  in  the  back  and  upper  parts  of  the  abdomen,  which  ceased  at 
midnight  after  taking  a  draught  with  half  a  drachm  of  the  solution  of  morphia. 
Aug.  16ih. — Since  last  report  has  been  in  the  Surgical  Hospital     Dr.  Bennett  pro- 
posed to  the  acting  surgeons  severally  the  operation  of  ovariotomy,  which  they 
declined  to  perform.    To-day,  accordingly,  she  returned  to  the  medical  ward.    During 
the  interval  her  general  health  has  been  good.     The  fluid  in  the  abdomen  is  again 
accumulating.     By  a  careful  examination  the  tumour  can  be  ascertained  to  be  quite 
free  from  adhesions  to  the  anterior  walls  oi"  the  abdomen.    These  latter  can  be  pulled 
forwards  and  held  steady,  while  the  tumour  is  made  to  roll  free  beneath.     Passed 
during  the  last  24=  hours  eighteen  ounces  of  urine.     The  liver  was  carefully  per- 
cussed.    Its  extreme  dulness  in  the  right  hypochondrium  is  three  inches  ;  it  is 
pushed  considerably  upwards,  the  upper  line  of  dulness  being  on  a  level  with  the 
nipple.     She  denies  ever  having  suffered  from  dyspeptic  symptoms,  or   so-called 
attacks  of  bile ;  and  her  general  health  is  in  every  respect  good,  and  the  amount  of 
urine  discharged  diminishing.     Her  general  health  is  not  so  robust  as  when  she  first 
entered  the  house.     Dismissed  from  the  Infirmary  August  2Ath. 

September  3d— After  leaving  the  Infirmary,  she  went  into  lodgings,  having  been 
placed  by  Dr.  Bennett  under  the  care  of  Dr.  Handyside.  On  the  2d  that  gentleman 
performed  paracentesis,  and  removed  four  gallons  of  fluid,  and  to-da}-,  having  satis- 
fied himself  that  it  was  a  case  urgently  caUing  for  the  performance  of  ovariotomy, 


OVARIAN   DROPSY.  709 

lie  consented  to  perform  it  according  to  tlie  request  previously  made  to  him  by  Dr. 
Bennett.  Sept.  SdA.— Bowels  liave  been  opened  four  times  during  tlie  uiglit,  tlie  last 
time  at  8  this  morning,  from  the  purgative  of  Ext.  Colocynth,  gr.  x.,  administered 
yesterday  evening,  and  a  domestic  enema  given  this  morning.  Slie  is  in  good  health 
and  spirits.     Tongue  clean. 

Operation  of  Ovariotomy. — The  operation  was  performed,  September  5th,  at 
half-past  12  by  Dr.  Handy  side,  in  the  presence  of  Drs.  Beilb}',  Simpson,  W.  Campbell, 
A.  D.  Campbell,  Baillie,  Bennett,  and  Struthers,  and  Professor  Goodslr.  The 
temperature  of  the  room  was  raised  to  72°.  The  patient  was  placed  on  a  table 
before  a  good  light,  her  feet  resting  on  a  stool,  and  her  shoulders  raised  and  supported 
by  pillows.  Dr.  Handyside,  now  standing  to  the  right  side  of  tlie  patient,  made, 
with  a  strong  scalpel,  an  incision  of  about  three  inches  in  length  through  the  skin 
and  subcutaneous  cellular  tissue,  midway  between  the  umbilicus  and  pubes  and 
over  the  linea  alba.  This  incision  was  deepened  carefully,  the  linea  alba  divided, 
and  the  peritoneum  reached.  A  fold  of  this  membrane  was  pinched  up  with  the 
forceps,  and  a  small  opening  made  into  it.  Through  this  opening  some  glairy  fluid 
escaped,  indicating  that  the  cavity  of  the  abdomen  had  been  opened.  With  a  probe- 
pointed  bistoury  the  peritoneum  was  now  slit  open  to  the  extent  of  an  inch  less 
than  the  external  wound.  A  large  quantity  of  the  glairy  fluid  then  escaped,  which 
occasioned  some  delay.  Through  this  opening  Dr.  Handyside  now  introduced  two 
of  his  fingers  in  order  to  ascertain  that  no  adhesions  existed  on  the  exterior  surface 
of  the  tumour.  Xone  being  felt,  the  wound  was  dilated  upwards  for  other  three 
inches,  with  a  probe-pointed  bistoury,  which  was  guided  by  two  fingers  introduced 
into  the  abdomen.  Through  this  opening  Dr.  Handyside  introduced  his  whole 
hand,  and  finding  the  tumour  nowhere  adherent,  the  wound  was  extended  upwards 
to  rather  more  than  midway  between  the  umbilicus  and  the  ensiform  cartilage,  and 
do\vnwards  to  within  two  inches  of  the  symphysis  pubis.  In  cuttmg  upwards, 
the  umbilicus  was  avoided,  the  incision  passing  to  the  left  side  of  it.  Through 
the  large  opening  the  fundus  of  the  tumour  now  presented,  and  the  charge 
of  it  was  committed  to  Professor  Simpson,  who  drew  it  gently  outwards.  At 
this  time,  as  well  as  before  and  after,  care  was  taken  to  prevent  protrusion  of  the 
intestmes.  This  was  done  by  Mr.  Goodsir,  who,  with  both  hands,  pressed  the  edges 
of  the  wound  downwards  and  backwards  against  the  intestines  and  from  the  tumour. 
On  the  anterior  aspect  and  fundus  of  the  tumour  were  now  observed  several  round 
smooth-edged  apertures,  through  which  some  of  the  glairy  fluid  was  seen  to  escape, 
being  of  the  same  character  as  that  which  had  flowed  from  the  peritoneal  cavity, 
but  rather  more  viscid  in  consistence.  One  of  these  openings  was  dUated  with  a 
bistoury,  which  allowed  of  the  escape  of  a  large  quantity  of  the  glairy  fluid.  This  had 
the  desired  eftect  of  diminishing  considerably  the  size  of  the  tumour.  The  pedicle 
of  the  tumour  was  next  examined,  and  it  was  found  to  consist  of  the  left  broad 
Ijo-ament  of  the  uterus,  somewhat  elongated  and  enlarged,  but  not  altered  in  texture. 
The  uterus  was  seen  to  be  of  normal  size,  though  of  a  rose-red  colour,  and  to  be 
unconnected  with  the  tumour,  except  through  the  medium  of  the  ligament.  The 
pedicle  of  the  tumour  being  now  put  on  the  stretch  by  exerting  slight  traction  on 
the  latter,  a  strong  curved  needle,  in  a  fixed  handle,  and  carrying  a  strong  double 
ligature,  was  passed  through  its  middle.  The  double  end  of  the  ligature  being 
divided,  each  half  was  tied  separately,  so  that  each  included  one-half  of  the  pedicle. 
Some  delay  was  occasioned  by  the  difficulty  experienced  in  tying  the  ligatures,  as 
the  elasticity  of  the  part  included  caused  the  first  half  of  the  knot  to  slacken  before 
the  other  half  could  be  thrown.  The  tumour  now  required  to  be  removed.  This 
was  done  by  cutting  carefully  with  a  scalpel  at  about  an  inch  beyond  the  part  sur- 
rounded by  the  ligatures.     In  domg  so,  a  cyst,  which  had  extended  down  to  the 


710  DISEASES   OF   THE   GEXITO-UEINARY   SYSTEM. 

pedicle,  was  necessarilv  opened,  and  some  more  of  the  glairy  fluid  escaped.  During 
the  division  of  the  pedicle,  venous  blood  escaped  freely  from  the  tumour,  but  after  the 
removal  of  that  latter,  no  bleeding  occurred  from  the  divided  surface  of  the  pedicle, 
although  the  mouth  of  at  least  one  large  artery  was  visible.  The  right  ovary  was 
now  examined,  and  it  was  found  to  be  enlarged  to  the  size  of  a  vralnut.  and  to  con- 
tain several  small  cysts.  Accordingly,  Dr.  Handyside  proceeded  to  remove  it  also. 
A  needle  carrying  a  double  hgature  was  passed  through  the  middle  of  the  ligament 
of  the  ovary,  and  the  ends  tied  separately  in  the  same  manner  as  on  the  other  side. 
Xo  bleeding  followed  the  division  of  the  ligament  beyond  the  ligature.  The  portions 
of  the  broad  ligaments  which  were  left  were  unaltered  in  structure.  The  four  ends 
of  ligature  attached  to  each  broad  ligament  were  now  tied  together  around  the 
latter,  and  then  three  of  the  ends  cut  oS,  so  as  to  leave  only  one  from  each  side 
hanging  at  the  lower  angle  of  the  wound.  The  blood  mixed  with  the  remainder  of 
the  glairy  fluid  was  now  sponged  carefully  out  of  the  lower  part  of  the  abdomen  and 
the  pelvis,  which  were  exposed.  The  peritoneum  lining  the  abdominal  wall,  as 
well  as  that  covering  part  of  the  intestines,  was  now  examined,  and  seen  to  be  of  a 
red  colour ;  but  on  no  part  was  there  any  mark  of  the  eflfusion  of  lympk  Such 
of  the  intestines  as  were  seen  were  quite  natural  in  their  appearance.  All  oozing 
of  blood  from  the  incisions  in  the  abdominal  wall  having  ceased,  no  vessel 
having  required  ligature,  the  edges  of  the  wound,  with  the  careful  exclusion 
of  the  peritoneum  only,  were  approximated  and  retained  in  accurate  apposition  by 
means  of  ten  twisted  sutures.  Corresponding  parts  of  the  edges  of  the  incision 
were  indicated  by  the  dark  points  and  cross  lines  which  were  previously  marked 
with  the  nitrate  of  silver,  and  which,  on  the  now  flaccid  skin,  were  found  to 
be  of  great  use.  A  long  pad  of  lint  was  now  laid,  as  a  compress,  along  each  side 
of  the  wound,  and  a  lighter  one  over  it,  and  these  were  retained  by  broad  strips  of 
adhesive  plaster.  Lastly,  over  these  pressure  was  made,  and  support  given,  by  the 
ends  of  a  double  many-tailed  bandage,  which  had  been  placed  under  the  patient 
before  the  operation  began,  and  which  were  crossed  and  pinned  alternately  at 
opposite  sides  of  the  abdomen.  The  patient  was  then  placed  in  bed,  a  dry  blanket 
having  been  previously  wrapped  round  the  thighs  and  pelvis.  The  patient  bore  the 
operation  well.  At  one  time  she  felt  faint  but  svncope  never  occurred,  so  that  no 
stimuU  were  given.  The  pulse  never  sunk  below  80,  but  remained  most  of  the  time 
between  90  and  100.  The  operation  occupied  in  all  about  forty  minutes.  Fifteen 
of  these  were  taken  up  in  the  preliminary  incision,  examination,  and  removal  of  the 
large  tumour, — five  in  the  removal  of  the  small  one,  and  twenty  in  sponging  out  the 
pelvis,  introducing  the  sutures,  and  applying  the  compresses,  straps,  and  the  many- 
tailed  roller. 

ScTJSEQUEXT  PROGRESS  OF  THE  Case. — Immediately  after  the  operation,  otie  drachm 
of  the  Solution  of  Morphia  was  administered.  At  4  p.m.  she  complained  of  acute 
pain  in  the  abdomen,  and  two  grains  of  solid  Opitim  were  given  in  the  form  of  piU. 
At  8  P.M.  another  grain  of  Opium  was  taken.  At  9  p.m.  the  pain  ceased  on  her 
being  turned  in  bed.  The  pulse  was  100.  soft,  and  eight  oz.  of  urine  were  drawn  oflF 
by  the  catheter.  September  6/A.— Has  taken  during  the  night  a  drachm  and  a  half 
of  the  solution  of  Morphia,  which  occasioned  drowsiness  but  no  sleep.  At  2  p.m.  there 
was  slight  difficulty  of  breathing.  At  9  p.m.  the  pulse  was  148,  full  and  strong,  and 
difficulty  of  breathing  was  increased ;  20  oz.  of  blood  were  taken  from  the  arm.  Sept. 
7th. — At   2   P.M.  was   allowed   to  have   a   little  warm  gruel,  followed  by  fifteen 

minims  of  the  "black  drop,''  as  she  was  very  irritable  and  restless.      Sept.  8th. 

Last  night  had  some  beef-tea  and  toast,  and  slept  several  hours.  The  wound  was 
dressed  at  2  P.M.  for  the  first  time.  Union  by  first  intention  had  taken  place  every- 
where,   except  where  the  ligatures  mterpose.      Sept.   lOth.—Woxmd  discharging 


OYARIAX   DROPSY.  711 

freely  around  the  ligatures.  Complains  of  tormina  and  restlessness.  Bowels  open. 
At  9  P.M.  there  was  considerable  tenderness  of  the  abdomen,  and  twenty-four  leeches 
were  applied.  Sept.  llth. — Passed  a  tolerable  night.  Abdominal  tenderness  dimi- 
nished, but  still  pain  in  left  iliac  region.  Pulse  130,  soft.  Respirations  35,  but  easy. 
Twenty  leeches  to  ie  applied  over  seat  of  pain,  and  three  grains  of  James''  powder,  with 
half  a  grain  of  Opium,  every  three  hoias.  Soda  ivater  with  Raspberry  Vinegar  for 
drink.  Sept.  22d. — Since  last  report  has  gone  on  well— occasional  symptoms  having 
been  carefully  ti-eated.  For  the  last  few  days  has  complained  of  cough,  but  on  aus- 
cultation and  percussion  the  lungs  appear  to  be  healthy.  The  nourishment  has  been 
gradually  increased,  and  she  has  taken  eggs  and  beef-tea,  and  to-day  allowed  two 
oz.  of  steak  for  dinner.  Between  three  and  four  oz.  of  laudable  pus  escape  daily 
from  the  wound  round  the  ligatures.  Sept.  28th. — Ts  so  well  that  she  sat  up  in  a 
chair  for  some  time.  Appetite  much  improved,  and  has  been  eating  meat  daily. 
October  3d— Has  had  slight  diarrhoea.  The  discharge  from  the  wound  is  copious 
and  foetid.  In  the  evening,  on  pulling  one  of  the  ligatures,  it  came  away,  with  a 
slough  about  three  inches  long,  and  the  diameter  of  a  crow  quill.  To  have  a  grain 
of  Opium.  Oct  10th. — Looseness  of  bowels  returns  occasionally  notwithstanding  the 
use  of  Lead  and  Opium  Fills.  Cough  has  been  troublesome,  with  to-day  tenacious 
sputa,  slightly  tinged  here  and  there  of  a  rusty  colour.  On  examining  the  chest,  a 
crepitating  rale  is  heard  for  the  tirst  time  about  the  middle  third  of  left  back,  and 
iuferiorly  there  is  sonorous  rale,  both  with  inspiration  and  expiration.  Over  the 
right  back  the  respiratory  murmurs  are  generally  harsh,  with  increased  vocal  reson- 
ance, but  no  rale.  On  tightening  the  ligature,  which  is  still  firmly  attached,  about 
three  ounces  cf  thick  greenish  otiensive  pus  flowed  from  the  opening.  To  lie  on  the 
fcLce  as  much  as  possible.  If,  Mucilag.  §j;  Syr.  Simp.;  Vin.  Ipecac.  i.dL  ^ss;  Sol. 
Mur.  Morph.  3  ij ;  Aq.  Font,  ^iv;  M.  Sumat  3  ss  quarto,  qudque  hord.  At  9  P.M. 
the  ligatures,  on  being  firmly  pulled,  suddenly  came  away,  producing  a  sensation  as 
if  she  had  received  a  blow  in  the  abdomen.  There  was  no  slough  attached,  and  the 
separation  was  not  followed  by  blood,  although  flakes  of  dead  tissue  were  observed 
in  the  pus.  Pressure  was  made  by  pads  over  the  iliac  fossa  and  umbilical  region,  so 
as  to  direct  the  pus  externally.  Oct.  20th. — Since  last  report  there  has  been  much 
cough,  with  all  the  signs  and  symptoms  of  limited  pneumonia  of  both  lungs,  poste- 
riorly and  iuferiorly.  The  pulse  has  varied  from  120  to  140,  and  been  soft,  and  the 
treatment  has  consisted  of  rest  in  bed,  anodynes  at  night,  with  wine  and  nutrients. 
Yesterday  a  blister  was  applied  to  the  left  thorax,  inferiorlj'-,  and  to-day  she  is  much 
better.  All  crepitation  has  disappeared;  the  cough  has  ceased.  Over  left  back 
iuferiorly,  near  spinal  column,  there  is  a  space  the  size  of  a  hand,  dull  on  percus.sion. 
In  the  last  few  days  she  has  been  eating  food  with  appetite,  and  sitting  up  an  hour 
daily.  November  \st. — Since  last  report,  although  the  physical  signs  of  chest  have 
undergone  little  change,  general  health  has  been  so  good  that  she  has  been  up  daily, 
and  walks  freely  about  her  room.  About  half  an  ounce  of  healthy  pus  is  discharged 
daily  from  the  wound.  At  half-past  4  p.m.,  during  the  temporary  absence  of  the 
nurse,  feeling  very  hungry,  she  went  to  the  press,  where  the  provisions  were  kept, 
and  ate  half  a  teacupful  of  arrowroot,  half  a  pint  of  strong  soup,  a  sraaU  piece  of 
roast  beef,  and  a  piece  of  bread,  being  all  the  food  she  could  get  at.  Immediately 
afterwards,  she  experienced  severe  griping  pains  over  the  whole  abdomen,  followed 
by  vomiting  of  the  matters  taken.  The  abdomen  became  distended  and  tympanitic 
above  the  umbilicus,  and  a  cuiwe  of  intestine  was  very  prominent  in  this  situation 
and  clear  on  percussion.  A  few  drops  of  01.  Menth.  Ftp.  afforded  slight  relief,  and 
ivarm  fomentations  were  applied  to  the  abdomen.  Frequent  vomiting  of  a  greenish 
fluid,  however,  continued,  and  in  the  evening  five  grains  of  Ojmim  ivere  given  in  the 
form  of  suppository.     Kov.  2d. — An  enema  was  given  at  10  a.u.,  and  another  four 


712  DISEASES   OF  THE   GENITO-URINARY   SYSTEM, 

hours  after\\-ards,  without  causing  any  evacuation  from  tlie  bowels,  which  have  not 
been  opened  since  6  p.ii.  on  the  3lsi  of  Octohtr.  S  p.m. — There  has  been  frequent 
retching  during  the  day,  witli  discharge  of  mouthfuls  of  mucus.  Marked  difierence 
between  t3'mpanitic  fulness  and  distension  above  the  umbilicus,  and  the  flatness  and 
collapse  of  the  abdomen  below  it.  Had  nothing  to  eat,  and  drank  only  a  little  cof- 
fee. 5  Calomel  gr.  viij ;  Gum.  Opii,  gr.  ij ;  Conserv.  Rosar.  q.  s.  Ft.  pil.  ij.  One  to 
he  taken  immediately.  Four  pounds  of  warm  loater  to  he  injected  slovjly.  If  no  motion 
hy  \2  o^clock,  to  have  an  enema,  composed  of  an  i'nfusion  of  six  ounces  of  hailing  water 
added  to  lb  grains  of  tobacco.  Kov.  3d. — The  warm  water  injection  returned  imme- 
diately with  much  flatus  and  some  small  pieces  of  foeculent  matter.  The  tobacco 
injection  was  not  given.  This  mornmg  the  countenance  is  anxious;  pulse  120,  small ; 
tongue  furred ;  great  thirst ;  no  appetite ;  considerable  distension  of  the  upper  part 
of  the  abdomen,  and  a  distended  knuckle  of  intestine  prominent  and  stronglj'  marked 
out  below  the  integument,  pressure  on  which  causes  tenderness.  Twelve  leeches  to  be 
applied  to  the  abdomen.  To  have  the  tobacco  injection.  8  p.m. — This  morning  the 
tobacco  injection  (not  quite  the  whole  of  it)  was  given.  It  was  retained  ten  minutes, 
and  caused  considerable  collapse,  with  tremors  and  vomiting.  Two  large  warm- 
water  injections  have  been  subsequently  given,  which  have  returned  without  foeces. 
No  tenderness  of  abdomen,  to  which  a  turpentine  embrocation  is  ordered  to  he 
applied.  Nov.  ith. — Complained  last  night  of  a  throbbing  pain  in  the  calf  of  left  leg, 
and  swelling  of  foot  and  ankle.  To-day  the  whole  limb  is  swollen  as  high  as  the 
groin,  and  an  induration  is  felt  in  the  course  of  the  femoral  vein.  The  vomited  mat- 
ters were  clearly  foeculent.  From  this  time  she  gradually  sank.  She  vomited  from 
time  to  time  matter  sometimes  fceculent,  at  others  bilious,  and  occasionally  felt  colic 
pains.  She  became  greatly  emaciated,  which  permitted  the  swollen  and  tympanitic 
intestines  to  be  strongly  marked  out  above  the  umbilicus.  The  pulse  varied  from 
130  to  150,  and  was  not  absolutely  weak  until  the  day  she  died.  Calomel  and  opium 
pills  were  continued,  with  occasional  injections  per  anum,  and  small  quantities  of 
nourishment.  The  mind  remained  unclouded  to  the  last,  and  latterly  the  tympanitic 
distension  of  abdomen  and  swelling  of  right  inferior  extremity  somewhat  diminished. 
On  Nov.  I2th,  at  midnight,  she  requested  the  nurse  to  raise  her  up.  This  was  done, 
w^hen  she  fell  back  and  expired — the  70th  day  after  the  operation. 

Sectio  Cadaveris. — Forty  hours  after  death. 

The  body  was  greatly  emaciated.     The  head  was  not  opened. 

Thorax — The  cavity  of  the  pleura  on  the  left  side  contained  about  one  ounce, 
and  on  the  right  about  two  ounces  of  serum.  On  the  left  side  the  pleurae  were  adhe- 
rent so  strongly,  that  the  lung  was  lacerated  in  removing  it :  this  more  especially 
between  the  inferior  surface  of  the  lung  and  upper  surfoce  of  the  diaphragm.  On 
the  right  side  the  pleurte  were  adherent  at  the  apex,  and  over  inferior  lobe,  but  the 
adhesions  were  easily  torn  through.  The  anterior  margin  of  the  upper  lobe  of  the 
left  lung  was  emphysematous;  its  posterior  portion  slightly  engorged.  On  section  it 
crepitated  readily,  and  was  healthy  in  structure.  The  inferior  lobe  felt  dense  exter- 
nally, and  on  section  the  parenchyma  was  of  a  brownish  red  colour;  splenified; 
easily  breaking  down  under  the  finger,  and  portions  of  it  placed  in  water  sunk  nearly 
to  the  bottom  of  the  vessel.  The  two  upper  lobes  of  the  right  lung  very  emphyse- 
matous anteriorly,  engorged  posteriorly  and  inferiorly,  but  otherwise  healthy.  The 
anterior  half  of  the  inferior  lobe  also  emphysematous,  with  here  and  there  indurated 
patches  of  chronic  lobular  pneumonia.  The  posterior  half  of  this  lobe  was  splenified 
throughout,  as  in  the  opposite  lung.  The  lining  membrane  of  the  bronchi  was 
healthy,  here  and  there  covered  with  mucus.     Both  lungs  were  small  in  volume. 


OVARIAX   DROPSY.  713 

The  heart  was  small  and  pale.  Its  right  cavities  contained  a  firm  dark  coagulum. 
The  valves  and  structure  of  the  organ  healthy.  In  the  aorta  there  was  a  small  but 
firm  coagulum,  partly  decolorized. 

Abdomen'. — On  reflecting  the  walls  of  the  abdomen,  a  few  clironic  bands  of 
lymph  were  torn  through,  uniting  the  opposite  portions  of  peritoneum.  The  line  of 
incision  was  firmly  united  except  at  its  lower  end,  where  a  round  opening  existed 
about  the  size  of  a  pea.  On  the  peritoneal  surface  the  union  was  marked  by  a  dark 
blackish  line,  which  was  perfectly  smooth  and  free  from  lymph.  The  omentum  was 
thhi  and  transparent,  destitute  of  fat,  and  stretched  tightlj'  over  the  intestines.  Its 
inferior  margin  adhered  strongly  to  the  visceral  and  parietal  peritoneum,  about  an 
inch  above  the  pubic  bones.  The  omentum  was  cut  through  transversely  about  its 
middle,  and  the  intestines  below  exposed,  which  were  greatly  distended  with  gas. 
These  were  found  to  be  portions  of  the  ileum,  the  coQs  of  which  were  more  or  less 
adherent  to  each  other,  to  the  mesentery,  omentum,  and  to  the  neighbouring  organs, 
by  bands  of  chronic  lymph.  The  adhesions  were  now  carefully  torn  through,  the 
gut  liberated  and  traced  downwards  Exactly  five  feet  and  a  half  from  the  coecum, 
above  and  to  the  left  of  the  umbilicus,  the  intestine  was  constricted  by  a  band  of 
lymph,  as  if  a  ligature  had  been  tied  round  it.  Above  the  constriction  the  gut  was 
distended  to  about  the  size  of  the  wrist ;  below,  it  was  collapsed  to  the  size  of  the 
little  finger.  Air  could  be  pressed  from  the  superior  portion  into  the  inferior,  but 
the  passage  of  water  poured  from  above  was  completely  checked  at  the  seat  of 
stricture.  All  the  intestines  above  the  stricture  were  greatly  distended  with  gas ; 
those  below  it,  including  the  coecum,  colon,  and  rectum,  were  small  and  collapsed. 
The  cavity  of  the  pelvis  was  blocked  up,  and  separated  from  the  general  cavity  of 
the  abdomen  by  firm  adhesions  between  the  surfaces  of  the  abdominal  walls,  the 
omentum,  and  knuckles  of  intestine.  The  peritoneum  in  this  place,  and  especially 
in  the  left  ihac  hollow,  was  covered  with  a  dense  layer  of  chronic  lymph.  This 
lymph  was  about  one-eighth  of  an  inch  in  thickness,  of  a  dhtj'  greenish  colour, 
mixed  with  black  pigmentary  matter,  of  great  hardness  to  the  feel,  and  cut  under 
the  knife  like  cartilage.  With  some  trouble,  the  united  knuckles  of  intestine  and 
portions  of  omentum  involved  were  separated  and  drawn  out.  A  cavity  was  thus 
exposed,  about  the  size  of  an  orange,  situated  between  the  uterus  and  rectum,  lined 
throughout  by  the  same  dense,  chronic  lymph  spoken  of  above.  The  anterior  sur- 
face of  the  uterus  was  firmly  united  to  the  bladder  by  chronic  adhesions.  On  the 
right  side  about  one  inch  of  the  Fallopian  tube  and  broad  ligament  remained,  the 
extremities  of  which  were  closely  united  to  the  anterior  wall  of  the  cavity.  On  the 
left  side  the  margins  of  the  uterus  and  short  pedicle  of  the  broad  hgament  were  so 
united  to  the  walls  of  the  cavity  that  they  could  not  be  separated.  This  cavity  or 
pouch  between  the  uterus  and  rectum  communicated  with  the  external  opening,  and 
was  evidently  the  place  where  the  pus  during  life  had  accumulated.  A  sinus  opened 
into  it  superiorly,  which  on  being  traced  upwards  was  seen  to  extend,  above  the 
descending  colon,  between  the  peritoneum  and  intestines  as  high  as  the  diaphragm 
on  the  left  side,  where  it  terminated  in  a  cul-de-sac,  the  size  of  a  hen's  egg.  The 
sinus  was  about  the  size  of  the  httle  finger,  and  lined  throughout  by  the  same  dense, 
greenish  lymph  formerly  noticed.  The  cul-de-sac  was  full  of  dirty-yellow  offensive 
pus,  and  bounded  by  a  portion  of  the  stomach  and  left  lobe  of  the  liver  internally ; 
the  diaphragm  above  and  posteriorly ;  and  the  colon  and  spleen  externally  and 
inferiorly.  It  also  was  lined  with  dense  chronic  lymph.  The  mucous  membrane 
of  the  stomach  and  small  intestines  was  healthy.  The  latter  contained  a  clayey 
coloured  soft  foeculent  matter.  The  large  intestines  were  empty.  No  appearance 
of  inflammation  existed  at  the  constricted  part.  The  internal  surface  of  the  rectum, 
extending  seven  inches  from   the  anus,   was   intensely  vascular,   thickened,    and 


714  DISEASES   OF   THE   GEXITO-UEIXARY   SYSTEM. 

inflamed.  Six  ulcers,  varyiug  in  size  from  a  sixpence  to  that  of  a  shilling,  were 
scattered  over  the  diseased  part  of  tlie  gut,  one  of  the  largest  being  only  an  inch 
from  its  extremity.  They  were  round  in  shape,  and  covered  with  a  raised  dirty 
greenish  slough.  The  liver,  kidneys,  and  spleen  were  ana?mic,  but  healthy  in  struc- 
ture. The  femm-al  and  saphena  veins  could  be  felt  hard  and  distended  below  the 
integuments.  On  dissection,  these,  as  well  as  the  external  iliac  vein,  up  to  the  point 
where  it  passed  under  the  layer  of  lymph,  in  the  left  iliac  hollow  formerly  described, 
were  found  to  be  obstructed  by  a  coagulum  of  blood.  This  coagulum  was  adherent 
to  the  internal  wall  of  the  vessel,  was  partially  decolorized,  and  of  the  consistence 
of  soft  cheese.  This  obstruction  of  the  vessels  ceased  about  three  inches  below 
Poupart's  ligament. 

Description  of  the  TuiiouRS  removed. — The  tumour  which  involved  the  left 
ovary,  on  being  removed,  weighed  nine  pounds  and  a  half.  It  was  of  an  oval  form, 
measured  thirteen  inches  in  its  longest,  and  nine  inches  and  a  half  in  its  shortest 
diameter.  Its  envelope  was  composed  of  white,  dense,  and  glistening  fibrous  tissue, 
having  upon  its  external  surface  patches  of  various  sizes,  resembling  chronic  lymph. 
On  its  anterior  surface  might  be  seen  openings,  or  ulcerations,  varying  in  size. 
The  edges  of  these  ulcerations  were  smooth  and  rounded,  and  of  the  same  thickness 
as  the  fibrous  envelope.  The  cut  surface,  which  had  been  near  the  ligature,  now 
presented  a  large  opening  into  the  tumour,  through  which  numerous  cysts,  varying 
in  size  from  a  pea  to  that  of  a  billiard  ball,  protruded.  The  incision  into  it,  made 
during  the  operation,  had  opened  up  one  of  these  cj^sts  about  the  size  of  a  cocoa- 
nut.  The  tumour  was  sent  to  the  University  Museum,  minutely  injected  by  Mr. 
Goodsir  and  afterwards  cut  up,  in  order  to  show  its  internal  structure.  In  dividing 
it,  some  of  the  internal  cysts  were  found  to  be  fuU  of  pus,  whUst  others  contained 
the  usual  glairy  fluid,  common  to  these  tumours.  Three  preparations  were  made 
from  this  tumour,  which  may  be  seen  in  the  museum,  and  which  demonstrate  the 
following  facts: — 

\st.  A  portion  of  the  fibrous  sac,  showing  the  attachment  of  numerous  cysts 
varying  in  size  and  shape.  A  minute  injection  has  been  thrown  into  the  arteries  (?) 
and  exhibits  how  richly  the  walls  of  the  internal  cysts  are  supplied  with  blood-vessels. 
One  of  these  cysts,  about  the  size  of  a  small  hen's  egg,  has  its  upper  half  fully 
injected,  whilst  the  lower  half  is  pale.  The  margin  between  the  two  is  uneven  but 
abrupt,  and  from  the  creamy  and  distended  appearance  of  the  cyst,  there  can  be  no 
doubt  that  it  is  full  of  pus. 

2d  A  portion  of  the  fibrous  sac,  showing  the  incision  which  separated  the 
tumour  from  its  attachments.  The  opening  is  of  an  irregular  form,  about  three 
inches  in  its  longest  diameter. 

3d.  A  portion  of  the  fibrous  sac,  showing  the  ulcerated  openings  formerly 
described. 

The  right  ovary  was  about  the  size  of  a  walnut.  It  was  formed  externally  of  a 
dense  fibrous  capsule,  and  internally  of  several  small  cysts.  The  natural  stroma  of 
the  organ  had  entirely  disappeared. 

Commentary. — The  life  of  this  young  woman  was  rendered  miser- 
able by  the  enormous  size  of  her  abdomen,  and  the  difficulty  it  caused 
to  the  functions  of  respiration,  micturition,  locomotion,  etc.  She 
earnestly  desired  that  any  operation  should  be  performed  which  held 
out  a  prospect  of  relief,  and  bore  the  excision  of  both  ovaries,  which 
-was  luost  skilfully  performed,  with  the  greatest  courage.  From  this 
she  may  be  said  to  have  recovered,  for,  notwithstanding  the  chest  com- 
plication which  arose,  she  was   from  the  forty-eighth  to  the  fifty-eighth 


OVARIAN  DROPSY.  715 

day  after  the  operation  so  well,  that  she  sat  up  and  walked  about  with- 
out inconvenience.  On  this  last  day,  feeling  the  intense  hunger  of  a 
convalescent,  she  took  advantage  of  the  nurse's  absence,  and  ate 
largely.  The  stomach  tliereby  was  distended,  the  intestines  displaced, 
so  that  a  filament  of  chronic  lymph,  attached  to  the  abdominal  walls, 
became  twisted  round  a  portion  of  bowel,  causing  complete  mechanical 
strangulation  of  it,  and  death  twelve  days  later,  Avith  all  the  symptoms 
of  ileus.  To  this  accidental  circumstance,  and  not  to  any  direct  intluence 
of  the  operation,  must  the  fatal  result  be  attributed. 

The  question  I  have  frequently  asked  myself  is,  A\  as  I  warranted  in 
proposing  and  urging  others  to  perform  the  operation  ?  The  reasons 
that  induced  me  to  do  so  were  the  following  : — 1st,  The  youth  and  good 
constitution  of  the  patient;  2dli/,  The  disease  was  rendering  her  life 
miserable,  and  she  earnestly  wished  the  operation  to  be  performed. 
3dli/,  Death  seemed  unavoidable  at  no  distant  period.  At  least  it  could 
not  be  anticipated  that  five  gallons  of  fluid  could  be  removed  from  the 
abdomen  every  three  weeks  for  any  length  of  time,  without  injury  to  the 
vital  powers.  4thb/,  Extirpation  of  the  tumour  appeared  to  be  the  only 
possible  means  of  cure,  itthli/.  The  care  I  had  taken  in  forming  the 
diagnosis,  and  my  conviction  of  its  accuracy,  which  was  afterwards  fully 
contirmed. 

Again,  on  looking  at  the  statistics  of  the  operation,  previously  pub- 
lished by  Dr.  Atlee,*  I  found  that  abdominal  section  had  been  performed 
for  ovarian  tumours,  real  or  supposed,  101  times.  If  we  extract  from 
this  list  cases  where  the  operation  was  not  completed,  and  those  on  the 
point  of  death  before  the  operation  was  begun,  we  shall  have  ninety 
remaining,  in  all  of  which  the  timaour  was  excised.  Of  these  sixty-two 
recovered  and  twenty-eight  died.  Thus,  whatever  might  be  thought  of 
the  correctness  of  the  statistics,  the  broad  fact  still  remained,  that  an 
ovarian  tumour  had  been  extracted  from  living  women  in  sixty -two  cases 
with  perfect  success.  An  acquaintance  with  the  structure  and  mode  of 
development  of  these  growths  must  convince  us  that  the  only  other  pos- 
sible mode  of  cure  is  by  rupture  of  the  cyst,  and  then  only  under  parti- 
cular circumstances.  This  is  an  occurrence  of  extreme  rarity,  and  yet, 
were  we  to  be  guided  by  the  opinions  of  those  surgeons  who  refuse  to 
perform  ovariotomy  in  any  case,  no  other  termination  is  to  be  expected, 
and  the  disease,  notwithstanding  the  facts  previously  stated,  is  to  be  con- 
sidered as  irremediable  by  art.  But  every  case  must  stand  upon  its  own 
merits,  and  when  all  the  circumstances  of  the  one  detailed  are  taken 
into  consideration,  the  perfect  diagnosis  that  was  established,  and  the 
probability  of  a  speedily  fatal  termination  (a  probability  afterwards  ren- 
dered certain  by  the  suppuration  discovered  to  exist  within  the  cysts),  it 
must  be  granted  that  the  operation,  if  admissible  at  all,  was  so  in  this 
instance. 

An  important  practical  question  presents  itself  in  regard  to  the  treat- 
ment after  the  operation,  on  which  there  was  a  difl:erence  of  opinion 
amono-  the  practitioners  who  witnessed  the  case  and  dissection,  viz..  How 
the  cavity  or  pouch  containing  pus,  between  the  uterus  and  rectum,  and 
the  sinus  leading  from  it  up  to  the  diaphragm,  were  connected  with  the 
pressure  made  on  the  abdomen  by  the  many-tailed  bandages  and  com- 
*  American  Journal  of  the  Med.  Sciences,  April,  1845. 


716  DISEASES   OF   THE   GENITO-URINARY  SYSTEM. 

presses,  in  order  to  direct  the  matter  towards  the  external  opening. 
Some  have  thought,  that  the  pressure  employed,  instead  of  directing 
matter  downwards,  may  have  forced  a  portion  of  it  upwards;  while 
others  are  inclined  to  believe,  that  if  the  pressure,  which  latterly  was 
much  relaxed,  had  been  more  steadily  continued,  the  formation  of  that 
cavity  and  sinus  might  have  been  prevented.  The  question  is  important, 
however,  in  reference  rather  to  the  proper  treatment  of  future  cases,  than 
to  the  fatal  event  of  this  case  ;  for  the  symptoms  of  ileus  and  the  death 
of  the  patient  were  obviously  dependent  on  the  constriction  of  the  portion 
of  ileum  above  noticed  by  a  band  of  lymph  which  was  at  the  distance 
of  some  inches  from  any  part  of  the  wound,  and  had  no  connection 
either  witli  the  cavity  or  the  sinus. 

Although  various  lesions  were  found  after  d^ath,  their  origin  and  con- 
nection with  each  other  will  easily  be  understood  from  a  perusal  of  the 
case,  and  of  the  iJost  mortem  examination. 

Notwithstanding  the  unsuccessful  termination  of  this  case,  I  am  still 
of  opinion  that  ovariotomy  is  warrantable  ^vllen  the  diagnosis  of  the 
tumour  is  certain,  and  other  circumstances  favourable.  The  more  fre- 
quently it  is  performed,  the  more  readily  will  experience  dictate  the 
avoidance  of  many  errors  that  even  now  encumber  the  practice  of  it. 
When  once  recognised  as  a  legitimate  mode  of  treatment,  and  only  per- 
formed in  appropriate  cases,  there  is  every  reason  to  hope,  from  the 
experience 'of  the  past,  that  the  degree  of  mortality  which  has  hitherto 
accompanied  it  will  gradually  diminish.  Before  such  a  result  can  be 
hoped  for,  however,  it  is  necessary  that  our  notions  of  the  pathology  and 
diagnosis  of  the  disease  should  be  improved.  To  these  points  1  shall 
refer  afterwards. 


Case  CLYI.* — Ovarian  Dropay — Si^ontaneous  Ulcerative  Oj^enivg  of  the  Cyst  into  the 
Bladder,  and  Evacuation  of  its  Contents — Jiecovery. 

History. — Anne  Pjper,  a  sei-vant,  set.  25,  was  admitted  Nov.  8,  1848.  She  had 
been  delivered  fourteen  daj-s  previously  of  a  male  child  in  the  Maternity  Hospital, 
the  labour  being  a  natural  one,  and  presenting  nothing  unusual.  On  the  birth  of 
tlie  child,  however,  the  abdomen  still  continued  enlarged,  and  at  first  led  to  the  sus- 
picion that  another  foetus  remained  in  the  uterus.  After  a  time,  the  true  nature  of 
the  case  was  rendered  manifest,  and  a  large  swelling  was  detected,  which  was 
movable  to  a  certain  extent,  and  presented  all  the  characters  of  an  encysted  tumour 
of  the  left  ovary. 

SniPTOMS  ox  Admission. — The  abdomen  was  swollen  to  about  the  size  usual 
during  the  sixth  or  seventh  month  of  pregnancy.  The  tumour  extended  from  the 
epigastrium  to  the  pubes,  but  bulged  considerablj^  towards  the  left  side.  Its  surface 
was  irregular ;  and  two  large  nodules,  each  the  size  of  a  cocoa-nut,  existed  about  its 
centre.  It  was  tense  and  firm  to  the  feel,  somewhat  elastic,  but  no  fluctuation 
could  be  detected.  The  tumour  was  firmly  fixed,  and  the  seat  of  constant  pain, 
especially  in  the  left  lumbar  region,  which  was  increased  by  pressure,  bj"  lying  on 
the  right  side,  or  on  assuming  the  erect  posture.  The  urine  was  of  a  slightly  yellow 
colour,  and  presented  its  normal  characters.  The  digestive,  respiratory,  circulatory, 
nervous,' and  integumentary  oi'gans  appeared  to  be  healthy.     She  had  observed  the 

*  Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


OVARIAN   DROPSY.  717 

tumour  seven  months  before  her  dehvery ;  and  it  has  gone  on  gradually  increasing, 
and  been  somewhat  painful  from  the  first.  EifjM  leeches  were  ordered  to  the  most 
painful  part  of  the  abdomen. 

Progress  op  the  Case. — For  four  days  the  patient  remained  in  the  same  con- 
dition, the  local  pain,  however,  having  been  relieved  by  the  leeches.  On  Nov.  12, 
my  attention  was  directed  to  the  urine,  which  now  presented  a  copious  white 
deposit,  occupying  two-flfchs  of  the  jar,  while  the  supernatant  portion  was  of  a 
light  amber  colour,  and  unusually  viscid.  The  deposit  was  determined  by  the 
microscope  to  consist  of  pus,  mingled  with  a  few  granule  corpuscles.  The  clear 
portion  was  strongly  coagulable  by  heat  and  nitric  acid.  At  first  it  was  imagined 
that  the  cyst  had  burst  into  the  vagina,  but  the  patient  and  nurse  concurred  in 
saying  that  there  was  no  discharge  between  the  intervals  of  micturition,  and  that 
all  the  fluid  came  from  the  bladder.  The  urine  presented  the  same  characters  for 
the  next  three  days ;  the  amount  discharged  during  the  twenty-four  hours  being 
about  three  pints.  On  the  loth,  the  tumour  had  somewhat  diminished  in  size,  its 
hardness  and  tensity  had  disappeared,  and  distinct  fluctuation  was  perceptible  in  it. 
A  broad  flannel  roller  ivas  ordered  to  he  applied  firmly  round  the  abdomen,  and  com- 
pression made  by  means  of  pasteboard,  previously  soaked  and  modelled  to  the  abdominal 
surface.  From  this  time,  the  abdomen  rapidly  diminished  in  volume,  while  the 
amount  of  purulent  viscous  fluid  discliarged  from  the  bladder  varied  from  three  to 
five  pints  in  tlie  twenty-four  hours.  The  appetite  and  general  health  conthiued 
good;  and  she  was  ordered  nutritious  diet,  with  four  ounces  of  wine  daily.  On 
the  23d,  the  amount  of  pus  contained  in  the  urine  was  greatly  lessened,  and  the 
clear  portion  presented  only  a  slight  haziness  on  the  addition  of  nitric  acid.  On  the 
21th  the  abdomen  had  regained  its  natural  size,  although  a  dense  mass,  evidently 
the  collapsed  ovarian  sac,  could  readily  be  distinguished,  occupying  the  left  iliac  and 
hypochondriac  regions.  The  urine  now  also  was  natural  in  quantity,  and  presented 
only  a  slight  sediment,  consisting,  as  shown  by  the  microscope,  of  some  crystals  of 
oxalate  of  lime,  and  a  few  pus  globules.  From  this  period  she  may  be  said  to  have 
recovered.  She  suffered  occasionally  from  uneasy  feelings  on  the  left  side,  some- 
times amounting  to  pain,  wliich  were  relieved  by  the  application  of  four  leeches, 
followed  by  a  small  blister.  One  of  the  leech  bites  ulcerated  superficiallj^,  but  soon 
healed  up.  She  was  dismissed  on  the  \Bth  of  December,  expressing  herself  as  being 
well  in  every  respect,  having  been  sitting  up  and  running  about  the  ward  for  the 
fortnight  previous.  The  indurated  mass  in  the  left  ihac  region  was  greatly  dimi- 
nished in  size,  but  still  very  perceptible  to  the  feel,  though  not  to  the  eye. 

Commentary. — The  history  of  this  case  can,  I  think,  only  lead  to 
one  conclusion,  namely,  that  an  ovarian  encysted  tumour  was  present 
on  the  left  side ;  that  the  individual  cysts  had,  if  not  altogether,  at  all 
events  for  the  most  part,  broken  down  to  form  one  large  cavity;  that 
the  contents  of  this  cavity  had  suppurated,  and  a  fistulous  opening 
fornieil  either  into  the  ureter  or  the  bladder  (most  probably  the  latter), 
through  which  the  contained  fluid  was  evacuated,  permitting  collapse 
of  the  sac  and  cure  of  the  disease.  The  permanency  of  this  cure  would 
depend  upon,  whether  all  the  secondary  cysts  had  been  ruptured  and 
were  broken  down  before  the  fistulous  opening  took  place.  This  is  a 
point  which  it  was  impossible  to  ascertain  with  certainty;  but  a  careful 
examination  of  the  woman  before  she  left  the  Infirmary,  convinced  me 
that  no  rounded  nodules  or  cysts  could  anywhere  be  felt. 

The  only  instance  I  am  aware  of,  in  which  an  opportunity  presented 
itself  of  dissecting   an   ovarian    encysted  tumour   some    time   after  its 


718  DISEASES   OF   THE    GENITO-URINARY   SYSTEM. 

spontaneous  rupture,  was  in  an  individual  I  saw  examined  by  tlie  late 
Dr.  Makellar.— (Mo/<//i^^  Juuntal,  Jan.  1847,  p.  558.)  In  that  case  the 
cavity  of  the  cvst  was  ahnost  obliterated,  and  its  walls  were  thickened 
and  of  cartilaginous  hardness.  A  fistulous  opening,  however,  was  kept 
up  between  tlie  tumour  and  the  abdominal  walls,  below  the  umbilicus, 
Avhere  it  had  burst,  and  the  patient  sank  from  the  continued  discharge. 
How  far  a  communication  with  the  external  atmosphere  in  this  instance, 
and  the  presence  of  chronic  peritonitis,  may  have  operated  unfavour- 
ably, I  do  not  know ;  but  the  total  cessation  of  all  dischai-ge,  and 
absence  of  these  circumstances  in  the  case  related,  augurs  well  for  her 
permanent  recovery. 

Whetlier  a  fistulous  communication  between  the  ovarian  sac  and 
urinary  passages  be  favourable  or  not,  is  uncertain ;  for  I  have  been 
unable  to  discover  any  recorded  case  in  which  this  has  ever  happened. 
Many  instances  are  to  be  met  with  where  similar  cysts  have  burst  into 
the  peritoneum,  the  fluid  been  absorbed,  and  excreted  in  large  quantities 
by  the  kidney  as  urine.  Other  cases  are  to  be  met  with,  where  the 
contents  of  tlie  tumour  have  burst  externally  by  ulceration  through  the 
abdominal  walls,  or  into  the  vagina,  or  into  the  intestines ;  but  in  none, 
so  far  as  I  am  aware,  previous  to  the  one  now  related,  have  the  contents 
of  the  tumour  been  evacuated  directly  as  a  purulent  viscous  fluid  from 
the  bladder,  proving  a  direct  communication  with  that  organ. 


Case  CLYII.* — Ovarian  Dro2mj  which  gradually  emptied  itself  spontaneously  by 
openings  through  the  Fallopian  Tube — Singular  attempt  at  Imposition  of  Figs' 
Bladders,  for  Cystic  Formations  in  the  Uterus. 

History. — Elizabeth  Allan,  set.  43,  servant,  a  tolerably  stout,  healthy-looking 
woman— admitted  September  30th,  1852.  States  that  she  enjoyed  good  health  up 
to  the  year  1829,  wheu  she  experienced  a  lingeriug  postpartum  recovery.  lu  1830 
her  abdomen  commenced  to  swell;  she  was  tapped,  and  190  oz.  of  fluid  removed. 
For  six  years  she  was  under  medical  treatment;  but  then  (1836)  she  had  so  far 
recovered  that  she  was  once  more  able  to  follow  her  usual  occupation.  In  1841  the 
abdominal  swelling  returned,  and  continued  till  1848.  At  the  beginning  of  that 
year,  the  abdomen  being  greatly  swollen,  she  felt  something  give  way,  followed  by 
intense  burning  abdominal  pain,  and  a  copious  discharge  of  an  opaque  fluid  from 
the  vulva.  Tlie  pain  subsided  in  a  few  days,  and  some  weeks  afterwards  she  was 
much  better,  and  was  enabled  to  get  out  of  bed.  She  says  the  same  thing  has 
happened  upwards  of  twenty  times  since,  at  various  intervals ;  the  last  occun-ed  on 
the  27th  of  August  1852.  She  also  states  that  about  seventeen  cysts  or  polypi  have 
at  diflerent  times  been  removed  from  the  uterine  passages— their  removal  being 
preceded  by  bearing-down  pains.  During  all  this  time  the  cataraenia  have  appeared 
regularly,  and  lasted,  on  an  average,  from  eight  to  ten  days.  She  further  says,  that 
for  the  last  twelve  years  she  has  had  repeated  attacks  of  hsematemesis.  In  1852, 
her  attention  was  drawn  by  her  medical  attendant  to  a  bulging  beneath  the  left 
clavicle,  where  she  has  frequently  experienced  a  deep-seated  pain  of  a  burning 
character,  with  a  sense  of  a  trembling  or  vibratory  movement. 

Symptoms  on  Admissiox  — On  admission,  the  patient  complains  of  uneasiness  and 
pain  in  the  lower  part  of  the  abdomen,  and  of  frequent  tympanitic  distension.    On 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


OVARIAN   DROPSY.  719 

examination,  the  abdomen  presents  the  appearance  of  a  woman  in  the  sixth  or 
seventh  month  of  pregnancy — is  everywhere  tympanitic  on  percussion,  but  on  pal- 
pation tliere  is  an  undefined  fuhiess  and  induration  in  the  left  iliac  and  hypochon- 
driac regions — no  pain  on  pressure  when  the  patient's  attention  is  directed  from  the 
part.  The  left  side  of  the  chest  appears  fuller  than  the  right  side,  but  expands  well  on 
inspiration.  No  dulness  on  percussion;  respiratory  sounds  normal;  no  cough  or 
pulmonary  symptoms.  Below  the  acromial  extremity  of  the  left  clavicle,  a  loud 
blowing  murmur  can  be  heard  over  the  subclavian  artery,  which  is  inaudible  on 
the  right  side.  Circulatory,  digestive,  urinarj^,  and  integumentary  systems  other- 
wise normal. 

Progress  of  the  Case. — The  patient  complained  of  tympanitis  and  pain,  for 
which  slie  was  treated  by  occasional  purgatives,  enemata,  carminatives,  and  anti- 
spasmodics. On  the  6th  of  October,  I  requested  Dr.  Simpson  to  examine  her  per 
vaginam.  He  found  the  cervix  uteri  about  three  quarters  of  an  inch  in  length, 
increased  in  tliickness  and  density.  The  os  uteri  was  patulous,  and  admitted  easily 
the  first  phalanx  of  the  index  finger.  The  edges  were  rough.  The  body  of  tlie 
uterus  was  mobile,  but  its  volume  was  increased.  The  left  ovary  was  enlarged,  and 
the  rectum  distended  posteriorly.  At  this  time  the  patient  expressed  her  opinion 
that  a  discharge  of  fluid  was  about  to  take  place.  Nothing  occurred,  however, 
until  the  5th  of  November,  when,  a  little  before  five  o'clock  p  M-,  rising  to  micturate, 
she  felt  something  give  way  in  the  lower  part  of  abdomen,  and  about  50  oz.  of 
fluid  escaped  on  the  floor.  A  small  quantity  was  carefully  collected,  and  was  found 
to  consist  of  slightly  opalescent  serum,  of  sp.  gr.  1005,  slightly  coagulable  by  means 
of  heat  and  nitric  acid.  On  introducing  the  uterine  probe,  the  cavity  of  the  uterus 
measured  three  inches  and  a  half  in  length,  and  contained  nothing  abnormal. 
Nothing  unusual  followed  the  discharge  of  fluid.  On  the  28th  of  Deceinher,  there 
was  also  a  considerable  watery  discharge. 

During  all  this  time  slie  continued  to  complain  of  vague  abdominal  pains,  which, 
were  evidently  feigned.  She  was  carefully  watched,  and  no  cysts  had  come  away. 
On  the  ith  of  January  she  expressed  herself  so  well  that  she  was  desirous  of  going 
out.  Feeling  satisfied  that  this  request  on  her  part  was  to  procure  the  means  of 
imposition,  permission  to  go  out  was  granted,  and  Mr.  William  Calder,  one  of  the 
clinical  clerks,  agreed  to  follow  her.  She  went  straight  to  the  market,  and  was  seen, 
after  making  inquiries  of  one  or  two  butchers,  to  purchase  a  pig's  bladder.  Three 
days  afterwards,  January  7th,  I  was  shown  at  the  visit,  a  macerated  piece  of  this 
bladder,  which  she  affirmed  had  been  passed  during  the  night,  and  was  a  portion  of 
a  ruptured  cyst.  According  to  her  own  account  there  had  been  violent  bearing- 
down  pains  for  three  nights  previously.  I  proceeded  to  inspect  the  substance,  and 
on  informing  her  that  it  was  a  piece  of  pig's  bladder,  her  astonishment  and  alarm 
may  easily  be  conceived.  She  subsequently  confessed  this  imposture,  but  nothing 
could  induce  her  to  communicate  anything  witli  regard  to  her  former  ones. 

Commentary. — In  June  1852,  I  received  from  a  higlily  respectable 
practitioner  in  the  north  of  Scotland,  a  bottle  containing  sevei-al  cj'sts, 
with  a  letter  informing  me  that  they  had  been  passed  ^jer  vcif/inmn  by 
this  woman  then  laboui'ing  under  ovario- uterine  disease.  He  wrote  that 
"The  patient,  about  eighteen  years  ago,  had  a  mature  child.  Her 
labour  was  followed  by  an  attack  of  peritonitis,  and  she  dates  her  pre- 
sent ailments  from  this  period.  Before  the  case  came  under  my  care, 
she  had  been  long  in  hospital  for  ovarian  dropsy,  and  was  tliere 
repeatedly  tapped.  During  the  last  few  years  she  has  passed  per 
vaffinam  from  time  to  time,  one  of  the  membranous  productions  of  which 


720  DISEASES   OF   THE   GENITO-URINAEY  SYSTEM. 

I    lierewith    send    you   specimens.      You   will    perceive  that    in    some 
instances  tliey  were  perfect  casts  of  the  interior  of  the  uterus;   in  others 
they  have  been  broken  in  the  removal.       When  she  first  applied  to  me, 
the  paracentesis  had  been  delayed  beyond  the  usual  time.     The  drop- 
sical accumulation  was  great,  and  her  general  health  in  a  very  unsatis- 
factory state  for  surgical   interference ;  and  before  I  could  make  up  my 
mind  to  operate,  nature  kindly  came  to  the  relief  of  doctor  and  patient, 
and  managed  the  thing  so  well  that  I  have  allowed  the  good  dame  to 
have  evervthing  her  own  Avay  since.     She  did  it  thus  :  a  membranous 
cvst  was  thrown  off,  and   this  was  immediately  followed   by  the  dis- 
charge, per  var/mam,  of  the  dropsical   fluid,  to   the  amount  of  several 
pints.     That    this   also    came    from    the  uterus,   I    satisfied    myself  by 
tactile  examination  whilst  the  fluid  was  passing.      Since  then  this  pro- 
cess, the  discharge  first  of  the  membiane  (distended  with    serum),  and 
immediately  after  of  the  efi:usion,  has  been  repeated   every  few   months, 
the  patient  in  the  interval  enjoying  an  astonishing  measure  of  health." 
Without  entering   into  a  minute  description   of  these  cysts,  it  will 
suffice  to  say,  that  after  carefully  examining  them,  I  came  to  the  con- 
clusion that  they  were  the  urinary  bladders  of  some  animal — and  from 
the  size  (between  two  and  three  inches  in  their  long  diameter),  per- 
haps of  lambs  or   small   pigs.      They   had  evidently  been    macerated, 
and    the    external    and    half  of  the  muscular  coat  removed,  and    the 
smooth   mucous  surface  turned  inside  out.     In  some  of  them,  however, 
there  could  be  seen  the  two  openings  of  the  ureters,  whilst  in  others 
fragments  of  one  or  both  tubes  Avere  still  attached.     On  communicating 
myopinion  as  to  the  nature  of  these  cysts  to  her  medical  attendant,  and 
hinting  that  so  far  the  woman  was  an  impostor,  he  replied  as  follows  : — 
"  I  removed  two  or  three  of  the  membranes,  on  as  many  dift'erent 
occasions,  from   the  vagina,  and  the  state  of  the  os  uteri,  as  ascertained 
on  their  removal,  Avas  always  such  as  to  leave  no  doubt  in  my  mind  as 
to  their  having  been  ejected  from  the  uterine  cavity.     On  each  occasion 
the  woman   suffered   severely,  having  had  regular  and   painful  uteiine 
contractions,    till    the    diseased    product    was    expelled,     and    profuse 
hsemorrhage  afterwards  generally  inducing  syncope.     I  mentioned   in 
my  former  note  that  I   have  more  than  once  felt  the  dropsical   fluid 
(which,  as  I   also  stated,  is  genei'ally  discharged   shortly  after  the   sac) 
passing  from  the  os  uteri.      Add  to  this  that  the  woman's  cii'cumstances 
are  such   that  it  would   be  next  to  impossible  for  her  to  procure  the 
means  of  perpetrating  the  trick  you  suspect  her  of.     The  membranes 
were  kept  by  me  for  years  immersed  in  spirits.     May  not  this  circum- 
stance have  rendered  your  examination  of  them  less  satisfactory?" 

In  this  letter  my  correspondent  announced  his  intention  of  sending 
the  woman  to  Edinburgh,  if  I  could  take  her  into  the  Clinical  Ward  of 
the  Infirmary.  This  I  promised  to  do,  and  having  passed  another  "cyst" 
in  the  interval,  she  came  to  Edinburgh. 

On  reviewing  the  facts  of  this  case,  it  appears  probable  that  cysts 
formed  in  the  left  ovary  had  burst  at  successive  times  into  some  portion 
of  the  left  Fallopian  tube,  and  so  been  gradually  emptied  ;  and  that  with 
a  view  of  exciting  further  sympathy,  she  had  introduced  the  macerated 
urinary  bladders  of  lambs,  sheep,  or  pigs  into  the  vagina,  and  pretended 
that  thev  had  been  formed  in  the  uterus. 


OVARIAN   DROPSY.  721 


Pathology  of  Ovarian  Dropsy. 

The  subject  of  encysted  tumours  of  the  ovary  has  been  considerably 
elucidated  by  numerous  writers,  but  more  especially  by  Hodgkin,  Sev- 
mour,  Bright,  Cruveilhier,  and  Miiller.  From  these  it  would  appear  that 
the  ovary  may  be  the  seat,  1st,  of  a  simple  cyst;  2d,  of  a  compound  cyst, 
formed  of  a  capsule  containing  a  number  of  secondary  cysts;  and  3d,  of 
similar  cysts  more  or  less  combined  with  a  sarcomatous  structure,  gene- 
rally considered  of  a  malignant  nature.  The  first  of  these  seldom  be- 
comes larger  than  an  orange,  and  is  for  the  most  part  only  detected  after 
death.  The  two  latter  frequently  reach  a  large  size,  and  contain  several 
gallons  of  fluid,  constituting  what  has  been  called  ovarian  dropsy.  In 
these  cases,  the  accumulation  of  fluid  sooner  or  later  interferes  with  the 
process  of  respiration,  so  as  to  render  paracentesis  necessary.  This  ope- 
ration is  repeated  again  and  again  at  shorter  intervals,  until  the  patient 
sinks.  On  dissection,  death  is  found  to  have  been  occasioned  by  peri- 
tonitis, by  suppurative  iuflammation  within  the  sac,  or  by  exhaustion. 

The  source  of  the  jfiihl,  removed  by  tapping  in  ovarian  dropsy,  was 
pointed  out  by  me  in  1846.*  On  some  occasions  the  serum  exists  with- 
in the  cavity  of  the  abdomen,  and  the  tumour  can  be  felt  to  move  or  float 
in  it.  At  other  times  it  is  confined  within  the  cystic  tumour.  Thus 
some  have  supposed  the  fluid  to  be  ascitic,  caused  by  pressure  on 
the  large  abdominal  veins,  whilst  others  have  supposed  that  the  growth 
irritates  the  peritoneum,  and  occasions  an  increased  efl"usion  of  serum. 
In  the  case  of  Fleming  (Case  CLV.),  it  was  also  argued  by  some  of  the 
objectors  to  ovariotomy,  that  excision  of  the  tumour  would  not  remove 
the  ascites,  as  that  was  probably  dependent  on  causes  unconnected  with 
it.  Xow,  in  that  and  similar  cases,  where  four  or  five  gallons  have  fre- 
quently been  removed  from  the  abdominal  cavity,  it  must  be  evident 
that  the  amount  of  fluid  could  not  be  contained  in  the  cysts  of  a  tumour 
only  the  size  of  the  human  head.  Xeither  could  it  have  been  the  result 
of  peritonitis,  as  the  fluid  was  clear  and  of  a  brownish  amber  colour. 
Again,  the  liver  and  other  abdominal  viscera  were  healthy,  and  they 
could  not  have  caused  venous  obstruction  ;  nor  was  it  likely  that  such  an 
ovarian  tumour,  floating  as  it  did  mostly  in  fluid,  could,  by  its  pressure, 
have  occasioned  eft'usion  of  that  fluid  from  the  veins.  It  must  be  con- 
cluded, therefore,  that  in  such  cases  the  fluid  is  secreted  within  the  tu- 
mour, and  passes  through  one  or  more  openings  in  its  walls  into  the 
peritoneal  cavity. 

The  mode  of  growth  and  the  structure  of  encysted  tumours  of  the 
ovary. — In  all  the  specimens  of  the  disease  I  have  examined,  whether 
the  growth  is  only  the  size  of  a  walnut,  or  is  so  large  that  it  has  entirely 
filled  the  abdomen,  the  original  form  and  structure  of  the  ovarv  has  dis- 
appeared. Whether  a  new  growth  is  produced,  or,  as  has  been  supposed 
by  some,  the  Graafian  vesicles  are  enlarged,  and  thus  originate  the  tu- 
mour, is  not  yet  determined.  I  am  inclined  to  adopt  the  latter  opinion, 
and  to  think  also  that  the  external  capsule  is  formed  by  the  thickening 
and  extension  of  the  serous  membrane  which  covers  the  organ.     Sooner 

*  Pathological  and  Clinical  Observations  on  Encysted  Tumours  of  the  Ovary. 
Edinburgh  Medical  and  Surgical  Journal.     Vol.  bcv. 

46 


722  DISEASES   OF   THE   GENITO-URINARY   SYSTEM. 

or  later  the  enlarged  ovary  is  found  to  consist  of  a  dense  fibrous  envelope 
or  sac,  containing  internally  numerous  secondary  cysts  attached  to  its 
walls.  As  the  tumour  d(;velopes  itself  these  cysts  become  larger,  more 
numerous,  and  crowded  together.  Each  individual  secondary  cyst  con- 
tains a  clear  ghiiiy  or  gelatinous  fluid,  and  is  composed  of  a  firm  fibrous 
capsule,  lined  by  a  smooth  membrane.  On  making  a  thin  section  com- 
pletely through  one  of  these  cysts,  its  greatest  thickness  will  be  found, 
on  a  microscopic  examination,  to  be  composed  of  fibrous  tissue,  lined  in- 
ternally by  a  delicate  membrane  covered  with  epithelial  cells.  (See  Figs. 
182,  183.)     The  whole  are  richly  supplied  with  blood-vessels. 

As  the  tumour  enlarges,  it  ascends  from  the  pelvis,  where  it  is  origi- 
nally confined,  and  occupies  more  and  more  of  the  abdominal  cavity.  The 
Fallopian  tube  and  broad  ligament  become  elongated.  The  fimbriated 
extremity  of  the  former  is  sometimes  obliterated,  at  others  it  stands  out 
from  the  morbid  mass.  Sometimes  the  tumour  forms  adhesions  exter- 
nallv,  more  or  less  extensive,  to  the  peritoneum,  omentum,  colon,  or 
neighbouring  viscera.  At  others  it  floats  loose  in  a  fluid  within  the 
abdominal  cavity. 

Meanwhile  the  internal  cysts  press  upon  each  other,  they  become  dis- 
tended with  fluid,  the  blood-vessels  are  compressed,  and  in  such  places 
further  growth  is  checked.  In  consequence  of  this,  absorption  of  their 
structure  occurs,  and  one  or  more  open  into  each  other,  as  was  pointed 
out  bv  Hodgkin,  constituting  a  nmltilocular  cyst.  Occasionally  the  pres- 
sure acting  upon  the  external  sac  causes  it  to  become  thinner  and  thin- 
ner, until  at  length  perforations  are  produced  in  it  also,  through  which 
the  fluid  contents  of  the  cyst  escape  into  the  abdominal  cavity.  Thus 
relieved  from  pressure,  the  margins  of  these  perforations  become  once 
more  vascular,  and  of  considerable  thickness,  often  resembling  the  round 
perforating  ulcer  of  the  stoma(;h  so  well  described  by  Cruveilhier.  Under 
such  circumstances,  the  internal  membrane  of  the  cyst  continues  to  secrete, 
and  pour  its  fluid  into  the  peritoneum,  rendering  paracentesis  necessary. 
At  other  times  no  opening  in  the  sac  takes  place,  the  secondary  cysts 
burst  or  open  into  each  other  internally,  so  that,  after  a  certain  period, 
three,  two,  or  only  one  cavity  may  remain,  with  bands  stretching  across 
and  forming  imperfect  septa,  or  with  a  few  small  cysts  attached  to  the 
internal  watl,  and  clearly  indicating  its  original  structure.  In  either  case, 
sooner  or  later,  suppuration  is  in  most  instances  established  within  one 
or  more  of  the  cysts,  or  within  the  external  sac  itself.  This  suppuration 
seems  to  occur  in  some  cases  by  the  formation  of  pus  corpuscles  in  the 
gelatinous  matter  ;  in  others  by  inflammation  taking  place  in  the  Avails  of 
the  cyst  or  sac,  leading  to  exudation,  which  is  afterwards  converted  into 
pus.  The  patient  does  not  long  survive  this  occurrence.  If  perforation 
have  taken  place  in  the  external  wall  of  the  tumour,  peritonitis  is  gene- 
rally induced  ;  if  not,  the  patient  sinks  exhausted,  whether  the  pus  be 
evacuated  or  not.  Occasionally  more  or  less  blood  is  extravasated  into 
the  inflamed  cysts,  which,  with  the  various  stages  of  suppuration,  cause 
the  sanguinolent,  coflfee-like,  greenish,  or  purulent  fluids  so  often  observed. 

The  gelatinous  contents  of  the  cysts  vary  greatly  in  dift'erent  cases  :  in 
some  being  diffluent,  in  others  glairy  like  white  of  egg,  whilst  in  many 
it  is  semi-solid,  resembling  coagulated  calfs-foot  jelly,  or  strong  size. 
"When  fluid,  it  frequently  contains  floccdi,  which  are  patches  of  epithelial 


OVARIAX   DROPSY. 


r23 


membrane,  more  or  less  united  together  by  granular  matter.  When 
gelatinitorm,  it  often  contains  taint  oval  corpuscles,  or  a  tew  primitive 
corpuscles.  (See  Figs.  179,  180.)  Occasionally  an  opalescent  or  opaque 
creamy  appearance  is  communicated  to  the  jelly  by  the  formation  of  pus 
corpnscles  or  minute  granules  (Fig.  298),  and  sometimes  it  is  wholly  tila- 
mentous,  mixed  with  granule  cells  and  other  products  of  inflammation. 

This  jellv-like  matter,  when  consistent,  presents  all  the  characters  of 
coagulated  liquor  saiif/iiinis,  which  has  not  yet  passed  into  organization. 
Acetic  acid  developes  in  it,  or  causes  to  be  precipitated,  a  white  membrane, 
having  all  the  characters  of  fibrous  tissue.  Frequently,  granules,  cells, 
and  filaments  may  be  observed  in  it  in  various  stages,  as  is  the  case  with 
recent  exudation  from  the  serous  membranes,  or  in  other  simple  forms 
of  hyaline  blastema. 

Not  unfrequently  the  ovary  contains  hairy  and  other  growths,  teeth 
(p.  167),  and  calcareous  deposits,  and  may  be  the  seat  of  cancer.  In  this 
last  case  I  also  pointed  out  and  figured  in  the  memoir  referred  to,  that 
the  so-called  cancer  often  consists  of  an  epithelioma  of  a  remarkable  kind, 
columnar  epithelial  cells  forming  and  separating  in  great  abundance.* 
I  have  now  examined  several  such  diseased  ovaries ;  one  especially,  for- 
warded to  me  by  the  late  Mr.  Russell,  of  Birmingham,  exhibited  to  the 
naked  eye  all  the  characters  of  cystic  encephaloma,  and  yielded  an  abun- 
dant milkv  juice.  On  examining  this  with  a  microscope,  it  was  seen  to 
contain,  1st,  numerous  columnar  epithelial  cells,  with  fatty  granules  accu- 
mulated within  their  broad  extremities;  2d,  a  multitude  of  diaphanous 
celloid  bodies;  and,  3d,  numerous  free  nuclei,  as  in  Figs.  441,  442,  443. 
See  also  Fiof.  184. 


Fig.   441. 


Fig.   442. 


The  diagnosis  of  ovarian  tumours  was  formerly  very  defective ;  so 
much  so,  indeed,  as  in  some  cases  to  have  led  to  the  opening  of  the  abdo- 
men to  excise  a  tumour  which  had  no  existence,  and  in  manv  others 
to  the  performance  of  an  operation  when,  from  adhesions  or  other  causes^ 


*  Ibid.  Case  II.  Fi?.  1. 


Fig.  441.  Groups  of  columnar  epithelium  iu  the  juice  of  an  encephalomatous  cystic 
growth  of  the  ovary,  with  fatty  grauules  accumulated  at  their  extremities. 

Fig.  442.  Diaphanous  celloid  bodies,  naked  nuclei,  and  granule  cells. 

Fig.  443.  a.  The  nuclei  after  the  addition  of  acetic  acid ;  b,  the  columnar  epithelium 
acted  on  by  the  same  re-agent.  250  diam. 


724  DISEASES   OF   THE   GENITO-URINARY   SYSTEM. 

the  ffrowtli  could  not  be  removed.  In  all  cases  of  abdominal  tumour, 
there  are  two  questions  which  every  practitioner  desires  to  answer  with 
certainty,  namely,  1st,  What  is  the  seat?  and,  2d,  What  is  the  nature 
of  the  tumour?  With  regard  to  the  first  point,  I  must  refer  to  obstetri- 
cal works,  in  which  all  the  circumstances,  local  and  general,  are  pointed 
out,  which  distinguish  such  ovarian  growths  from  pregnancy,  with  which 
they  have  often  been  confounded.  Therein  also  will  be  found  the  means  of 
exploring  the  cavity  of  the  uterus  with  the  uterine  sound,  an  instrument, 
which,  by  enabling  tlie  practitioner  to  elevate,  depress,  or  bring  forward, 
the  fundus  of  the  organ,  so  as  to  permit  of  its  being  felt  through  the 
integuments,  in  various  positions  above  the  pubes,  aftbrds  most  valuable 
information. 

In  cases  of  ovarian  dropsy,  the  information  thus  arrived  at  is  negative, 
but  this  becomes  of  immense  importance  when  the  question  arises  (as  it 
always  does),  Is  the  tumour  uterine  or  ovarian  ?  In  the  case  of  Fleming, 
this  point  was  anxiously  debated,  but  when  on  the  introduction  of  the 
sound  the  fundus  of  the  uterus  could  be  distinctly  felt  above  the  pubes  pre- 
senting its  usual  rounded  character,  there  could  no  longer  be  any  sus- 
picion that  the  tumour  originated  in  that  organ.  Again,  by  pushing  the 
uterus  from  side  to  side,  we  are  enabled  to  act  upon  the  ovaries,  and  to 
determine,  by  the  impulses  communicated  to  the  hand,  whether  the  tu- 
mour be  on  the  right  or  left  side,  and  to  form  a  tolerable  idea,  in  certain 
cases,  whether  it  be  free  or  attached.  By  means  of  this  instrument,  then, 
we  are  materially  assisted  in  resolving  the  first  important  question  re- 
garding the  seat  of  the  tumour. 

A  microscopic  examination  of  the  fluid  removed  by  paracentesis  may 
also  sometimes  give  important  indications  as  to  t\\Qnature  of  the  tumour. 
If,  for  instance,  the  fluid  be  clear,  with  polygonal  or  rounded  and  swollen 
epithelial  cells  (see  Figs.  80  and  175),  they  arc  highly  characteristic  of 
cystic  ovarian  growths.  If  columnar  epithelial  cells  are  found  in  quan- 
tity, there  is  probably  an  epitheliomatous  cancroid  of  the  ovary  (see  Figs. 
184,  441,  and  442).  If,  on  the  other  hand,  there  be  pus  or  blood  cor- 
puscles, areolar  texture,  or  calcareous  salts  and  deposits,  the  amount  of 
purulent  formation,  hajmorrhage,  disintegration,  or  mineral  degeneration, 
may  be  judged  of  thereby.  . 


Treatment  of  Ovarian  Dropsy. 

The  anatomical  examination  of  encysted  tumours  of  the  ovary  must 
convince  every  one  that  they  are  not  curable  by  internal  medicines.  The 
idea  that  a  dense  fibrous  envelope,  containing  numerous  secondary  cysts, 
all  richly  furnished  with  blood-vessels,  can  be  absorbed  through  the 
agency  of  mercury,  iodine,  or  any  other  drug,  is  purely  imaginary.  There 
is  not  one  positive  fact  to  support  such  an  opinion.  Neither  can  it  be 
supposed,  from  what  has  been  described  of  the  mode  in  which  these 
tumours  are  developed,  that  so  long  as  any  of  the  secondary  cysts  remain 
intact,  a  cure  can  be  hoped  for.  But  we  have  seen  that  the  natural  course 
of  these  secondary  cysts  is  to  open  into  each  other,  until  at  length  only 
one  large  cyst  remains.  Under  such  circumstances  it  may  be  conceived 
that  a  rupture  might,  by  exciting  inflammation,  and  thus  destroying  the 


OYARIAX   DROPSY.  725 

secreting  surfaces,  or  inducing  adhesions  between  them,  cause  a  radical 
cure  of  the  disease.  Such  is  probably  tlie  explanation  of  those  rare  cases 
of  cvsts,  well  established  in  science,  which  have  apparently  burst,  and 
rapidlv  disappeared.  A  case  of  this  kind  has  been  recorded  by  Lebert,* 
in  which  tlie  tumour  burst  into  the  peritoneum  and  subsequently  disap- 
peared. In  other  cases  the  tumour  may  unite  with  neighbouring  hollow 
viscera,  and  by  ulceration  empty  its  contents  into  them,  so  that  they  are 
discharged  (Cases  CLVI.  and  "CLVIT.),  or  it  may  open  on  the  external 
surface.  When  a  perfect  cure  has  been  brought  about  in  this  way,  it 
will  generally  be  observed  that  the  progress  of  the  morbid  growth  has 
been"  chronic,  that  consequently  time  has  been  allowed  for  all  the 
secondary  cysts  to  open  into  each  other,  and  that  the  inflammation 
which  follows  the  rupture  may  then  be  supposed  to  act  by  obliterating 
or  causing  adhesions  between  the  walls  of  the  cyst,  as  in  the  case  of 
hydrocele.  When,  on  the  other  hand,  sudden  rupture  of  the  external 
sac  takes  place,  whilst  some  of  the  cysts  remain  entii-e,  the  termination 
in  cure  is  impossible,  and  the  peritonitis  occasioned  more  frequently 
causes  death. 

The  occasional  occurrence  of  such  spontaneons  recoveries  has  led  to 
the  proposition  of  producing  permanent  artificial  openings,  with  a  view 
of  imitating  a  natural  cure.  Mr.  Bainbridge  of  Liverpool  suggested 
making  an  incision  into  the  sac,  and  uniting  its  edges  with  the  external 
wound ;  and  Dr.  Tilt  of  London  has  proposed  making  a  minute  aperture 
by  means  of  Vienna  paste,  so  as  to  cause  a  permanent  opening.  Such 
practice  can  only  be  useful  at  a  particular  period  in  the  growth  of  ovarian 
tumours — that  is,  when  all  the  internal  cysts  have  broken  down  into  one. 
But  such  cases  are  exceedingly  i-are,  and  such  practice  can  be  of  no  real 
advantage  until  we  learn  to  distinguish  in  the  living  subject  unilocular 
from  multilocular  cysts.  Numerous  cases  and  dissections  of  ovarian  tu- 
moui's  have  convinced  me,  that,  in  the  present  state  of  the  art,  this 
knowledge  is  not  to  be  arrived  at  with  any  degree  of  certainty ;  and  that 
consequently  any  proposal,  however  valuable  in  itself,  which  is  founded 
upon  the  assumption  of  our  possessing  that  knowledge,  is  not  likely  to  be 
practically  beneficial.  The  same  remark  applies  to  injections  of  the 
tincture  of  iodine  or  any  other  fluid,  which  can  only  operate  on  indivi- 
dual cysts,  and  not  on  the  entire  growth. 

It  is  astonishing  how  some  individuals  accommodate  themselves  to  very 
large  abdominal  swellings.  I  have  known  several  cases  where  the  patient 
has  laboured  under  an  enormous  encysted  tumour  of  the  ovary  for  ten 
and  even  fifteen  years.  On  the  other  hand,  many  facts  demonstrate  that 
when  once  paracentesis  is  had  recourse  to  as  a  palliative  measure,  sup- 
puration within  the  cysts,  and  a  cachectic  state  of  the  constitution,  is  more 
likelv  to  supervene.  One  important  practical  rule,  therefore,  to  be  fol- 
lowed in  the  treatment  of  these  cases  is,  not  hastily  to  have  recourse  to 
tapping,  but  rather,  by  all  possible  means  of  delay,  to  further  the  natural 
disposition,  which  the  internal  cysts  exhibit  under  pressure,  of  forming 
one  lapi-e  sac.  This  once  accomplished,  there  is  nothing  inconsistent  in 
supposing  that  inflammation  produced  artificially  is  as  capable  of  producing 
a  permanent  cure  as  is  a  spontaneons  ruptui'e.  There  is  every  reason  to^ 
believe  that  artificial  pressure  is  capable  of  facilitating  the  absorption  of 
*  Physiologie  Pathologique,  tome  ii.  p.  71. 


726  DISEASES   OF   THE    GEXITO-URIXARY   SYSTEM. 

the  walls  of  the  secondary  cysts,  and  their  opening  into  each  other;  hnt 
we  possess  no  means  of  ascertaining  when  only  one  sac  is  produced.  That 
it  has  succeeded  in  obliterating-  and  ultimately  curing  the  disease,  how- 
ever, has  been  proved  by  Mr.  Isaac  Brown,*  who  by  binding  a  book  on 
the  tumour  firmly,  has  caused  inflammation  and  disintegration  of  the 
internal  cysts,  and  then  letting  out  the  pus,  has  actually  cured  some  cases. 
The  practice,  however,  is  by  no  means  safe. 

Case  CLVI.  seems  to  me  illustrative  of  tlie  eflects  of  pressure.  It  must 
be  acknowledged  that  the  seven  months  which  had  elapsed  between  the 
time  the  tumour  was  first  perceptible,  and  the  period  when  it  sponta- 
neousl)"  burst  into  the  bladder  and  collapsed,  was  a  remarkably  short  one. 
In  the  most  favourable  cases  this  result  takes  about  two  years  to  accom- 
plish by  itself;  but  in  the  instance  of  Pyper,  the  tumour  was  subjected 
to  the  gradually  increasing  and  equable  pressure  of  the  pregnant  uterus, 
and  to  its  influence  must,  I  think,  be  attributed  the  fortunate  result  and 
rapid  breaking  down  of  the  secondary  cysts.  The  ulceration  into  the 
bladder  was  probably  determined  by  the  direction  the  pressure  had  as- 
sumed in  this  case,  and,  of  course,  could  not  be  imitated  artificially. 

There  still  only  remain  two  methods  of  curing  an  ovarian  dropsy  by 
art — viz.,  1st,  by  excision ;  and  2d,  by  pressure  followed  by  puncture. 
Cases  CLVI.  and  CLYII.  confirm  the  views  suggested  by  pathology  with 
regard  to  the  modus  operandi  of  the  latter  treatment ;  and  if,  in  cases 
Avhich  do  not  admit  of  extirpation,  pressure  be  so  gradually  and  equably 
applied  as  to  obliterate  the  internal  or  secondary  cysts,  an  artificial 
opening  then  made  would  cure  the  disease.  The  difiiculty  is  to  ascer- 
tain when  the  moment  for  making  the  puncture  has  arrived — in  other 
words,  when  a  multilocular  is  converted  into  a  unilocular  cyst.  In  the 
present  state  of  the  art,  this,  as  I  have  said,  is  impossible;  but,  as  an 
exact  indication  of  the  difficulty  is  often  the  best  preliminary  to  its 
removal,  I  do  not  despair  of  one  day  seeing  it  completely  conquered 
by  the  cultivators  of  medicine. 

As  regards  excision,  the  practice  of  late  years  has  tended  to  confirm 
its  propriety  in  such  cases  as  that  of  Fleming  (Case  CLV.),  in  which 
the  tumour  has  no  adhesions  of  any  extent  to  the  abdominal  walls, 
where  its  presence  is  the  cause  of  great  deformity  and  much  sutfenng, 
and  where  the  youth  and  general  health  of  the  patient,  and  freedom 
from  other  diseases,  hold  out  hopes  of  a  favourable  result.  Dr.  Clay 
of  Manchester  has  recently  stated  that  he  has  operated  in  "79  cases  of 
ovarian  tumour,  55  of  which  have  been  successful,  and  that  he  is  con- 
fident that,  operating  de  novo,  from  his  increased  experience  he  would 
not  have  more  than  25  per  cent,  of  fatal  cases. 


NEPHRITIS  AND  PYELITIS. 

Case  CLTin.-|- — Acute  Kephro-Pyelitis — Recovery. 

History. — Helen  Kessick,  set.  65,  a  nurse — admitted  Xovember  25,  1852.    States 

*  See  cases  recorded  in  the  Lancet. 

f  Reported  by  Mr.  F.  B.  de  Chaumont,  Clinical  Clerk. 


NEPHRITIS   AND   TYELITIS.  iZi 

that,  for  the  last  twentv  years,  she  has  been  subject  at  intervals  to  occasional  pains 
in  the  lumbar  region.  She  had  never  experienced  any  difficulty  or  uneasiness  in 
micturition,  till  about  five  years  ago,  -when  she  noticed  that  the  urine  was  tinged 
with  blood ;  this  was  accompanied  with  pain  in  the  right  lumbar  region,  preceded 
by  shivering,  and  followed  by  febrile  symptoms.  She  was  admitted  into  the 
Royal  Infirmary,  where  she  remained  for  seven  weeks,  and  was  dismissed  cured. 
She  had  no  return  of  the  symptoms  till  about  tn-elve  months  ago,  when  she  was 
again  seized  with  shivering,  and  a  return  of  the  lumbar  pain.  During  the  summer 
the  urine  was  tinged  with  blood  for  two  days,  but  afterwards  again  became  normal, 
and  slie  continued  better  till  about  four  weeks  ago,  when  she  once  more  experi- 
enced pain  on  passing  water,  which,  with  increased  uneashiess  in  the  lumbar  region, 
has  continued  up  to  the  present  date. 

Symptoms  ox  Admission'. — On  admission,  tongue  much  furred;  appetite  bad: 
great  thirst ;  no  nausea ;  complains  of  pain  in  the  epigastric  region,  but  no  tumour 
or  hardness  can  be  detected ;  bowels  have  not  been  opened  for  two  days.  She  has 
considerable  pam  in  right  lumbar  and  both  hypochondriac  regions,  also  in  the 
hypogastrium,  after  making  water,  which  is  passed  in  less  quantity  than  usual. 
Urine  sp.  gr.  1016,  coagulable  by  heat  and  nitric  acid,  and  deposits,  on  standing,  a 
copious  ropy  mucus-like  sediment,  showing,  under  the  microscope,  large  quantities  of 
pus  globules,  and  a  few  crystals  of  triple  phosphate ;  pulse  76,  soft ;  no  palpitation  of 
heart;  complains  of  occasional  headache  with  frequent  giddiness,  and  muscae  voli- 
tantes ;  sleeps  ill  at  night,  and  complains  much  of  cold  feet ;  other  functions  normal. 
3  Liquor.  Potass.;  Sp.  ^th.  Xd.  aa  3ij;  Sol  Mur.  Morph.  I'm;  Mist. 
Camph.  3  v.  M.  Sumat  "^  ss  quartd  quaque  hord.  5  01.  Ricinil].  Sumai  statim. 
To  use  barley  water  as  a  drink. 

Progress  of  the  Case. — December  Atli. — Feels  very  weak ;  continues  otherwise 
in  much  the  same  state ;  urine  still  albuminous,  with  copious  deposits,  containmg 
pus  and  triple  phosphates.  To  have  3  oz.  of  wine.  Dec.  11.— Continued  to  improve 
till  last  night,  when  she  was  seized  with  shivering  and  pain  in  lumbar  and  epigas- 
tric regions;  great  nausea  and  vomiting;  tongue  moist,  but  much  furred;  great 
headache  ;  urine  as  before.  Omiti.  mist,  et  vinum.  $  Sol.  Antimon.  5  iij ;  Sp. 
jEth.  Xit.  3.i;  Aquce  Acei.  Amnwn.  et  Aqxue  i^  3  iiss.  M.  Sumat  Zs&terin  die. 
Warm  fomentations  to  be  applied  to  the  loins.  Dec.  \Uh.—^as  rather  better 
yesterday,  but  has  still  pain  in  right  lumbar  region.  To-day  she  is  stdl  sick,  the 
pain  in  right  lumbar  region  somewhat  increased;  there  is  great  dysuria;  the  urine 
is  of  high  colour;  still  albuminous,  sp.  gr.  1018,  with  copious  sediment,  showmg, 
under  the  microscope,  numerous  blood  globules,  and  a  quantity  of  debris  of  cells 
mixed  with  the  pus  and  triple  phosphate-s,  which  are  stUl  as  abundant  as  formerly. 
Dec.  loth. — "Was  no  better  yesterday,  and  began  to  complain  of  severe  pain  in  the 
hypogastrium.  Omitt.  mist.  I^  Tinct.  Eyoscyam.  gss;  Sol.  Mur.  Morph.  3iss; 
MuciUvjinis  ^ij;  Aqu<jR  I'm.  M.  Sumat  3J  ter  in  die.  To-day  she  still  complains 
of  the  pain  in  hypogastric  and  lumbar  regions.  The  urine  is  diminished  in  quan- 
titv,  and  deposits,  on  standing,  a  viscid  tenacious  sediment,  which,  in  addition  to 
the  blood  corpuscles,  pus,  and  triple  phosphates,  now  shows  casts  of  the  urinary 
tubes,  crowded  with  granules.  To  be  cupped  on  the  lumbar  region  to  8  oz.  Dec. 
lQ(]i_ — Only  six  oz.  were  obtained  by  the  cupping.  The  pain  in  back  is  much 
relieved,  and  she  is  able  to  sit  up  in  bed  without  uneasiness,  but  there  is  still  pain 
in  the  hypogastrium;  pulse  72,  soft;  tongue  still  furred  ;  no  nausea  or  vomiting,  but 
some  pain  in  the  bowels ;  headache  nearly  gone ;  urine  of  a  dirty  red  colour,  stiU 
coao-ulable ;  showuig  blood,  pus,  and  phosphates  under  the  microscope  as  before. 
Habeat  enema  domesticum  et  sumat  Sol.  Mur.  Morph.  3ss,  et  Mucilaginis  §j  ex  aqua 
hord  somni.     Dec.  ISth. — Symptoms  much  the  same  as  at  last  report.     Urine  sp. 


728  DISEASES   OF   THE   GEXITO-URINARY  SYSTEM. 

gr.  1015,  and  again  shows  casts  of  the  urinary  tubes.  The  bladder  was  sounded 
to-day,  but  nothing  abnormal  could  be  detected.  Dec.  20th. — Urme  contains  a 
large  quantity  of  gelatinous  mucus,  in  which  a  lew  broken-down  granular  casts  can 
be  detected.  5  /Sol  Mur.  Morph.  3  ss ;  Tind.  Hyoscyam.  %  i ;  Muciluginis  §  j ; 
Fiat  haunt,  omni  node  sumendus.  5  Decod.  Uvce  Ursi  §  x ;  Tind.  Hyoscynm.  §  j ; 
Sp.  ^th.  Nit.  §j;  Mucilaginis  §ij.  M.  Sumat  §i  ter  in  die.  Dec.  2Qth. — Conti- 
nues in  much  the  same  state,  but  the  pain  in  the  hypogastrium  has  considerably 
increased.  She  had  some  sweating  last  night,  and  tiie  pulse  is  now  86  and  soil; 
the  tongue  is  still  furred ;  no  appetite ;  great  thirst ;  bowels  not  open  for  some  days ; 
great  dj-suria;  urine  presents  the  same  characters  as  before.  Applic.  kirudines 
quatuor  hypiogastrio  et  postea  bene  foveatur.  IJ  Fulv.  Jalapce  et  Fulv.  Scammon. 
aa.gr.  vi.  "M..  Sumat  hord  somni.  ]J  Sol.  Mur.  Moiph.  Zss;  Mudlagij,  is  5j-  ^^^ 
Sumat  eras  mane.  Dec.  29tt. — The  pain  in  the  hypogastrium  having  greatly 
abated,  the  leeches  were  omitted  at  the  patient's  request ;  the  bowels  wei'e  well 
opened  by  the  medicine.  To-day  she  feels  much  better,  and  slept  well. without  the 
draught.  Tongue  more  clean  and  moist,  but  the  urine  contains  rather  more  blood. 
January  \st,  1853. — She  still  continues  improving,  but  pain  in  the  hypogastrium  is 
not  quite  gone.  The  urine  is  more  natural  in  colour,  the  deposit  greatly  decreased, 
and  the  blood  has  now  disappeared.  March  9th. — Since  last  report  has  experienced 
occasional  lumbar  pain,  but  on  the  whole  has  been  slowly  getting  well.  The  urine, 
which  has  gradually  been  getting  clearer,  is  reported  to-day  as  quite  normal,  and 
free  from  albumen.  A  slight  hernial  protrusion  has  been  discovered  in  the  right 
iliac  region,  to  which  a  truss  was  applied.  March  28th. — Dismissed  relieved  of  all 
her  symptoms. 

Commentary. — This  was  a  case  of  acute  nephritis,  with  tendency  to 
recurrence,  exhibiting  local  pain,  inflammation  of  the  mucous  membrane 
(pyelitis),  as  shown  by  the  e.xcessive  discharge  of  mucus  and  pus,  and 
inflammation  of  the  secreting  substance  of  the  organs,  as  proved  bv  the 
frequent  appearance  of  blood,  casts  of  the  tubes  and  the  peisistent 
albumen.  During  a  period  of  four  months,  however,  during  which  a 
variety  of  treatment  was  had  recourse  to,  as  recounted  in  the  report, 
all  the  urinary  symptoms  disappeared,  although  there  was  still  a  tendency 
to  the  return'  of  pain  in  the  lumbar  region.  This  case  indicates  the  mode 
in  which  acute  diseases  of  the  kidney  frequently  pass  into  chronic  ones; 
but  from  the  circumstance  that  the  right  kidney  only  was  attacked,  and 
that  the  left  one  could  still  secrete  a  sufficient  quantity  of  urine,  no 
oedema  or  dropsy  occurred. 


Case  CLIX.* — Subacute  Kephritis,  with  great  Anasarca — Recovery — Acute  Xep)hritis 
of  Left  Kidney — Recovery. 

History.— Anne  Hewison,  a^t.  18,  a  servant — admitted  Dec  14th,  1S56.  She 
has  been  in  the  Surgical  Hospital  on  three  occasions  during  the  last  four  months,  on 
account  of  abscesses  in  and  about  the  axilke,  from  which  she  is  now  free.  For  six 
weeks  she  has  experienced  pain  in  the  lumbar  regions,  most  severe  when  the 
weather  was  cold,  and  increased  by  coughing  and  hard  breathing.  A  fortnight  ago 
she  observed  that  the  feet  and  abdomen  were  swollen.  Since  then  she  has  become 
gradually  anasarcous. 

*  Reported  by  Mr.  M-Leod  Pemberton,  Clinical  Clerk. 


NEPHRITIS   AXD   PYELITIS.  729 

Symptoms  ox  Admission". — The  integument  all  over  the  body  is  oedematous,  and 
the  face  especially  is  considerably  swollen.  All  the  depending  parts  of  the  trunk, 
together  with  the  extremities,  are  pale,  pitting  readily  on  pressure.  The  catamenia 
have  appeared  on  three  occasions  at  the  interval  of  a  fortnight,  and  been  very 
copious.  The  urine  is  highly  albuminous,  sp.  gr.  1010,  diminished  greatly  in 
quantity,  but  the  exact  amount  cannot  be  ascertained.  Numerous  waxy  casts  are 
visible  in  it  under  the  microscope.  The  chest  is  resonant  everywhere  on  percussion. 
Sibilant  sounds  are  audible  at  the  apex  of  right  lung,  both  with  inspiration  and 
expiration,  the  remains,  she  says,  of  a  cold  that  has  troubled  her  for  five  weeks.  She 
suffers  occasional!}^  from  palpitation ;  but  the  circulatory  system  on  examination  is 
normal.  Pulse  80,  of  good  strength.  The  abdomen  very  tumid,  with  distinct  fluc- 
tuation, and  painful  on  pressure  over  the  whole  anterior  surface,  but  most  so  on  the 
right  side  opposite  the  lumbar  region.  The  digestive  system  otherwise,  and  the 
nervous  functions  are  normal.     Habeat  Potass.  Bitart.  3j  ter  in  die. 

Progress  of  the  Case. — December  IGth. — The  amount  of  urine  passed  is  greatly 
increased,  and  has  amounted  to  51  oz.  during  the  last  24  hours.  Dec.  20ih. — The 
whole  body  is  now  much  less  oedematous.  Pulse  75.  Passed  150  oz.  of  urine  dur- 
ing the  last  24  hours.  Dec.  25th. — Has  passed  about  100  oz.  of  urine  daily,  which  is 
pale,  sp.  gr.  1010,  and  now  only  faintly  albuminous.  (Edema  of  extremities  has  now 
disappeared  ;  but  still  some  swelling  of  face  and  abdomen.  There  are  slight  febrile 
symptoms.  Pulse  100,  weak.  Complains  to  day  of  sore  throat.  The  tonsils  are 
enlarged,  and  the  mucous  membrane  of  fauces  congested.  An  astringent  gargk  ivas 
ordered,  and  warm  poultices  to  be  apjMed  to  the  throat.  Dec.  26ih. — Yesterday  after- 
noon and  to-day  she  passed  urine  of  a  dark  brown  colour.  It  is  highly  albuminous, 
with  a  sediment  composed  of  urates  and  blood  discs,  as  seen  under  the  microscope. 
There  is  pain  in  the  left  loin.  Throat  not  so  painful.  Face  anxious.  Pulse  90,  of 
good  strength.  To  omit  the  bitartrate  of  potass.  Ijl  Sp.  JSther.  Nit.  3  ij ;  Mucilaginis 
§  ij ;  Aq.  Font.  §  vj.  M.  Tivo  tabl&^poonfuls  to  be  taken  every  four  hours ;  warm 
fomentations  to  the  left  lumbar  region.  Dec.  28ih. — Has  continued  to  feel  pain  in  the 
left  loin,  which  is  increased  on  pressure.  Has  passed  24  oz.  of  urine  during  the  last 
24  hours,  highly  albuminous,  less  dark,  and  now  of  a,  light  chocolate  colour,  turbid, 
with  no  layer  of  fat  perceptible  on  repose,  but  numerous  tube  casts  and  some  urates 
and  blood  corpuscles  seen  in  it  with  the  microscope.  All  sore  throat,  fever  and- 
oedema  of  the  integuments  have  now  disappeared.  Pulse  84,  firm.  Dec.  3lsi. — 
Has  passed  from  50  to  60  oz.  of  urine  daily.  Has  still  dull  pain  in  the  loins,  but 
otherwise  better.  From  this  time  she  began  to  sit  up  and  walk  about  the  ward. 
The  lumbar  pains  returned  at  intervals,  but  finally  left  her  Jan.  2Gth.  The  urine 
also  retained  a  trace  of  albumen  for  some  time ;  occasionally,  however,  disappearing 
for  a  day.  On  the  19th  of  Jan.  she  took  Potass.  Bitart.  gr.  x.  ter  in  die.  The  urine 
was  examined  daily,  and  on  Jari.  2'ith  up  to  the  30th,  not  a  trace  of  albumen  could 
be  discovered.     She  was  then  dismissed  quite  well. 

Commentary. — In  tins  case,  a  somewhat  clironic  form  of  nepliritis  or 
Briglit's  disease  appeare<l  before  her  admission,  whioli  occasioned  intense 
general  anasarca  of  the  bodv,  and  was  characterised  by  albuminous  urine 
containing-  numerous  wa.xy  casts.  The  oedematous  face  and  general 
appearance  were  in  this  girl  highly  distinctive  of  renal  dropsy.  The 
strong  diuretic  effects  of  the  bitartrate  of  potash,  in  scruple  doses,  caused 
this  to  disappear.  She  was  then  seized  with  acute  nephritis  of  the  leit 
kidney,  as  indicated  by  the  febrile  .symptoms,  pain  in  the  left  loin,  in- 
creased on  pressure,  blood)"  and  tui'bid  urine,  etc.  From  this  also  she 
gradually  recovered  under  the  employment  of  gentle  diuretics,  dcmul- 


730  DISEASES   OF   THE   GENITO-URINARY  SYSTEM. 

cents,  and  warm  fomentations  locally.  All  trace  of  tendency  to  perma- 
nent albuminuria — so  common  a  sequela  of  nephritis — was  also  got  rid 
of  by  the  action  of  small  doses  of  cream  of  tartar.  The  occurrence  of 
sore" throat  and  febrile  symptoms  with  this  last  attack,  induced  me  to 
inquire  carefully  as  to  whether  there  was  any  proof  of  scarlatina,  but  I 
could  not  discover  any. 


Case  CLX.*— Acute  Desquamative  Xephriti.s,  proving  rapicUy  fatal  from  Diminished 
Fluiv  of  Urine,  General  Atiasarca,  and  CEdema  of  the  Lungs. 

History. — William  Lawson,  set.  34,  married,  was  admitted  to  the  Skin  Ward 
Nov.  28,  1856,  for  an  attack  of  scabies,  whicli  liad  lasted  four  montlis.  He  has 
been  drinking  freely  lately— is  anaemic  and  emaciated.  On  examination,  innume- 
rable minute  isolated  vesicles  are  to  be  seen  scattered  over  the  whole  body,  with 
the  exception  of  the  head  and  neck ;  most  abundant  on  the  flexor  surftices.  On 
the  legs  there  are  a  few  patches  of  eczema.  Dec.  2d— He  was  ordered  to  rub  him- 
self all  over  twice  a  day  with  simple  lard,  which,  on  the  6th,  was  exchanged  for 
sulphur  ointment. 

CoMMEXCEiiEXT  OF  THE  DISEASE. — Dec.  Uth. — Especial  attention  was  directed 
to  him  to-day  in  consequence  of  cough  and  evident  dyspnoea.  He  thinks  he  must 
have  caught  cold  from  being  so  long  naked  when  employed  rubbing  himself.  Since 
the  7th  he  has  observed  slight  oedema  of  his  feet,  which  was  followed  by  cough. 
He  has  paid  little  attention  to  these  symptoms.  The  urine  is  found  to  be  highly 
albuminous  and  of  brownish  colour.  On  microricopic  examination  of  the  sediment, 
it  was  seen  to  contain  numerous  desquamative  tube  casts.  His  cough  troubles  him 
chiefly  at  night,  when  he  finds  there  is  difficulty  of  breathing  or  lying  in  the  hori- 
zontal posture.  On  percussion  there  is  slight  impairment  of  resonance  over  right 
chest  anteriorly,  below  level  of  third  rib.  There  is  no  increase  of  vocal  resonance. 
The  respiratory  murmurs  are  more  feeble  than  on  the  left  side,  and  inspiration  is 
occasionally  sibilant.  Posteriorly,  percussion  over  lower  half  of  both  sides  gives 
resonance  of  a  somewhat  flat  tone.  Fine  moist  sounds  attend  the  close  of  inspira- 
tion, and  expiration  feeble  below,  is  exaggerated  superiorly.  g  Sj).  J^ther.  Nit. 
3  ss ;  Tr.  Digitalis,  Tr.  Scillce,  aa  3  iss ;  Aquce  ad  §  vj.  M.  A  tahle-spoonful  to  he 
taken  every  four  hours. 

Progress  of  the  Case. — December  12th. — Over  dull  region  anteriorly  moist 
sounds,  clicking  in  character  and  few  in  number,  attend  the  extreme  close  of 
inspiration.  Vocal  resonance  also  slightly  increased  in  the  area  of  dulness,  and 
posteriorly  there  is  slight  comparative  dulness  over  middle  third  of  right  side. 
Urine  of  brown  smoky  colour,  with  blood  corpuscles  visible  under  the  microscope. 
Sputum  scanty,  purulent,  not  streaked  with  blood.  Extract  |  iv  of  blood  from  the 
loiiis  by  cupping.  Omit  the  mixture.  To  have  3  ss  of  Bitarirate  of  Potash  three 
times  a  day.  3  ij  of  Gin  daily.  Dec.  I5ih. — Since  last  report  the  dyspnoea  has 
been  gradually  increasing,  and  the  pulse  becoming  weaker.  It  is  now  100,  and 
soft.  The  sputum  is  scanty,  purulent,  not  tinged  with  blood.  Percussion  over 
both  lungs  iuferiorly  and  posteriorly  is  impaired,  especially  on  the  riglit  side.  On 
auscultation,  a  fine  moist  rattle  accompanies  the  inspiration,  and  there  is  an  in- 
crease of  the  vocal  resonance.  Urine  presents  the  same  characters  as  formerly, 
and  contains  clilorides  in  abundance,  but  does  not  amount  to  §  xx  daily.  The  gin 
is  increased  to  3  iij  daily.     To  have  3  iv  of  port  wine  in  addition.      ^  Amnion.  Carb. 

*  Reported  by  Mr.  Wm.  Guy,  Clinical  Clerk. 


NEPHRITIS   AXD   PYELITIS.  731 

9ij ;  Tr.  Card.  Comp.  3  j ;  Aquce  ad  §  vj ;  Ft.  mitt.  A  taUe-spoonful  to  he  taken 
every  second  hour.  Dec.  lltli  — Has  beeo  steadily  getting  worse.  Tlie  respirations 
are  now  40  in  the  minute,  and  he  is  obliged  to  retain  the  sitting  posture.  Takes  no 
nourishment.  Pulse  126,  very  feeble.  Creiiitation  and  increased  vocal  resonance 
now  heard  posteriorly  as  high  as  spine  of  scapula.  Xo  pain.  Pulse  80,  of  good 
strength.  To  be  dry  cupped  over  chest  and  back ;  warm  bottles  to  feet.  Towards 
evening  the  face  more  pallid,  hands  and  forearms  cold  and  slightly  oedematous. 
At  9  P.M.  the  breathing  was  48  jper  minute,  and  so  laboured  that  he  was  bled  to 
about  3  xiij.  Toward  close  of  venesection  the  pulse  at  left  wrist,  previously 
imperceptible,  could  be  detected  smaU  and  exceedingly  weak;  and  patient  (on 
inquiry)  admitted  himself  to  be  slightly  relieved,  although  to  others  this  was  not 
perceptible.  Fifteen  minims  of  Sol.  Mur.  Morph.  ordered.  Dec.  18ih. — His  wife 
states  that  he  slept  from  three  to  six  o'clock  this  morning.  The  dyspnoea  is  as 
great  as  before  the  venesection ;  respirations  catching  in  character.  Has  passed 
very  little  urine,  and  that  at  stool ;  on  examination  it  was  found  to  contain  pus 
corpuscles  in  considerable  quantity,  beside  the  casts  before  mentioned.  He  is 
obliged  to  sit  up  and  lean  forward  in  bed ;  his  intellects  are  somewhat  impaired. 
During  the  night  delirious.  Dec.  20th. — Evidently  sinkmg,  but  conscious.  Dec. 
21st. — Died  this  morning  at  half-past  three  o'clock. 

Sectio   Cadaveris. — Thirty-three  hours  after  death. 

The  body  is  generally  anasarcons,  with  great  oedema  of  the  scrotum ;  surface  pale ; 
no  trace  of  scabies,  with  the  exception  of  a  few  small  circular  cicatrices  about  the 
hands  and  fingers. 

Thorax. — All  the  cavities  of  the  heart  and  large  vessels  were  distended  with 
blood,  for  the  most  part  coagulated  and  decolorized.  The  cavities  of  the  heart  itself 
in  consequence  were  dilated.  ,  This  was  especially  observed  of  the  left  ventricle,  the 
walls  of  which  were  rather  thinner  than  natural.  The  pericardium  and  all  the 
valves  were  healthy.  The  heart  weighed  16  oz.  The  right  pleura  was  everywhere 
strongly  adherent.  The  right  lung  was  moderately  voluminous,  and  felt  heavy. 
On  section,  it  was  seen  to  be  highly  oedematous,  yielding  on  pressure  a  copious 
frothy  fluid.  No  solid  exudation  anywhere.  The  left  lung  was  unadherent,  and 
rather  less  voluminous  than  the  right  one,  and  though  oedematous  was  not  so  in  the 
same  degree. 

Abdojiex. — On  stripping  ofl"  the  capsule  from  the  surface  of  the  kidneys,  they 
both  appeared  of  their  normal  size  and  of  a  pale  fawn  colour.  When  cut  into,  the 
cones  were  found  somewhat  congested,  the  cortical  tissue  pale.  The  latter  con- 
tained numerous  white  lines  or  streaks,  generally  directed  at  right  angles  to  the 
circumference  of  the  organ.  There  was  no  trace  of  granulation,  and  the  density 
of  the  kidneys  was  much  diminished,  the  organs  being  more  sott  than  usual.  The 
liver  was  congested,  'out  otherwise  normal ;  it  weighed  4  lbs.  The  other  abdominal 
viscera  were  healthy. 

Microscopic  Examixatiox. — On  scraping  a  fresh  cut  surface  of  the  kidney,  a 
pulpy  matter  was  readily  obtained,  which,  on  examination  under  a  power  of  250 
diameters,  was  seen  to  be  conaposed  of  large  fragments  of  the  tubes,  crowded  with 
epithelial  cells,  which  were  agglutinated  together  by  a  fine  moleular  matter.  Groups 
of  these  cells  surrounded  by,  or  imbedded  in  this  molecular  substance,  could  also  be 
seen  isolated.  On  the  addition  of  acetic  acid,  the  molecular  matter  and  the  walls 
of  the  cells  were  rendered  more  transparent,  whilst  the  nuclei  were  unafl:ected.  The 
urine  in  the  bladder  contained  a  few  desquamative  casts  of  the  tubes,  spermatozoa, 
and  a  number  of  isolated  epithelial  cells  from  the  kidney. 


732  DISEASES   OF   THE   GENITO-URINARY   SYSTEM. 

Commentary. — The  acute  disease  of  which  tliis  man  died,  came  on 
in  the  ward  during  the  inunctions  he  practised  over  the  body  in  order 
to   remove   a  chronic   scahies,  which   extended   itself  to  a  great  extent 
over  the  integument.      The  first  approach  was  so  slow^  as  not  to  excite 
attention — hehimself  considering  it  as  an  ordinary  cold.      On  the  10th 
of  December,  when   cough  and  some  dyspnoea  attracted  my  notice,  the 
feet  and   legs  were  already  oedematous,  and  the   urine  diminished  in 
quantity,  as'well   as  highly  albuminous.      It  was  observable,  however, 
that  there  were  no  symptoms  of  fever,  no  local  pain,  and  the  question 
arose,  whether,  in  conjunction  with  diminished  urinary  excretion,  there 
Avas  or  was  not  pneumonia.     My  diagnosis  in  the  negative  was  assisted 
not  only  by  the   absence    of  febrile  symptoms,  and   by  the   loud  and 
superficial   character  of  the   crepitating  rale   in  both   lungs    spreading 
upwards,  but  by  the  constant  presence  of  chlorides  in  the  urine  (see  p. 
643.)     On  the  other  hand,  the  chemical  and  microscopical  examination 
of  the  urine  soon  left  us  in  no  doubt  that  ve  had  to  do  with  an  acute 
attack  of  desquamative  nephritis,  producing  general  anasarca,  and  more 
especially  rapid  a'dema  of  the  lungs.     This  diagnosis  was  fully  confirmed 
by  the  dissection   after  death,  the  cortical  portion  of  the  kidneys  being 
pale  and  comparatively  free  from  blood,  whilst  the  tubes  Avere  gorged 
with  exudative  granular  matter,  mingled  with  a  mass  of  epithelial  cells. 
Both   lungs,  especially  the  right  one,  were  infiltrated  with  serum.     The 
rapid    progress   of   this   case,    evidently    dependent   on    obstruction    of 
the  renal  "tubes,   seemed  to  demand   active  remedies.      But  the  state 
of  the    pulse    and    tendency    to    prostration    from    the   commencement 
forbade    antiphlogistic    remedies,    even    had    other    considerations    not 
pointed  out  their  inutility   (see  p.  264.)       For  the   same  reasons,  dia- 
phoretics were  too  slow  and  uncertain  in  their  action  to  be  depended 
on,  although  morphia  and  local  warmth   were  tried.     Diuretics,  there- 
fore, were  given,  and  subsequently  stimulants  to  counteract  exhaustion, 
a  practice  which,  though  condemned  by  some  on  the  principle  that  we 
stimulate  an    organ   already  in   a  state  of  irritation,  we  have  too  fre- 
qucntlv  seen  succeed  when  all  other  remedies  have  failed,  to  have  any 
doubt  "as  to  its   value.      The  real   danger,  however,  in   this  case  was 
early  to  be  traced  to  the  consecutive  effect  on  the  lungs,  and  the  diffi- 
culty the  heart  experienced  in  propelling  the  blood  through  those  organs, 
so  tliat  at  length  as   a  palliative   I   determined   on  venesection.     The 
man's  arm  was  so  oedematous,  and  the  vein  so  small,  that  I  was  obliged 
to  perform  the  operation  myself,  and  it  is  remarkable,  as  illustrative  of 
the  infrequency  of  phlebotomy    now-a-days,    that   of  three    advanced 
students  present  only  one  had  ever  seen  an  individual  bled,  and  that  the 
nurse  who  held  the  basin  fainted  away.     At  this  time  the  man's  pulse 
was  imperceptible  at  the  wrist,  although  the  heart's  action  was  strong. 
He  stated  that  he  felt  somewhat  better,  but  I  regretted  to  observe  that 
little  or  no  relief  was  afforded  to  him. 


NEPHRITIS   AND    PYELITIS.  733 


Case  CLXI.* — Acute  Desquamative  and  Hemorrhagic  Nephritis — Hydrothorax — Col- 
lapse of  the  Right  Lung — Pulmonary  (Edema  and  Bronchitis,  xvitJi  Symptoms  of 
Pneumonia. 

History. — Andrew  Craig,  pet.  45,  a  waiter,  stout  and  fot — admitted  July  Lst, 
1851.  He  has  had  dehriuiu  tremens  several  times,  and  been  of  very  di.ssipated 
habits.  Six  days  ago,  after  unusual  exertion,  during  which  he  was  exposed  to  wet, 
he  was  seized  with  rigors,  fever,  and  vomiting.  Next  day  he  observed  his  feet  to 
be  (Edematous,  and  his  urine  to  be  highly  coloured ;  cough  and  expectoration  subse- 
quently made  their  appearance,  and  yesterday  the  breathing  became  very  difficult, 
symptoms  which  continued  to  increase. 

Symptoms  ox  Admission. — On  admission  the  body  generally  is  anasarcous,  and 
the  lace  pufty  and  bloated.  He  labours  under  great  dy.spuuea,  has  a  troublesome 
cough  accompanied  with  a  viscid  sputum,  in  some  places  of  a  rusty  colour,  and  in 
others  mingled  with  clots  of  blood  the  size  of  a  pea.  On  percussion  there  is  marked 
comparative  dulness  at  the  base  of  right  lung  anteriorly,  extending  two  inches  above 
the  hepatic  dulness.  Inspiratory  murmur  over  this  dull  portion  is  accompanied  by 
harsh  and  tubular  breathing,  with  increase  of  the  vocal  resonance.  Posteriorly,  also, 
marked  dulness  on  right  side,  over  lower  half  of  lung,  with  loud  crepitation  on 
inspiration,  and  bronchophony.  The  heart  sounds  are  quick,  healthy  in  character, 
impulse  strong.  Pulse  100,  feeble.  The  urine  is  of  a  dark  brown  colour,  turbid, 
and  much  diminished  in  quantity ;  sp.  gr.  1014 ;  highly  coagulable  on  the  addition 
of  heat  and  nitric  acid,  and  exhibiting  under  the  microscope  numerous  desquamative 
casts,  mingled  with  blood  corpuscles.  Other  functions  normal.  IJ  Via.  Antim.  3  ij  ; 
Sp.  jEther.  Kit,  3ij ;  Aquoe  §  vss.  M.  A  tahh-spoonful  to  he  taken  every  four  hours. 
To  have  §  "j  of  wine  daily. 

Progress  of  the  Case. — July  2d. — The  dulness  and  crepitation  posteriorly  is 
now  as  high  as  the  middle  of  scapula  on  the  right  side,  and  there  is  commencing 
dulness,  wdth  crepitation  audible  low  down,  posteriorly  over  left  lung.  Dyspnoea 
increased.  Other  symptoms  the  same.  To  be  cupped  over  chest,  and  3  v  of  blood 
extracted.  Hah.  Pulv.  Jalap,  comp.  3  j.  July  3d. — Dulness  now  extends  over  two 
thirds  of  both  lungs  posteriorly  and  inferiorlj',  with  loud  bubbling  rattles  on  inspira- 
tion, and  bronchophony.  Anasarca  has  greatly  increased,  the  lower  extremities 
and  the  scrotum  being  enlarged  and  distended.  Only  8  oz.  of  urine  passed  since 
yesterday,  of  dirty  brown  colour,  and  turbid ;  otherwise  the  same.  Bowels  well 
open.  Dj'spncea  now  urgent.  Cough  frequent  and  troublesome.  Sputum  pneu- 
monic. Pulse  120,  weak.  To  have  Pot.  Bitart.  3  ss  three  times  a  day,  and'^W]  of 
gin  instead  of  the  wine;  nutrients.  July  4th. — Has  passed  16  oz.  of  urine,  and  is 
somewhat  better.  Prostration  continues  great.  Otherwise  the  same.  July  5th. — 
Comatose,  and  evidently  sinking.     He  expired  on  the  morning  of  the  Qth. 

Sectio   Cadaveris. — Fifty  hours  after  death. 

Anasarca  of  the  whole  body. 

Head. — The  subarachnoid  cavity  contained  a  considerably  quantity  of  fluid,  ele- 
vating the  surface  above  the  convolutions.  The  lateral  ventricles  contained  little 
serum.     Otherwise  normal. 

Thorax. — Each  pleural  cavity  contained  about  a  pint  of  sero-sanguinolent  fluid. 
Both  lungs  condensed  from  collapse  posteriorly,  but  crepitant  anteriorly.  On  section 
they  presented  a  smooth  surface  of  purple  colour,  and  yielded  on  pressure  a  copious 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


73i  DISEASES   OF   THE   GENITO-URINARY  SYSTEM. 

frothy  fluid.  The  large  bronchi  were  filled  with  muco-purulent  matter,  and  their 
lining  membrane  was  stained  of  a  dark  mahogany  colour,  and  highly  congested. 
Heart  weighed  19  oz.  Hypertropliy,  with  dilatation  of  right  ventricle.  Valves 
healthy. 

Abdomen. — Kidneys  of  large  size,  the  two  weighing  18  oz.  They  were  exter- 
nally of  a  brownish  purple  colour,  the  vessels  everywhere  congested,  with  hfemor- 
rhagic  spots,  the  size  of  pins'  heads,  scattered  numerously  over  their  surface.  On 
section,  the  cortical  substance  was  mottled;  the  dark  congested  patches  being 
mingled  with  white,  opaque,  and  fawn-coloured  substance.  The  malpighian  bodies 
here  and  there  were  tinged  with  blood.  The  tubular  cones  were  of  a  deep  purple 
colour,  especially  towards  their  base.  The  mucous  membrane  of  the  pelvis  mode- 
rately congested.     Liver  congested  and  somewhat  enlarged.     Other  organs  normal. 

Microscopic  Examination. — The  fawn-coloured  portion  of  the  cortical  substance 
of  the  kidneys  was  soft,  and  the  tubes  crowded  with  desquamated  epithelial  cells 
mingled  with  molecular  exudation.  The  vessels  in  the  congested  parts  were  tinged 
with  blood.  The  hemorrhagic  spots  depended  on  the  extravasation  of  blood  into  one 
or  more  convolutions  of  the  tubes. 

Comnientarij. — This  case  was  in  many  respects  like  the  last,  but  its 
profji'ess  was  even  more  rapid.  The  pulmonaiy  oppression  and  oedema 
caine  on  more  quickly,  and  having  been  at  first  confined  to  the  right  side, 
accompanied  with  tenacious  sputum  of  a  rusty  colour,  and  ushered  in  by 
rio-oi's  and  febrile  symptoms,  presented  all  the  symptoms  and  physical 
sio-ns  of  a  pneumonia.  Thus  the  febrile  attack  corresponded  witli  the 
commencing  period  of  the  supposed  pneumonia.  Then  the  man  Avas  a 
waiter,  and  an  habitual  tippler,  and  we  were  called  upon  to  decide 
whether  the  acute  symptoms  were  connected  with  the  lung  or  with  the 
kidney.  Now  it  is  rare  to  see  a  case  of  acute  nephritis  producing 
general  anasarca,  and  running  its  course  so  rapidly,  and  in  consequence 
we  considered  the  renal  disease  to  have  been  chronic — in  short,  an 
ordinary  case  of  Bright's  disease,  with  supervening  pneumonia.  It 
turned  out,  however,  to  be  an  acute  attack  of  nephritis,  accompanied 
by  rigors,  fever,  vomiting,  etc.,  followed  by  rapid  anasarca,  and  death  by 
coma"  The  rusty  sputum  was  also  calculated  to  mislead  ;  for  although 
tlie  air  tubes  svere  filled  with  tenacious  purulent  mucus,  there  was  no 
appearance  after  death  of  bloody  extravasation  into  the  parenchyma  of 
the  lung.  It  must,  therefore,  have  been  altogether  bronchitic.  Such  a 
case  of  acute  nephritis,  so  complicated,  must  be  considered  of  extreme 
rarity.  It  occurred  before  the  value  of  testing  the  urine  for  chlorides 
was  known,  as  a  diagnostic  sign  of  pneumonia,  or  I  might  have  assisted 
in  attributing  the  acute  symptoms  to  the  kidneys  rather  than  to  the  lungs. 
On  dissection  there  was  found  the  same  desquamative  nephritis  as  in  the 
last  case,  associated  with  hemorrhage  into  the  tubes  and  malpighian 
bodies,  and  intense  congestion  of  the  capillaries,  especially  on  the  surface. 
This,  of  course,  added  to  the  obstructive  character  of  the  lesion,  and 
increased  the  fatality  of  the  case.  I  cannot  help  thinking  that  many 
such  cases  as  the  two  just  recorded  must  have  been  mistaken  by  physi- 
cians for  pneumonia,  before  the  advantages  of  auscultation  were  known. 
If  complicated  with  aortic  disease,  there  would  have  been  a  hard  vibrat- 
ino-  pulse,  and  large  bleedings,  and  antiphlogistic  remedies  used,  which 
would  have  hastened  the  fatal  result.  Modern  medicine,  by  pointing  out 
that   such,  cases   depend  on   obstruction   of  the    nriniferous   tubes   by 


NEPHRITIS   AND   PYELITIS.  735 

desquamated  epithelium  or  extravasated  blood,  surely  demonstrates  that 
blood-lettiijg  can  have  little  to  do  with  their  relief.  Even  as  a  palliative 
it  often  tails,  as  Case  CLX.  sufficiently  shows. 

The  hemorrhage  into  the  tubes  and  great  vascular  congestion  in  this 
case  occasioned  greater  obstruction  to  the  renal  excretion  than  occurred 
in  the  former  one.  Hence  the  urftmia  and  head  symptoms  which  existed 
for  twenty-four  hours  before  death,  a  symptom  from  which  Lawson  was 
comparatively  free. 


Case  CLXII.* — Acute  Nephritis — Chronic  Pneumonia — (Edema  of  the  Lung   and 
Anasarca  proving  fatal — Perforating  Ulcer  of  the  Duodenum,  luithout  syniptoms. 

History. — James  Abernethy,  fet.  41,  a  cooper — admitted  July  21,  1855.  States 
that  he  always  enjoyed  good  health  until  swelling  and  suppuration  occurred  in  his 
left  hand,  for  which  he  entered  tlie  surgical  hospital  last  April.  Six  weeks  ago  he 
observed  his  urine  become  as  dark  as  porter,  and  his  feet  and  legs  to  be  swollen. 
These  symptoms  were  preceded  by  rigors,  but  no  pain  in  the  loins  or  anywhere  else. 
The  oedema  continued  to  extend,  and  three  weeks  ago  dyspnoea  came  on,  which  has 
gradually  increased  until  now.     He  has  had  no  cough  nor  expectoration. 

Syjiptoms  on  Admission. — The  urine  is  of  a  muddy  brown  colour,  deficient  in 
quantity,  no  pain  or  difficulty  in  voiding  it.  It  contains  a  considerable  amount  of 
albumen,  with  the  normal  amount  of  chlorides;  sp.  gr.  1020.  With  the  microscope 
there  can  be  seen  numerous  waxy  casts  of  various  sizes,  some  stretching  completely 
across  the  field,  and  branched,  others  convoluted.  Many  are  filled  with  epithelium, 
several  only  half  filled,  and  not  a  few  are  composed  of  a  pale  diaphanous  membrane. 
There  are  also  jiresent  a  few  pus  and  blood  corpuscles,  and  a  good  many  granules 
and  granule  cells,  with  an  abundance  of  phosphates.  On  percussing  the  chest  the 
resonance  is  equal  and  good  on  both  sides  anteriorly.  On  the  mouth  being  opened, 
a  loud  cracked-pot  sound  can  be  elicited  over  the  whole  anterior  surface  of  right  lung. 
Posteriorly  there  is  dulness  over  the  inferior  half  of  this  lung,  with  panting  resonance 
of  the  voice,  and  crepitation  on  inspiration.  There  is  also  slight  crepitation,  with 
sibilation  over  the  lower  half  of  the  left  lung  posteriorly,  but  no  dulness  or  increase 
of  vocal  resonance.  Heart  sounds  are  normal ;  pulse  94,  regular  but  weak.  No 
appetite,  great  thirst;  abdomen  somewhat  distended  and  fluctuating.  Skin  generally 
anasarcous ;  that  over  the  back  pitting  deeply  on  pressure.  The  left  arm,  from  tlie 
elbow  down,  is  one  mass  of  ulceration,  with  purulent  infiltration  in  the  cellular  tissue. 
He  is  very  weak  and  exhausted.  5  Sp.  ^th.  Nit.  3ij;  Sp.  J^th.  Chloric.  3iss* 
Sol.  Mur.  Morph.  3j ;  Aqu(R  ad  3  viij ;  Ft  mist.  One  ounce  to  he  taken  every  night,  or 
when  the  breathing  is  urgent.     Habeat  Potass.  Bitart.  3j  ter  in  die. 

Progkess  of  the  Case. — July  25th. — There  has  been  little  change  until  to-day, 
when  he  has  become  somnolent.  Cannot  take  nutrients.  Pulse  continues  very 
weak.  Dry  cupping,  diaphoretics,  and  diuretics  have  failed  to  increase  the  amount 
of  urine.  Continue  nutrients  and  wine  at  intervals.  Jidy  2Qth. — Loud  crepitations 
now  heard  over  both  lungs  posteriorly.  Dyspnoea  urgent.  Surface  covered  with 
sweat,  but  no  alleviation  in  the  symptoms.     Died  on  the  27th. 

Sectio  Cadaveris. —  Twent>/  hotirs  after  death. 

Body  generally  anasarcous ;  left  forearm  the  seat  of  erysipelatous  ulceration. 
Thorax. — Both  lungs  oedematous,  with  coherent  pleural.     On  separating  these  on 

*  Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


736  DISEASES   OF   THE   GEXITO-URINARY   SYSTEM. 

the  right  side  posteriorly,  the  puhnonary  texture  broke  up,  being  rendered  soft  by 
chronic  pneumonia,  and  being  ev'erywhere  infiltrated  vvitli  serum.  At  the  apex  of 
right  lung,  a  few  cretaceous  masses. 

Abdomen. — On  the  under  surface  of  the  right  lobe  of  the  liver,  below  the  peritoneal 
coat,  were  several  calcareous  concretions  the  size  of  millet  seeds,  adherent  in  two 
places  to  the  coats  of  veins,  and  projecting  slightly  into  their  canal  (phlebolites).  The 
gall-bladder  was  slightly  thickened ;  the  cystic  duct  obstructed  in  its  centre ;  but  the 
hepatic  duct  pervious.  Both  kidneys  were  of  a  pale  yellow  colour  externally,  slightly 
mottled  with  vascular  patches.  On  section  the  cortical  substance  was  slightly  dimi- 
nished in  thickness,  and  the  cones  unusually  congested.  An  inch  beyond  the  pylorus, 
the  duodenum  was  perforated  by  a  round  ulcer,  the  size  of  a  fourpenny-piece,  the 
edges  of  which  were  adherent  by  soft  lymph  to  the  pancreas  and  a  neighbouring  coil 
of  intestine.  Internally  the  edge  of  the  ulcer  was  black,  and  around  it  were  several 
patches  varying  in  size  from  a  threepenny-piece  to  that  of  a  shilling,  quite  black. 
The  peritoneum  contained  about  half  a  gallon  of  serum.     Other  organs  normal. 

Microscopic  Examination. — The  cortical  substance  of  the  kidneys  showed  the 
convoluted  tubes  to  be  filled  with  desquamated  epithelium,  a  considerable  proportion 
of  which  had  undergone  the  fatty  degeneration. 

Commentari/. — Following  on  a  prolonged  ulceration  in  the  arm,  which 
had  contined  this  patient  to  the  surgical  hospital,  there  snperveued  de- 
sciuamative  nephritis,  general  anasarca,  and  a-denia  of  the  lungs,  similar 
to  what  occurred  in  the  two  preceding  cases.  There  was  also  present 
universal  adhesion  of  both  pleura^  and  disorganization  of  the  posterior 
and  inferior  half  of  the  right  lung,  as  I  conceive,  from  a  limited  exuda- 
tion into  its  te.xture.  What,  however,  constitutes  a  remarkable  feature 
in  this  case,  is  the  presence  of  a  chronic  ulcer  in  the  duodenum,  which 
had  not  been  manifested  bj'  any  symptom  whatever ;  which  was  attended 
bv  limited  hemorrhage  into  the  mucous  coat  of  the  intestine  internally, 
and  externally  by  exudation,  or  so-called  eftusion  of  lymph  (peritonitis), 
without  any  local  pain  or  uneasiness. 

The  term  Desquamative  Xephi-itis  was  introduced  by  Dr.  Johnson, 
to  denominate  a  lesion  in  which  the  tubes  of  the  kidney  are  blocked  up, 
not  only  bv  exudation,  but  by  the  separation  and  accumulation  of  their 
epithelial  cells.  Such  descpiamation,  I  believe,  occurs  occasionally  in 
all  epithelial  and  epidermic  structures.  I  have  occasionally  seen  it 
in  the  lung,  forming  what  may  be  called  a  desquamative  or  vesicular 
pneumonia.  If  it  occurs  generally  throughout  both  kidneys,  as  in  the 
three  last  cases  narrated,  it  is  usually  fatal ;  but  if  partial,  and  a  sufficient 
number  of  tubes  are  left  unobstructed,  so  as  to  admit  of  increased  action 
under  tlie  stimulus  of  diuretics,  a  cure  may  be  anticipated.  Under  such 
circumstances,  also,  a  spontaneous  recovery  may  be  hoped  for,  which  may 
be  assisted  by  diaphoretics.  So  far  from  considering  diuretics  injurious, 
I  believe  that  in  such  cases  they  hold  out  the  only  chance  of  successful 
treatment.  Cuppiug  and  diaphoretics  in  such  violent  and  rapid  cases 
are  wholly  insutKcient  to  overcome  the  tubular  obstruction,  however 
they  may  occasionally  relieve.  On  the  other  hand,  the  good  effects  of 
diuretics  were  well  observed  in  Cases  CLVIII.  and  CLIX. 


NEPHRITIS   AND   PYELITIS.  tol 


Case  CLXIII.* — Xephrilis  foUowed  by  the  fonnation  of  a  large  Abscess  in  the  Eight 
Kidney,  opening  into  tlie  lumbar  cellular  tissue — Ulceration  of  Ureter  and  Bladder 
—  Thickening  of  Mitral  and  Tricuspid  Valves — Partial  Atrophy  of  Lungs,  icilh 
and  without  Induration — Partial  (Edema. 

History. — ilargaret  Martin,  jet.  47,  servant— admitted  18th  October.  1852.  She 
always  enjoyed  good  health  till  about  twelve  months  ago,  when  she  was  exposed  to 
cold,  and  got  her  feet  wet.  Shortly  after,  she  was  attacked  with  dysuria.  and 
observed  that  the  urine  was  of  a  very  dark  red  colour,  and  much  diminished  in 
quantity.  A  week  afterwards,  she  experienced  sharp  cutting  pains  in  the  hypo- 
gastrium,  stretching  down  tlie  thighs.  She  was  still  able,  however,  to  follow  her 
usual  occupation,  till  the  beginning  of  September  last,  when  she  suffered  from  pain 
in  region  of  right  kidney,  in  the  larger  joints,  and  from  oedema  of  the  legs,  especially 
the  right.  The  bowels  have  been  very  costive,  and  the  abdomen  has  become  much 
distended.  Four  weeks  ago  she  passed  some  very  dark,  bloody-looking  matter  in 
the  urine,  which  continued  of  a  red  colour  for  live  days.  Her  habits  appear  to  have 
been  rather  intemperate. 

Symptoms  on'  Admission". — On  admission,  the  tongue  is  loaded  in  the  centre  with 
a  dark  fur :  great  thirst,  but  appetite  good ;  bowels  open.  There  is  distinct  fulness 
and  dulness  on  percussion  in  the  right  lumbar  region,  extending  as  flir  forward  as 
the  umbilicus,  and  fiUiug  up  the  space  between  the  felse  ribs  and  crest  of  the  ilium  ; 
and  there  is  great  tenderness  on  pressure  over  the  same  extent.  Has  some  pain  in 
micturition,  shooting  down  the  thighs,  especially  on  right  side,  which  is  also  some- 
what oedematous.  Urine  passed  in  very  small  quantity,  sp.  gr.  1015.  It  is  albumi- 
nous, and  deposits  on  standing  a  copious  sediment,  showing  under  the  microscope 
numerous  pus  and  blood  corpuscles.  Pulse  90,  of  good  strengtii,  but  occasionally 
intermitting.  She  has  occasional  palpitation.  The  cardiac  dulness  is  somewhat 
increased  transversely ;  impulse  very  strong,  and  an  indistinct  hollow  murmur 
accompanies  the  first  sound,  and  is  heard  loudest  at  the  apex.  The  thorax  is  con- 
sideral:)ly  deformed,  and  the  sternum  highly  arched ;  but  the  chest  is  otherwise 
normal.     Rabeat  enema  c.  01.  Terebinth.   5  i- 

Progress  of  the  Case — Kov.  20th. — ^The  bowels  not  having  been  fully  acted  on 
by  the  enema,  she  was  ordered  last  night,  half  a  drachm  of  Compound  p)ov:der  of 
Jjlap,  which  caused  copious  stools.  5  Tnfus.  Papav.  3  v ;  Tinct.  Eyoscyam.  3  ij  ; 
Syrupi '^'x.  M.  Sumat  r^  iter  indie.  Nov.  21. — Has  been  complaining  much  of  pain 
in  loins  and  right  leg.  She  was  ordered  an  enema  vjith  half  a  drachm  of  the  Sol.  of 
Morphia  on  the  evening  of  the  20tli:  and  last  night,  the  pain  having  again  returned 
and  prevented  her  from  sleeping,  she  had  the  following  draught:  §  Sol.  Mur. 
Morph.  3  ss;  Tinct.  Hyoscyam.  3j ;  Miicilaginis  et  Aq.  Menth.  aa  §.ss.  M.  Xov.  22. 
— Feels  much  better  to  day.  There  is  less  swelling  of  abdomen,  little  or  no  pain  in 
the  hypogastrium,  but  a  feeling  of  soreness  in  right  lumbar  region.  Bowels  con- 
fined; urine  p;issed  in  small  quantity,  albuminous,  and  contains  a  large  deposit, 
consisting  chiefly  of  pus.  Xov.  24. — Continues  in  the  same  state,  but  complains 
much  of  pain  in  bowels,  which  are  still  confined.  Urine  passed  in  small  quantity. 
She  was  ordered  yesterday  the  following:  —  §  Bitart.  Potass.  3  ii;  Gamhog.  gr.  ij. 
31.  fi.  pulv.  hora  somni  sumend.  et  habeat  inane  Pulv.  Doveri  gr.  xv.  Tlie  bowels 
were  freely  opened,  with  considerable  rehef  to  painful  distension  of  abdomen,  but  no 
diminution  of  the  swelling  and  hardness.  Appil.  Tinct.  lodin.  ahdomini.  Xov.  28. — 
Is  complaining  much  of  pain  in  abdomen  and  right  leg.  for  which  she  had  10  grains 

*  Reported  by  Mr.  Francis  M.  RusseU,  Chnical  Clerk. 
47 


738  DISEASES   OF   THE   GENITO-URINARY   SYSTEM. 

of  Dover's  pmvder  last  night,  with  partial  relief.     The  cough  is  now  troubling  her 
more,  and  she  seems  much  weaker.     5  uWi.  Chlor.  3  ij ;  Sol.  Mur.  Morph.  3j ;   Sj). 
Armnon.  Aromat.  3  iij ;  Mist  Camph.   |  vss.     M.  Swnai  3  ss  ter  in  die.     Xov.  30.— 
On  auscultation  of  chest,  occasional  moist  rales  are  to  be  heard,  with  prolonged 
expiration  ;  but  no  increase  of  vocal  resonance.     The  sounds  of  the  heart  very  dis- 
tinct over  the  whole  chest.     The  apex  beats  in  epigastrium ;  its  action  is  irregular, 
and  a  blowing  murmur  accompanies  the  first  sound.     Tliere  is  still  tenderness  in 
right  lumbar  region,  with  great  pain  in  right  iliac ;  the  swelling  of  abdomen  lias  not 
diminislied,  and  upon  deep  pressure,  a  distinct  fulness  and  liardness  can  be  felt  in 
right  iliac  fossa,  to  ivhich  four  leeches  were  ordered  to  be  applied,  folloived  by  ivarm 
fomentations.      ]J  Sp.  jEther.  Nit.  I  ss ;  Liquor.  Potass.  3  ij ;  Mucilag.  §  ij ;   Sol  Mur. 
Morph.  3  iij ;  Aquce  §  iij.    M.     Sumat  |  ss  omni  hord.     Intermitt.  alia  medicamenta. 
Haheat  Sp.  Juniperi  Co.  %  iii  per  diem.     December  3.— Feels  rather  better,  but  bowels 
verj'  costive,  unaffected  by  a  powder  of  calomel  and  jalap  administered  last  night. 
The  urine  is  still  albuminous;  sp.  gr.  1015.     Quantity  not  ascertained.     There  is 
now  slight  but  painful  oedema  of  right  arm.     Hah.  enema  catharticum.     Dec.  6. — 
Bowels  well  open.     She  now  feels  much  relieved  of  the  pain  in  abdomen ;  the  tumour 
in  right  lumbar,  umbilical,  and  iliac  regions,  remains  unaffected.     The  cedema  of  leg 
has  now  disappeared ;  but  the  pain  and  swelling  of  arm  have  gradually  increased, 
and  extend  as  far  as  the  shoulder.     The  whole  arm  is  exquisitely  tender.     No  cir- 
cumscribed tumours  can  be  anywhere  detected  in  the  arm  or  axilla.     For  the  last 
three  days,  the  quantity  of  urine  has  varied  from  12  to  20  oz.  in  the  24  hours.     There 
is  still  a'very  copious  mucus-like  sediment ;   when  examined  by  the  microscope  no 
blood  globules  can  now  be  detected ;  but  there  are  still  numerous  disintegrated  pus 
corpuscles,  with  crystals  of  triple  phosphates  and  amorphous  urate  of  ammonia.    The 
albumen  has  not  disappeared.     Lotion  of  Acetate  of  Lead  and  Opium  to  be  ap2)lied  to 
the  arm,  with  warm  fomentations.     Dec.  8.— Complains  of  great  pain  in  arm,  which 
is  very  much  swoUen,  and  generally  hard,  but  pits  slightly  on  pressure,  and  is  of  a 
white  colour  at  the  upper  part ;  but  at  the  wrist  it  is  much  darker,  and  on  tlie  back 
of  the  hand  two  large  phlyctenfe  have  formed  during  the  night,  and  other  portions 
of  tlie  surrounding  surf;\ce  vary  in  colour,  from  a  slight  red  to  a  yellow  and  brownish 
green.     There  is  some  oedema  of  leg,  but  of  slight  extent ;  and,  for  a  few  days  back, 
some  dark  purple  spots,  permanent  on  pressure,  have  appeared  on  the  inside  of  right 
thigh  and  knee.     She  complains  much  of  loss  of  sensibility  in  the  arm,  and  of  cold 
feet,  but  their  temperature  appears  natural  to  the  touch.     She  is  very  weak,  and 
takes  no  food.     The  pulse  120,  feeble  and  fluttering.     Urine  sp.  gr.  1015.     Not 
affected  by  heat  or  nitric  acid.     It  is  now  passed  involuntarily  in  bed.      U  Sp. 
Amman.  Arom. ;  JSth.  C/itor.  aa  3  ij ;   Tinct.  Card.  Co.lW:  Mist.   Camph.  l\n;  M. 
Sumat  r]  singulis  horis.     To  have  4  oz.  of  Brandy.     Dec.  9. — Died  this  morning 
about  ten  o'clock. 

Sectio  Cadaverls. —  Twentif-si.v  hours  after  death. 

Anasarca,  especially  of  right  arm  and  leg,  but  nowhere  extreme.  A  large  tumour, 
elastic,  not  fluctuating,  moderately  tense,  occupied  the  abdomen  on  the  right  side 
from  the  liver  to  the  ilium,  and  from  the  loins  to  the  umbilicus,  projecting  in  either 
direction.  Percussion  over  it  generally  dull.  It  can  be  limited  from  the  liver, 
which  is  not  large. 

TiiOR.vx. — Pericardium  contains  about  an  ounce  of  serum,  and  on  the  surface  of 
the  heart  are  numerous  opaque  fibrous  patclies.  Heart  rather  small.  The  free 
edo-es  of  the  tricuspid  and  mitral  valves  were  tliickened  and  rounded,  but  with  no 
distinct  appearance  of  deposit  on  their  suriiice.  In  the  substance  of  the  septal  seg- 
ment of  mitral  valve,  near  its  roots,  there  were  a  few  calcareous  masses.     "Weight  of 


NEPHRITIS   .AJS'D   PYELITIS.  739 

heart,  9^  oz.  Lungs. — -Right  pleura,  normal;  lung  throughout  free  from  adhesions; 
some  serous  engorgement,  with  considerable  collapse  posteriorly;  anteriorly,  no 
marked  emphysema.  Left  Lung  presents  firm  adhesions  over  upper  lobe,  which 
is  much  diminished  in  volume,  and  has  a  dense,  scarcely  crepitating  tissue. 

Abdomen'. — On  opening  the  abdomen,  the  tumour  was  found  to  be  situated  behind 
the  ascending  colon.  The  right  lobe  of  the  liver  overlapped  it  in  front  to  the  extent 
of  several  inches,  and  was  adherent  to  it  by  firm  and  close  fibrous  bands.  The  peri- 
toneum was  stretched  over  the  tumour  so  as  to  obliterate  the  mesocolic  folds  in  front^ 
and  keep  the  ascending  colon  closely  in  contact  with  it.  It  proved  to  be  an  absces.', 
containing  about  a  quart  of  fluid,  which  was  sero-purulent  (with  large  proportion  of 
pus),  of  a  yellow  colour,  with  a  faint  greenish  tinge,  and  a  good  deal  of  toetor.  The 
main  sac  of  this  abscess  was  situated  in  the  lumbar  cellular  tissue  of  the  right  side, 
and  had  in  front  of  it  the  right  kidney,  the  interior  of  which  communicated  by  several 
ulcerated  openings  with  the  cavity  of  the  abscess.  The  posterior  wall  of  the  abscess 
rested  on  the  lumbar  muscles,  and  on  the  right  side  of  the  vertebrte,  the  periosteum 
of  which  was  entire.  The  superior  wall  was  very  closely  adherent  to  the  liver,  which, 
at  its  anterior  part  had  a  depression  or  excavation  about  half  an  inch  in  depth,  and 
two  or  three  inches  in  diameter.  The  left  lobe  of  the  liver  was  displaced  upwards, 
and  the  right  lobe  was  elongated  downwards,  being  closely  adherent  to  the  right  and 
upper  aspect  of  the  swelling.  The  stomach  and  neighbouring  viscera  were  displaced 
by  the  tumour,  but  were  healthy.  Left  kidney  normal.  Bight  kidney  much  dis- 
organized; its  size  not  altered;  on  section,  numerous  absce.sses  containing  pus  like 
that  within  the  tumour,  occupying  both  the  cortical  and  tubular  part ;  the  walls  of 
the  abscess  composed  of  floeculent  and  curdy  greyish-yellow  matter,  presenting 
under  the  microscope  the  debris  of  cell  forms,  witli  very  numerous  granules.  The 
pelvis  of  the  kidney  could  scarcely  be  identified,  being  converted  into  a  receptacle 
for  pus.  The  intervening  tissue  between  the  abscesses  was  condensed  and  indurated, 
and  at  some  points  enclosed  a  quantity  of  matter  similar  to  that  constituting  the 
walls  of  tlie  abscesses.  Several  angular  calculi,  the  size  of  mustard  seeds,  were 
impacted  in  one  of  the  infundibula.  the  mucous  membrane  of  which  was  smootli  and 
free  from  ulceration.  On  examination,  they  proved  to  be  composed  chiefly  of 
phosphatic  earthy  salts  and  animal  matter.  The  ureter  was  thickened  throughout, 
not  dilated ;  the  mucous  membrane  totally  disorganized,  rough,  and  resembling  the 
walls  of  tiie  renal  abscesses.  The  bladder  had  also  fully  one  half  of  the  mucous 
membrane  removed  in  irregular  patches  by  ulceration ;  the  remaining  parts  were 
much  congested,  but  smooth.  Xo  deposit  of  calcareous  matter  in  any  quantity. 
The  ulceration  of  the  vesical  mucous  membrane  extended  to  the  neck  of  the  bladder, 
and  ended  abruptly  at  the  commencement  of  the  urethra,  which,  with  the  exception 
of  some  congestion  of  the  mucous  membrane,  was  nomiaL  The  uterus  contained  a 
polypus,  the  size  of  a  bean,  composed  principally  of  the  mucous  membrane,  and 
attached  to  the  posterior  wall  Os  uteri  slightly  tinged,  of  a  purplish  colour. 
Ovaries,  vagincL  and  external  parts  normal     Other  organs  normal. 

Commentary. — The  occurrence  of  abscess  in  the  kidney  is  often  a  verv 
insidious  disease,  existing  frequently  for  many  months,  and  giving  rise  to 
obscure  pain  in  the  back,  occasional  rigor,  feverishness,  and  high-coloured 
or  muddy  urine,  which  when  examined  microscopically,  may  be  seen 
to  contain  blood  and  pus  corpuscles.  If  the  disorganizing  process  con- 
tinue, and  an  opening  form  externally,  inflammation,  followed  by  sup- 
puration of  the  cellular  tissue  behind  the  peritoneum,  occurs,  causing 
fever  of  a  low  tvpe,  and  oedema  more  or  less  general.  Such  an  occur- 
rence usually  proves  fatal.     In    the    present   case,   death   was   delayed 


740  DISEASES    OF  THE    GENITO-URIXARY   SYSTEM. 

apparently  from  the  abscess  having  been,  to  a  certain  extent,  circum- 
scribed, and  forming  a  large  cyst,  so  as  to  present  the  form  of  a  tumour, 
the  nature  of  whichrduring  life,  it  was  very  ditfienlt  to  determine,  although 
the  renal  disease  was  clearly  apparent. 


Case    CLXIV.* — Scrofidom  KcpJiriiis    and   Abscesses   in  the  Kidneys — Extensive 
Deposition  of  Tubercle  in  the  Lungs  and  Intestines. 

History. — George  Paton,  set.  20,  sailor — admitted  19th  July.  1854.  States  that 
he  enjoyed  good  health  until  seven  years  ago,  when  he  noticed  his  urine  tinged  with 
blood,  after  having  undergone  considerable  exercise  in  sliding  on  ice.  The  hfema- 
turia  o-ave  him  no  uneasiness  until  three  weeks  afterwards,  when  he  began  to  sutler 
pain  in  the  epigastrium',  and  a  deep-seated  burning  pain  in  the  pelvis.  He  could 
get  little  rest  in  consequence,  and  his  micturition  became  frequent,  almost  every 
hour.  He  continued  to  sutler  more  or  less  in  this  way  for  two  years,  the  pain  and 
hjematuria  abating,  and  again  recurring  at  intervals  of  a  few  weeks.  He  then  went 
to  sea,  and  remained  tolerably  free  of  the  disease  for  three  years.  His  ailment  then 
returned  again  in  aggravated  form,  after  exposure  to  a  storm.  He  obtained  admis- 
sion on  board  the  Dreadnought  hospital  ship  at  this  time,  and  had  his  bladder 
repeatedly  examined  for  stone,  but  no  calculus  could  be  detected.  After  being  a 
few  weeks  in  the  Dreadnought,  he  left  it  and  went  to  sea  again,  though  in  very 
imperfect  health.  About  twelve  months  ago,  whilst  lying  in  the  Downs,  he  had  a 
very  severe  attack  of  deep-seated  pelvic  pain  and  hematuria.  He  now,  for  the  first 
time,  complained  of  pain  in  the  back,  which  has  never  left  him  since,  and  the 
character  of  the  urine  underwent  a  change.  It  became  white  and  turbid,  and  on 
standing,  emitted  a  putrid  odour.  He  recovered  partially  from  this  attack,  and  went 
shortly  afterwards  on  a  voyage  up  the  Danube,  where  his  disease  became  aggra- 
vated from  the  exposure  he  was  subjected  to.  Since  that  time  his  general  health 
has  been  declining  more  rapidly  than  formerly. 

SYiiPTOiiS  ON  Admission. — On  admission,  he  is  considerably  emaciated,  counte- 
nance pale,  and  his  expression  anxious ;  skin  dry ;  urine  white  and  turbid,  sp.  gr. 
1010-  on  standing,  a  large  sediment  falls  down,  which  under  the  microscope  is 
found  to  consist  of  pus,  and  under  heat  and  nitric  acid  a  large  coagulum  forms.  He 
complains  of  pain  in  the  hypogastrium  and  right  lumbar  region,  of  a  dragging 
character ;  he  has  also  pain  in  the  point  of  the  penis  during  and  after  micturition ; 
tono-ue  moist  and  florid ;  he  complains  of  sore  throat,  and  on  examination  the  ton- 
sils are  seen  to  be-  enlarged  and  covered  with  pus.  He  has  tenderness  of  the 
epiotvstrium,  and  is  troubled  with  vomiting  immediately  after  taking  food.  Bowels 
regular.  On  percussing  the  chest,  dulness  can  be  detected  at  the  apex  of  the  right 
luno-,  anteriorly  and  posteriorly ;  on  auscultation  there  is  slight  sibilation  under  the 
rio-ht  clavicle,  with  slight  inci-ease  of  the  vocal  resonance.  He  has  a  slight  cough, 
but  no  expectoration ;  pulse  88,  and  of  good  strength.  Cardiac  sounds  feeble : 
heard  loudest  over  the  sternum,  and  a  little  to  its  right  side;  otherwise  they  are 
healthv.  B  Infus.  Lini  }bj.  To  be  taken  ad  libitum.  Throat  to  be  sponged  xcith  a 
solution  of  nitrate  of  silver.     Good  diet. 

Progress  of  the  GxsE..—Jidy  2oth. — The  sponge  has  been  three  times  applied 
to  the  throat,  and  it  is  nearly  well.  The  pain  has  left  the  hypogastric  region,  and 
he  has  now  a  feeling  of  weakness  in  the  right  lumbar  region.  Urine  of  a  milky 
colour,  contains  less  albumen,  sp.  gr.  1007.     $    Tinct.  lodinii  3  i.     To  be  painted 

*  Reported  by  Mr.  Almeric  "W.  Seymour,  Clinical  Clerk. 


NEPHRITIS   AND   PYELITIS.  741 

over  the  lumbar  region.  IJ  Decoct.  Uvce  Ursi  fbj.  One  ounce  to  he  taken  four  times 
a  day.  August  8th. — During  last  week  he  lias  been  suffering  from  nausea,  vomiting, 
and  looseness  of  bowels.  Aug.  \1th. — These  few  days  past  he  has  had  rigors, 
followed  by  heat  of  skin  and  sweating.  The  attacks  last  only  for  a  couple  of  liours, 
and  come  on  regularly  at  two  o'clock.  He  has  been  ordered  the  following  pills :  — 
^.  Sulph.  Quince  3ss;  Conf.  Hosar.  quant,  suff.  ft.  massa  in  pilul.  xx.  dividenda. 
Two  to  he  taken  every  sixth  hour  during  the  intermissions.  Diarrhoea  has  continued, 
and  for  it  he  has  been  using  the  following  mixture : — B  Tinct.  Catechu  Z^'i;  Sol. 
Mur.  Mor2)h.  3  ij ;  Conf.  Aromat.  3  i ;  Mist.  Cretce  §  v.  M.  One  table-spoonful  to  he 
taken  three  times  a  day.  Aug.  lUh. — Diarrhoea  relieved;  urine  less  turbid:  sp. 
gr.  1009;  not  coagulable  by  heat  and  nitric  acid.  Aug.  2\st. — Since  last  report 
has  been  gradually  growing  weaker.  Mucous  rale  has  been  occasionally  audible 
under  the  right  clavicle ;  expectoration  insignificant  He  has  been  unable  to  retain 
any  food  on  his  stomach  for  several  days,  scarcely  even  wine  and  water.  Diarrhoea 
has  also  returned.  Latterly  his  strength  has  become  very  much  exhausted,  and 
during  the  last  two  days,  he  has  lain  in  a  state  of  great  prostration;  his  pulse  often 
scarcely  to  be  felt  at  the  wrist;  his  intellect,  however,  never  became  impaired. 
Tliis  morning  he  died  at  four  o'clock. 

Sectio  Cailaveris. — Forty-eight  hours  after  death. 

Body  much  emaciated;  rigor  mortis  considerable. 

Thorax. — Pericardium  normal ;  contained  about  three  drachms  of  clear  straw- 
coloured  serum.  Heart  small  and  soft;  valves  healthy;  muscular  substance  pale: 
under  the  microscope,  the  muscular  fibres  appear  deficient  in  stria;,  and  loaded  with 
small  fatty  granules.  Left  pleura  normal.  Rigid  pleura  presents  dense  adhesions 
over  the  whole  of  the  lung,  more  marked,  however,  at  the  apex  and  base.  The 
right  lung  itself  was  small,  collapsed,  and  excessively  emphysematous,  along  its 
anterior  free  margin.  The  apex  presented  numerous  hard  cicatrices,  and  on  being 
cut  into,  showed  numerous  tubercular  masses  in  all  stages,  some  of  them  commenc- 
ing to  break  down  and  disintegrate,  others  undergoing  the  process  of  hardening  and 
repair.  In  one  spot,  about  an  inch  below  the  apex,  a  small  vomica,  about  the  size 
of  a  hazel  nut,  existed.  Left  toig- voluminous ;  highly  emphysematous ;  cicatrized 
around  the  apex,  the  cicatrices,  as  in  the  other  lung,  being  very  firm  and  dense. 
On  being  cut  into,  masses  of  tubercular  matter  were  found,  but  in  a  more  latent 
state  than  in  right  lung. 

Abdomex  — Liver  normal  in  size,  undergoing  the  fatty  degeneration :  jjale- 
coloured  and  friable ;  under  the  microscope,  the  hepatic  cells  appeared  loaded  with 
fat.  Spleen  normal.  Small  intestines  healthy,  slightly  congested  towards  the 
lower  part.  Large  intestines.  The  mucous  membrane,  throughout  the  whole  extent, 
but  particularly  in  the  descending  colon,  sigmoid  flexure  and  rectum,  apjjeared 
thickened,  congested,  and  in  many  places  ulcerated :  the  ulcers  were  small,  their 
edges  very  slightly  elevated,  and  their  surface  undergoing  the  process  of  separation. 
Bight  kidney  was  much  enlarged;  quite  smooth;  the  capsule  densely  adherent. 
On  dividing  the  ureter,  pus  escaped  in  considerable  quantity  from  the  pelvis  of  the 
kidney ;  and  on  cutting  into  the  substance  of  the  gland  itself,  several  ulcers,  varying 
in  size  from  a  horse-bean  to  that  of  a  small  walnut,  were  found ;  their  contents 
varied  in  consistence;  in  some,  the  pus  was  thin  and  diffluent;  in  others,  it  had  the 
consistence  and  appearance  of  white  paint.  The  ureter  on  this  side  was  greatly 
thickened,  of  the  size  of  an  ordinary  little  finger;  the  thickening  extended  bej-ond 
the  orifice  of  the  ureter  along  the  trigone  of  the  bladder;  the  ureter  was  quite  per- 
vious, and  contained  a  quantity  of  pus  Left  kidney  was  small  and  lobulated;  the 
substance  of  the  gland  was  found  to  have  disappeared,  leaving  a  large  cavity,  which 


742  DISEASES   OF  THE    GENITO-URIXARY   SYSTEM. 

was  enclosed  by  a  covering  of  the  proper  substance  of  the  kidney,  not  exceeding  four 
lines  in  thickness,  and  filled  with  cheesy  matter  of  the  consistence  of  putty;  the 
ureter  was  closed,  except  for  two  inches  above  tlie  bladder;  externally,  it  was  oi 
normal  size:  muscular  wall  of  bladder  somewhat  thickened,  especially  around  the 
orifice  of  the  right  ureter;  mucous  coat  congested  and  much  softened;  the  bladder 
contained  about  6  oz.  ot  thick,  turbid,  semi-purulent  matter. 

Commentary. — In  tins  case,  the  renal  absce.sses  formed  in  a  young 
man  of  scrofulous  constitution,  and  exhibited  a  moi'e  lino-erino;  tendency 
than  in  the  foi-mer  one.  Indeed,  notwitlistanding  the  g-reat  disorganiza- 
tion found  in  the  kidnevs  after  death,  the  fatal  result  was  chietly  brought 
about  by  the  intestinal  disease,  and  the  exhaustion  caused  by  colliquative 
diarrhoea.  The  left  kidney  evidently  presented  the  incipient  changes 
which  commonly  precede  the  spontaneous  cnre  of  scrofulous  abscesses 
in  this,  as  in  other  internal  organs.  The  purulent  matter  was  of  the  con- 
sistence of  putty,  the  animal  portion  liaving  for  the  most  part  been 
broken  down  and  absorbed,  while  the  mineral  portion  was  comparatively 
increased.  In  this  manner,  not  unfrequently  encysted  cretaceous  masses 
form  in  the  kidney  and  remain  latent,  the  rest  of  the  renal  substance 
performing  its  normal  function.  Sometimes  an  entire  kidney  may,  in 
this  manner,  be  completely  destroyed,  and  the  whole  converted  into  a 
calcareous  mass,  of  which  I  possess  a  remarkable  example,  from  an  indi- 
vidual who  had  quite  recovered  from  the  disease,  and  wliose  remaining 
kidney,  though  enlarged,  was  in  its  texture  healthy.  Indeed,  the  spon- 
taneous cure  of  tubercular  depositions  in  the  kidney,  pr-esents  the  same 
patholoo-ical  history  as  that  we  have  described  of  similar  lesions  occur- 
rino-  in  the  lungs,  p.  680,  and  the  puckerings,  cicatrices,  cretaceous  and 
calcareous  concretions  resulting  from  them,  have  a  similar  significance. 
It  follows  that  onr  general  principles  of  treatment  should  also  be  the 
same,  namely,  supporting  the  constitution  by  analeptics  and  especially 
by  coddiver  oil,  so  as  to  enable  nature  to  bring  about  a  cure.  This 
should  always  be  the  primary  object  of  treatment ;  whilst  remedies 
dii'ected  to  the  renal  symptoms  should,  although  by  no  means  neglected, 
be  subordinate  to  that  great  end.  In  the  present  case  this  indication 
could  not  be  fulfilled  on  account  of  the  great  irritability  of  the  alimen- 
tary canal,  especially  of  the  stomach.  For  another  example  of  this  disease, 
see  Case  CXLVI. 

Case  CLXV.* — Calculous   Ne^yJiritis   and    Gangrenous  Abscess  of  Eight  Kidney — 
Wo.o:y  Liver — Eecio-  Vesical  Fistula. 

History. — James  Allen,  aet.  25,  a  tin  and  copper  smith — admitted  Augti.st  18, 
1848.  At  three  years  of  age  was  cut  for  stone  by  Mr.  Liston.  Thereafter  he 
enjoyed  good  health  until  three  years  ago,  when,  after  straining  himself  at  a  trial 
of  strength,  he  was  suddenly  seized  with  a  sharp  pain  in  the  right  flank,  just  below 
the  ribs.     At  the  same  time  tlie  urine  became  turbid,  and  was  of  a  high  colour. 

The  pain  left  him  at  the  end  of  three  months,  but  the  turbidity  of  the  urine  con- 
tinued. After  six  months'  interval  he  had  a  similar  attack — this  time,  he  says, 
induced  by  drinking  a  glass  of  spirits — which  also  lasted  three  months.     After 

*  Reported  by  Mr.  Frederick  Hunter,  Clinical  Clerk. 


NEPHRITIS    AND   PYELITIS.  743 

another  interval  of  about  six  months,  the  pain  and  urinarj^  sjnnptoms  again  returned, 
and  have  continued  more  or  less  severe  ever  since.  He  was  in  tlie  surgical  hospital 
for  three  months,  wliere  he  was  frequently  examined  for  stone,  but  none  was  found. 
At  this  time  he  was  observed  on  several  occasions  to  pass  air  by  the  uretlu-a,  the 
urine  being  of  a  gangrenous  odour.  He  left  the  surgical  hospital  last  Maj-,  and  has 
been  somewhat  better  since,  the  urine  for  some  time  having  been  clear  and  healthy. 
But  having  bathed  in  the  sea  a  fortnight  ago,  he  was  seized  with  rigors,  followed 
by  fever,  together  witli  the  former  local  symptoms,  which  have  continued  ever  since. 

Symptoms  on  Admission. — Tlie  countenance  is  pale  and  sallow,  expression 
dejected ;  body  not  emaciated,  but  with  a  general  look  of  chronic  disease.  He  com- 
plains of  great  pain  and  tenderness  in  the  riglit  lumbar  region,  which  on  examina- 
tion presents  a  fulness,  witliout  great  deformity,  but  well  marked  when  compared 
with  tlie  opposite  side.  The  hepatic  duloess  on  percussion  measures  five  inches  ver- 
tically, the  lower  margin  anteriorly  being  on  a  line  with  the  umbilicus,  and  stretch- 
ing across  the  abdomen  into  the  left  hypochondrium.  He  has  never  suffered  from 
pains  sliooting  down  to  the  bladder,  nor  in  the  bladder  itself  But  there  is  occasional 
pain  after  micturition,  and  always  frequent  desire  to  pass  urine— indeed  every  hour 
— although  little  is  voided.  The  urine  is  turbid,  of  dirty  yellow  colour ;  acid,  of  sp. 
gr.  1017,  very  foetid,  highly  coagulable,  and  contains  a  considerable  sediment  of 
pus  and  mucus.  The  pulse  is  108,  soft.  Tongue  covered  with  a  whitish  fur. 
Appetite  good.  Other  functions  well  performed.  ^  Tart.  Anlim.  gr.  ij:  Aquce 
1  viij ;  Solve.  Sumat  ?  ss  teriid  qudque  hord.  Aj)j)Ucent.  hirudines  viii  lateri  doknti, 
et  postea  foveatur. 

Progress  of  the  Case  —September  2Gth. — The  local  pain  has  been  relieved  by 
the  treatment,  but  it  returns  with  severity  at  intervals.  For  some  time  the  urine 
has  been  clear.  Ho  has  had  a  slight  diarrlioea,  which  has  been  checked  by  a  chalk 
and  aromatic  mixture;  and  has  occasionally  taken  at  night  Pulv.  Dove.ri  gr.  viij. 
October  ?>d. — Two  days  ago  was  again  seized  with  rigors,  fever,  and  acute  pains  in 
the  right  flank.  The  urine  is  again  loaded  with  pus  and  mucus,  and  of  foetid  odour. 
The  appetite  is  gone;  there  is  thirst  and  frequent  vomiting.  Pulse  120,  soft.  A 
saline  antimonial  mixture.  Oct.  Gth. — Anxious  countenance;  pain  continues,  pre- 
venting sleep.  Can  take  no  nourishment.  Much  exhausted.  Vomiting  diminished. 
IJ  Pidv.  Doveri  gr.  x.  liora  somni.  Nutrients.  Wine  four  ounces  daily.  Wann 
fomentations  to  the  side.  Oct.  lOth. — Local  pain  somewhat  diminished.  Complains 
of  diarrlioea.  IJ  Acid.  Gallic.  3  ss ;  Ojni,  gr.  xij ;  Oonf.  Rosar.  q  s.  ;  ft.  pil.  xij. 
Sumat  unam  sextd  qudque  hord.  Oct.  lUth. — Since  last  report  has  gradually  sunk, 
and  died  this  morning. 

Sectio  Caclaveris. — Forty-eight  hours  after  death.    • 

TiiOR.Ax. — Pericardium  contained  about  a  draclim  of  turbid  serum,  with  a  few 
floating  flakes  of  lymph.     Lungs  and  heart  healthy. 

Abdomen  — The  liver  was  considerably  enlarged,  and  had  undergone  the  waxy 
degeneration;  its  substance  being  pale  and  dense,  with  a  smooth  surface  on  section. 
On  attempting  to  remove  it,  the  right  lobe  was  found  to  be  adherent  to  the  colon  ; 
and  on  separating  this  adhesion  with  the  fingers,  a  quantity  of  pus  escaped.  This 
originated  from  a  large  abscess  in  the  right  kidney,  containing  about  half  a  pint  of 
pu,s,  mixed  with  curdy  matter.  The  superior  wall  was  composed  of  the  substance 
of  the  liver,  a  portion  of  the  lower  and  posterior  border  of  which  organ  was  absorbed- 
The  posterior  wall  rested  on  the  quadratus  lumborum  muscle,  and  anteriorly  it  was 
in  contact  witli  the  transverse  colon  and  the  pyloric  end  of  the  stomach.  "When 
opened  from  behind,  the  walls  of  the  abscess  were  found  to  be  covered  with  shreds 
of  gangrenous  tissue,  of  a  dark  greenish  colour,  of  gangrenous  odour.      Renal  sub- 


7-1-i  DISEASES   OF   THE    GENITO-URINARY   SYSTEM. 

stance  could  only  be  delected  at  the  lower  part ;  the  rest  of  the  kidney  was  con- 
verted into  a  fibro-cystic  structure,  in  some  places  of  great  density.  Two  of  the 
cysts  contained  uric  acid  calculi ;  one  resembling  in  size  and  form  two  walnuts  united 
together  by  a  neck,  the  other  of  a  somewhat  angular  form,  with  rounded  edges,  the 
size  of  a  hazel  nut.  These  calculi  were  imbedded  in  pus,  and  partly  projected  into 
what  might  have  been  the  pelvis  of  the  kidney,  but  which  was  converted  into  a 
fibrous  sac  communicating  with  the  ureter.  Tlie  bladder  presented  at  its  neck  the 
cicatrix  of  an  incision  made  in  the  usual  situation  for  lithotomy.  About  two  inches 
above  this  were  three  mucous  excrescences  the  size  of  peas.  In  the  centre  of  these 
was  a  depressed  spot,  tlirough  which  a  director  readily  passed  backwards  and 
upwards  through  the  cellular  tissue  into  the  rectum.  The  mucous  surfece  of  the 
rectum  at  this  point  was  highly  vascular,  and  covered  with  lymph  in  patches  to  the 
extent  of  four  inches  in  depth  round  the  gut.  Left  kidney  weighed  13^  oz.,  and 
appeared  healthy  in  structure      Otlier  organs  normal. 

Microscopic  Examination. — The  structure  of  the  left  kidney  was  quite  natural. 
The  liver  presented  the  usual  atrophied  and  translucent  appearance  in  the  cells, 
characteristic  of  the  waxy  degeneration,  a  few  only  containing  a  small  number  of  fat 
granules. 

Conimentari/. — The  local  and  p-eneral  symptoms  in  tliis  case  were  so 
clear  as  to  leave  me  in  no  doubt  from  the  first,  that  this  man  Iiad  a  cal- 
culus imbedded  in  his  right  kidney,  causing  an  abscess  in  that  organ. 
The  recurring  rigors  and  fever,  with  pains  shooting  down  the  right  groin 
to  the  bladder,  and  occasional  vomiting ;  the  turbid,  bloody,  purulent, 
and  gangrenous  urine  ;  the  remarkable  fulness  in  the  right  lumbar  region, 
■with  tenderness  on  pressure;  and  the  past  history  of  the  case,  constituted 
an  nnmistakeable  group  of  phenomena  diagnostic  of  calculous  nephritis. 
Indeed,  so  certain  was  the  fact,  that  more  than  once  nephrotomy  was 
spoken  of  as  a  possible  means  of  relieving  him,  every  other  organ  Avith 
the  exception  of  the  liver  being  at  one  time  apparently  healthy.  It  was 
with  great  interest,  therefore,  that  the  dissection  after  death  was  watched, 
which  fully  confirmed  the  diagnosis.  It  also  pointed  out  that  the  other 
kidney  was  enlarged  and  healthy,  peiforming  double  duty  without  diffi- 
culty ;  that  the  liver  was  enlarged  and  waxy,  and  that  a  recto-vesical 
fistula  existed,  causing  disease  of  the  intestinal  mucous  membrane  to 
■which  the  diarrhoea  latterly  might  be  attributed.  In  reference  to  an 
operation,  it  appeared  to  me  at  the  time  that  it  might  easily  have  been 
etfected  after  the  method  of  Marchetti,*  as  the  two  calculi  were  loose 
within  cysts,  and  surrounded  by  pus.  The  enlargement  of  the  liver 
prevented  the  performance  of  such  an  operation  being  seriously  enter- 
tained in  this  case.  But  here,  as  in  ovariotomy,  the  great  difliculty  is  to 
establish  in  the  living  subject  an  e.xact  diagnosis,  and  this  I  had  no  diffi- 
cultv  in  doing  six  weeks  before  his  death,  and  when  his  general  liealth 
was  tolerably  good.  For  such  a  disease  nothing  but  palliatives  are  to  be 
thought  of.  As  the  size  of  the  stone  cannot  be  known,  dikients  are 
indicated  with  the  possibility  of  favouring  its  descent  along  the  ureters 
to  the  bladder,  a  practice  which,  should  it  fail  in  that  respect,  is  also 
useful  in  carrying  off'  the  pus  which  may  accumulate  in  the  pelvis  of  the 
kidney,  should  perchance  any  healthy  secreting  texture  still  remain  in  it. 

*  An  account  of  a  gentleman  being  cut  for  the  stone  in  the  kidney,  with  a  brief 
inquiry  into  tlie  antiquity  and  practice  of  nephrotomy,  by  C.  Bernard. — PJdl.  Trans. 
October  1696. 


NEPHRITIS   AND   PYELITIS. 


Case   CLXVI.* — Chronic   Pyelitis,    and    Cystic   Kidneys — Dikitaiion  of   Ureters — 
Fungoid  Ulceration  of  Urinary  Bladder. 

History. — Jane  Watson,  ?et.  74,  widow — admitted  November  15tli,  1852.  As 
far  as  can  be  ascertained  from  the  patient,  wliose  mental  faculties  are  very  much 
impaired,  she  has  been  labouring  under  her  present  complaint  for  the  last  eight 
months  About  that  time,  she  was  exposed  to  cold  from  sleeping  on  damp  straw, 
and  was  seized  with  rigors,  pain  in  the  back,  and  in  the  larger  joints.  The  urine  at 
the  same  time  decreased  considerablj^  in  quantity,  with  frequent  micturition,  accom- 
panied by  pain.  Tliese  sj'mptoms  lasted  for  about  a  month,  after  which  the  amount 
of  water  passed  became  greatly  increased  in  quantity,  and  dysuria  disappeared.  For 
the  last  three  months,  the  urine  has  been  occasionally  mixed  with  blood,  continuing 
for  a  few  days,  and  then  becoming  natural.  Since  the  date  of  her  first  attack,  she 
has  complained  of  pain  in  the  region  of  the  right  kidue}-,  much  increased  at  those 
periods  when  blood  was  observed  in  the  urine. 

Symptoms  on"  Admission. — On  admission,  she  has  a  peculiar  cachectic  appearance, 
and  is  much  emaciated.  Tongue  moist,  cracked  in  the  centre,  great  thirst,  appetite 
impaired,  bowels  costive.  She  has  considerable  pain  and  tenderness  on  pressure  in 
the  right  lumbar  region,  where  there  is  also  some  fulness.  The  urine  is  passed  in 
considerable  quantit}-,  specific  gravity  1010,  alkaline,  highlj'  coagulable  on  the  addi- 
tion of  heat  and  nitric  acid.  It  is  quite  turbid  when  passed,  and  deposits  on  standing 
a  copious  yellowish  gelatinous-like  sediment,  which,  under  the  microscope,  is  seen  to 
contain  numerous  pus  corpuscles,  granule  cells,  and  casts  of  the  tubes,  crowded  with 
granules.  When  the  bladder  is  about  half  empty,  there  is  frequently  a  sudden  stop- 
page of  the  flow  of  urine,  when  she  suffers  from  severe  pain  in  the  hypogastrium, 
stretching  down  the  thighs,  especially  on  the  right  side.  Pulse  90,  of  moderate 
strength.  Heart's  sounds  feeble,  otherwise  normal.  Other  functions  natural.  The 
bladder  was  examined  by  Mr.  Syme,  and  a  large  ulcer  was  detected,  occupying  the 
base  and  neck  of  the  bladder.  IJ  Tinct.  Hyoscyami  3  vi ;  Tinct.  Opii'Zx]]  Mucila- 
ginis  d  Aquce  aa.  §  vi.     M.     Sumat  |  j  ter  indies. 

Progress  of  the  Case. — November  I8th. — Continues  much  in  the  same  state. 
Urine  presents  the  same  characters  as  before.  Omittalur  mistura  Hyoscyami.  5 
Potassce  Acetatis  ^ss;  Sp.  ^Etheris  Xitrici  3  iij ;  Miicilaginis  et  Aquce -0.0,  3  iij.  M- 
Sumat  t^ i  quai'id  qudque  hard.  5  Sol.Mur.  Mor^Mce  3j;  Mist.  Carnphora  ^.i-  M. 
Sumat  dimidium  liora  somni  et  alierum  j)ost  lioras  tres  si  opus  sit.  Warm  fomentations 
to  be  applied  to  the  loins.  Nov.  2lst. — The  warm  fomentations  were  applied  as  ordered, 
and  afforded  considerable  relief;  she  sleeps  well  at  night  after  taking  the  draught ; 
the  casts  have  now  disappeared  from  the  urine,  but  a  few  granule  cells  are  still  visible, 
mixed  with  pus  corpuscles,  blood  globules,  and  some  crystals  of  triple  phosphate. 
Urine  still  of  specific  gravity  1010,  highly  albuminous,  and  of  a  very  putrid  smell 
immediately  after  being  pH.ssed.  Nov.  24^/t. — The  quantity  of  urine  is  now  greatly 
diminished;  presents  the  same  characters  as  on  the  2lst.  There  is  still  pain  and 
tenderness  in  right  lumbar  region ;  frequent  desire  to  pass  water,  the  first  half  of 
which  flows  with  comparative  facility,  but  the  remainder  comes  away  slowly,  requir- 
ing external  pressure  to  empty  the  bladder,  at  the  same  time  there  are  sharp  shoot- 
ing pains  in  the  vulva,  and  the  inner  side  of  the  thighs,  extending  down  to  the  knees. 
She  appears  much  exhausted;  pulse  weak,  96.  To  have  four  ounces  of  wine.  Nov. 
28th. — Is  much  in  tlie  same  state;  the  urine  is  still  highly  coagulable  ;  the  sediment 
examined  by  the  microscope  presents  a  large  number,  1st,  of  finely  molecular  exuda- 
tion casts ;  2dly,  groups  of  broken  down  pus  cells ;  3dly,  crystals  of  triple  phosphate ; 

*  Reported  by  Mr.  Robert  Francis  M.  Russell,  Clinical  Clerk. 


746  DISEASES   OF   THE    GENITO-URIXARY   SYSTEM. 

Aildy,  granular  cells ;  bihly,  blood  corpuscles.  December  4J/(.— Is  now  passing  her 
foeces  and  urine  inv^oluntarily;  appetite  rather  improved;  pulse  85,  weak.  The 
warm  fomentations  have  been  continued  since  the  ISth  ult.  To  have  six  ounces  of 
wine.  Dec.  8(h  — Still  passes  everything  in  bed  ;  complains  of  great  pain  and  tender- 
ness in  right  lumbar  region ;  still  takes  food  well ;  pulse  90,  of  better  strength.  Dec. 
Igth. — Appetite  very  much  impaired  within  the  last  two  or  tiiree  days;  still 
complains  of  pain  over  right  kidney,  and  passes  dejections  involuntarily.  Only  an 
ounce  of  urine  could  be  obtained  for  examination.  It  is  still  coagulable :  the  sedi- 
ment presenting,  under  the  microscope,  tlie  same  characters  as  on  the  28th  ult.,  with 
an  increase  in  the  number  of  blood  corpuscles  ;  pulse  100,  very  weak.  Dec.  23d. — 
Since  last  report  the  patient  has  been  gradually  sinking,  and  she  died  this  morning. 

Sectio  Cadaveris. — Fifty  hours  after  death. 

Body  emaciated. 

Thorax. — Pericardium  contains  about  two  ounces  of  serum.  Heart  small,  presents 
a  large  amount  of  fat  on  its  surface ;  valves  and  endocardium  perfectly  normal.  Left 
lung  slightly  adherent  at  apex ;  middle  and  lower  lobes  of  right  lung  strongly  adherent 
posteriorly;  both  lungs  were  crepitant  throughout  with  the  exception  of  some 
hardened  deposits  at  apex  of  the  left,  which  look  like  old  tubercle.  Bronchi  contain 
much  frothy  mucus.  The  aortu  througli  the  whole  of  its  course  (and  both  iliac 
arteries)  contained  a  large  amount  of  calcareous  deposit,  principally  seated  in  the  arch 
of  the  aorta,  and  the  thoracic  portion  of  that  ves.sel. 

Abbohes.— Stomach  and  intestinal  canal  normal;  pancreas  pale:  f^j^leen  very 
small ;  liver  small  congested,  firm,  and  dense.  Lumhar  glands  considerably  enlarged, 
and  contain  a  very  great  amount  ef  yellowish  opaque  juice,  evidently  purulent,  but 
no  distinct  abscesses  Both  kidneys  of  normal  size  when  viewed  externally ;  the 
ureters  dilated  to  the  size  of  swan  quills ;  pelvis  of  both  kidneys  dilated  to  three  or 
four  times  the  normal  size ;  cortical  and  tubular  substance  correspondingly  small  in 
volume ;  several  of  the  pyramids  distorted  and  crooked  in  direction,  but  their  basic 
line  always  distinct :  cortical  substance  pale ;  malpigliian  bodies  and  stria?  destitute 
of  blood ;  surface  smooth,  but  more  adherent  to  capsule  than  usual.  On  careful 
examination  with  tlie  naked  eye,  a  considerable  number  of  cysts  from  the  smallest 
visible  size  up  to  i  inch  diameter  are  obsei-ved  in  the  cortical  substance,  especially 
near  the  surface.  The  Madder  of  normal  size ;  all  its  walls  much  thickened ;  the 
raucous  membrane  presents  a  soft  fungoid-looking  ulcerated  mass,  in  which  no  peculiar 
or  characteristic  structure  could  be  observed.  All  parts  of  the  mucous  membrane 
were  equally  diseased. 

Microscopic  Ex.^mixatiox  — The  cysts  in  the  kidney  can  be  traced  down  to  very 
minute  sizes  (the  smallest  observed  was  about  the  600th  of  an  inch  in  diameter), 
having  the  usual  appearance  of  such  cyst  formations.  The  malpighian  bodies  slirunk, 
bloodless  and  opaque,  without  apparent  morbid  deposit,  but  with  thickening  of  their 
membrane  and  nuclei.  In  some  of  the  tubes  similar  thickening  and  epithelial 
engorgement,  producing  an  appearance  of  opacity  in  the  tubuli  without  any  recog- 
nisable granular  deposit.  When  the  tubules  are  washed  out  and  examined  sepa- 
rately, they  appear  (most  of  them)  smooth.  Epithelium  small  and  compressed,  but, 
generally,  regularly  disposed  and  normally  developed.  In  a  few  places,  traces  of 
granular  and  molecular  exudation,  but  to  an  insignificant  extent. 

Comrnentari/. — The  complication  of  renal  and  vesical  disease  here 
met  with,  is  bv  no  means  an  uncommon  one  in  aged  persons.  Its 
existence  leads  to  obstruction  of  the  ureter,  at  its  entrance  into  the 
bladder,  distension  of  the  ureter  above,  accumulation  of  urine  in  the 


NEPHRITIS   AND   PYELITIS.  747 

pelvis  of  tlic  kidney,  and,  as  a  consequence,  inflammation  and  distension 
of  its  mucous  lining  ■walls,  pressure  on  the  secreting  portion,  and  atrojthy 
of  its  substance.  Such  a  lesion,  if  it  exist  in  both  kidneys,  must  neces- 
sarily at  last  so  interfere  with  their  functions,  as  to  be  incompatible  with 
life.  The  chronic  disease  of  the  bladder,  on  which  the  renal  disease  for 
the  most  part  depends,  oidy  admits  of  palliative  measures  for  its  relief. 

Ci/sfic  disease  of  the  kidney  may  originate  in  various  ways, —  1st,  From 
greater  or  less  obstruction  in  the  tubuli  uriniferi,  and  consequent  accumu- 
lation of  the  fluid  above,  forming  cystic  collections.  2d,  It  may  originate 
in  the  sacs  surrounding  the  malpighian  bodies,  the  fluid  accumulating  in 
them  producing  distension,  and  so  causing  cysts.  3d,  In  the  enlarge- 
ment of  the  secreting  cells  of  the  organ,  which  here,  as  in  the  ovary, 
become  distended  with  fluid,  and  bv  pressing  upon,  compress  one 
another. 

1.  The  obstructions  found  in  the  tubuli  uriniferi  are  of  various  kinds, 
and  may  consist  of  coagulated  exudation,  of  pus,  of  blood,  of  altered 
epithelium  cells,  or  of  diflerent  salts,  such  as  mates,  carbonates,  phos- 
phates, etc.  etc.  The  bloody  points  so  frequently  observed  on  the  surface 
of  diseased  kidneys,  most  frequently  arise  from  extravasation  of  blood 
into  the  convoluted  extremities  of  the  tubes.  Small  calculi  may  be 
formed  fioin  mineral  deposits,  but  more  commoidy  the  tubular  cones 
present  a  diff"used  white  appearance  from  their  occurrence.  That  such  a 
condition  is  a  frequent  somce  of  cysts,  may  be  easily  proved  by  exami- 
nation. Tlie  cysts  so  foimed  may  be  of  dift'erent  sizes,  vaiying  fi-om  that 
of  a  millet  seed  to  that  of  an  orange,  and  the  destruction  of  the  secreting 
portion  of  the  kidney  will,  of  course,  be  proportionate  to  their  volume  and 
number.  The  contents  of  such  cysts  are  also  of  various  kinds,  such  as 
serum,  blood,  pus,  fibrous  exudation,  colloid  and  fatty  matter,  fluid  hold- 
ing various  crvstals  in  suspension,  whether  fattv  (cholesterine  or  marga- 
rine), or  saline  (phosphates,  urates,  etc.).  I  have  frequently  seen  all  the 
forms  in  the  following  figure  (Fig.  444),  and  occasit)nally  the  I'adiated 
bodies  represented  Fig.  297. 

2.  That  numerous  cvsts  mav  form  from  distension  of  the  minute  sacs 
surrounding  the  malpighian  bodv,  I  have  satisfied  mvself  of  bv  careful 
examination,  and  possess  prepai'ations  demonstrating  the  fact.  In  this 
case,  the  cysts  are  generally  numerous  and  scattered  through  the  cortical 
substance.  It  would  appear  to  arise  from  some  obstruction  at  the  com- 
mencement of  the  excreting  duct,  although  I  have  never  been  able  to 
detect  any.  Fluid  collects  outside  the  membrane  in  immediate  contact 
with  the  tuft  of  vessels  constituting  the  malpighian  bodv,  and  inside 
another  membrane  continuous  with  the  basement  membrane  of  the  latter. 
Indeed,  it  is  in  cases  of  this  kind  that  we  may  satisfy  oui'selves  that  the 
membrane  investing  the  tuft  of  vessels  is  really  double,  forming  a  shut 
serous  sac,  in  the  cavity  of  which  the  fluid  accumulates.  This  fluid  is 
invariably  clear,  varies  in  quantity,  but  each  cyst  seldom  exceeds  a  sniall 
pea  in  size.  As  it  forms,  it  gradually  presses  on  the  vascidar  tutt,  and 
causes  its  atrophy,  and  so  impedes  the  secretory  power  of  the  organ. 

3.  The  third  form  of  cystic  formation  in  the  kidney  evidently  origi- 
nates in  the  secreting  cells  themselves,  as  they  may  be  seen,  on  a 
microscopic  examination,  to  exist  in  clusters,  vai-ying  in  size  from  the 


748 


DISEASES   OF   THE   GENITO-URINARY   SYSTEM. 


600th  to  the  16th  of  an  inch  in  diameter.     In  such  a  case,  the  paren- 
chyma  of  the   organ  seems  to  be  infiltrated  with  them,  and  strongly 


444. 


remind: 
vesicles 


the  observer  of  a  section  of  the  ovary,  loaded  witli  Graafian 
Many  still  retain  their  nucleus,  whilst  in  others  it  has  dis- 
appeared. Mr.  Simon,  of  London,  who  first  described  this  form  of 
cystic  formation,  says,  as  explanatory  of  its  formation,  "  that  certain 
diseases  of  the  kidney  (whereof  subacute  inflammation  is  by  far  the 
most  frequent)  tend  to  produce  a  blocking  of  the  tubes;  that  this 
obstruction,  directly  or  indirectly,  pi-odiices  rupture  of  the  limitary 
membrane;  and  that  then,  what  should  have  been  the  intra-tnbnlav 
cell-growth  continues,  with  certain  modifications,  as  a  parenchytic  deve- 
lopment."* 

One   or   all  of  these  forms  of  cystic  growth  in  the  kidney   may  be 
associated  with  the  next  lesion  to  be  treated  of,  viz.,  Bright's  disease. 


PERSISTENT  ALBUMINURIA,  OR  BRIGHT'S  DISEASE. 

That  albumen  in  urine  was  a  symptom  of  certain  dropsies,  was  first 
noticed  l)y  Dr.  Wells  of  St.  Thomas's  Hospital,t  and  Dr.  Blackball  of 
Exeter ;  that  it  indicated  especially  venal  dropsies,  was  the  discovery 
of  Dr.  Bright,  who  has  given  us  a  careful  account  of  the  phenomena 

*  Medico-Chirurgical  Transactions,  vol.  xxx.  p.  152. 

f  Trans,  of  a  Society  for  promoting  Medical  and  Surgical  Knowledge,  vol.  iii. 
pp.  147,  167. 


Fig.  444.  Structures  occasionally  seen  in  cysts  of  the  kidaey ;  a  and  Z*,  Structure- 
less transparent  colloid  masses;  c  to  g,  Colloid  bodies,  composed  of  one  or  more 
nuclei,  imbedded  in  albuminous  matter ;  h  to  i,  Colloid  masses,  surrounded  by  con- 
centric laminaj;  k,  A  colloid  mass,  with  fatty  granules  arranged  in  an  areolar  manner. 
—{Wtdl)  3o0  diam. 


bright's  disease,  749 

-which  characterize  the  disease  that  has  since  borne  his  name,  as  Avell 
as  of  the  changes  observed  in  the  kidney  after  death.  The  subsequent 
observations  of  Christison,  Martin  Solon,  Raver  and  others,  as  well  as 
the  more  recent  investigations  of  Gluge,  Johnson,  Simon,  Frerichs 
and  others,  have  rendered  it  certain  that  the  lesions  of  the  kidney 
accompanying  albuminuria  are  various.  Some  are  dependent  on  what 
mav  be  considered  an  acute  or  chi'onic  form  of  inflammation  (see 
Nephritis),  whilst  others  mast  be  referred  to  what  we  now  call  the 
fattv  and  waxy  degenerations.  In  selecting  the  following  cases  as 
illustrative  of  the  disease,  1  have  kept  in  view  its  natui-al  piogress, 
and  endeavoured  to  show  how,  by  judicious  treatment,  it  sometimes 
terminates  in  recovery  ;  how  at  other  times  it  frequently  becomes  obsti- 
nate, and  in  what  manner  it  may  ultimately  cause  death.  Of  the 
pathology  and  treatment  I  shall  speak  separately,  after  describing  the 
facts  we  have  studied  at  the  bedside. 


Case    CLXVU.*—Albumi)mria—Ge7ieral   Anasarca— (Edema   of  Lung—Recorery. 

History.— Elizabeth  Brady,  fet.  30,  cook,  married— admitted  March  19tli,  1854. 
She  states  that  her  health  was  good  until  four  weeks  ago,  when,  after  exposure  to 
cold  and  wet,  she  was  seized  with  pains  in  the  chest  and  cough,  but  without  shiver- 
ing. Three  days  afterwards  her  feet  began  to  swell,  and  gradually  the  swelling 
extended  upwards,  involving  her  whole  body. 

Symptoms  os  Admission. — On  admission,  chest  well  formed;  breathing  slightly 
laboured.  On  percussion,  unusual  resonance  is  perceived  over  the  upper  portion  of 
both  sides  anteriorly.  There  is  marked  dulness  on  the  left  side  below  the  nipple 
and  lower  angle  of  scapula.  On  applying  the  stethoscope  over  the  portion  marked 
as  dull,  fine  crepitation  is  perceived.  Elsewhere  on  the  left  side,  the  inspiration  is 
harsh  and  the  expiration  prolonged;  pulse  100,  small  and  hard;  cardiac  sounds 
normal;  tongue  covered  with  a  brown  fur;  complains  of  nausea  and  disinclination 
for  food.  The  abdomen  is  distended  with  fluid,  and  she  has  pain  in  the  epigastric 
region;  bowels  constipated;  urine  rather  scanty,  sp  gr.  1028,  is  turbid  when  voided, 
and  on  standing  deposits  a  copious  sediment,  which,  when  placed  under  the  micro- 
scope, presents  chiefly  amorphous  urate  of  ammonia,  with  a  few  tube-casts.  On  the 
application  of  heat  and  nitric  acid  a  large  coagulum  is  thrown  down.  Catamenia 
regular.  Her  skin  is  hot :  her  face  flushed  and  swollen  ;  she  suffers  from  general 
anasarca;  her  lower  extremities,  however,  being  especially  affected  and  pitluig 
easily  on  pressure. 

Progress  of  the  C.\se. — March  2\st. —  Ordered  to  be  bled  at  the  arm  to  the  extent 
of  twelve  ounces.  ^  Pulv.  Doveri  Ql  Taksvi.  One  to  be  taken  at  bed-time.  March 
22d. — Fifteen  ounces  of  blood  were  withdrawn  from  the  arm,  and  the  pulse  shortly 
fell  to  70.  She  expressed  herself  as  greatly  relieved.  After  takhig  the  Dover's 
powder  she  had  a  short  sleep,  but  no  diaphoresis  -was  produced.  The  blood  with- 
drawn presents  no  buffy  coat ;  her  urine  is  voided  in  larger  quantity,  but  still  depo- 
sits a  considerable  sediment ;  pulse  90,  soft  and  weak.  1^  Potass.  Acet.  3  i ;  Sp. 
^iEth.  Xit.  3vi;  Syrup.  Aurantii  |i;  Aqiue  3  iv.  M.  One  ounce  to  be  taken  three 
times  a  day.  5  Pulv.  Gambogice  gr.  v ;  Potass.  Bitart.  3  ij.  M.  To  be  taken  at 
bed-time.  March  2.3d.— Her  bowels  have  been  well  opened,  and  her  general  appear- 
ance is  greatly  improved,  her  face  being  much  less  swollen;  urine  less  turbid,  and 

*  Reported  by  Mr.  W.  W.  Clark,  Clmical  Clerk. 


750  DISEASES   OF   THE    GEXITO-URIXARY   SYSTEiL 

in  larger  quantity.  Tatermitkdur  mist.  5  P^^-  Scilkz  et  Digital,  xii.  One  to  be 
taken  every  sixth  hour.  March  24:th. — Her  cougli  lias  abated  greatly,  and  she  feels 
herself  much  better.  Repttat.  Pulv.  Gamb.  et  Potass.  Bitart.  vespere.  March  2Gih. — 
Urine  deposits  ver}'  little  sediment  on  standing ;  and  under  the  microscope,  no  tube 
casts  can  be  detected;  sp.  gr.  1018.  A  slight  coagulum  is  produced  on  applying 
heat  and  nitric  acid.  Her  appetite  is  greath' improved.  March  29th — On  examin- 
ing her  chest  to-day,  the  dulness  on  percussion,  which  previously  existed  on  the  left 
side,  cannot  now  be  detected,  and  on  auscultation  over  that  portion  the  respiratory 
murmur  is  heard  normal.  Under  the  right  clavicle  the  inspiration  appears  unusually 
harsh.  Her  urine  presents  the  same  character  as  at  last  report.  Repetantur  Pil. 
ScHlcb  et  Digital,  et  Pulv.  Potass.  Pltart.  3ss  ter  indies.  April  3d. — She  is  now 
nearly  convalescent,  and  has  taken  no  medicine  for  two  days.  To  have  steak  diet. 
May  Sth. — Complains  to-day  of  pain  in  the  epigastrium  and  of  vomiting ;  bowels 
constipated ;  pulse  natural ;  urine  yields  no  coagulum  to  the  usual  re-agents ;  sp.  gr. 
1008 ;  contains  no  tube-Ciists  on  microscopic  examination.  Menstruation  rather 
frequent,  and  in  the  intervals  of  the  catamenial  periods,  she  is  subject  to  a  leucor- 
rhoeal  discharge.  5  Naphthce  Medicinal.  3  i ;  Tinct.  Cardam.  Co.  |  i ;  Aquce  3  v. 
M.  A  table  spoonful  to  be  taken  ivhen  tlie  vomiting  is  troublesome.  5  Magnesice 
Carb.  3ss;  Aq.  Cinnam.  §i;  Infus.  Semue.  Co.  3  ij.  M.  Ft.  haust.  hora  somni 
sumendus.  Inter mittantur  alia.  July  liith. — Since  last  report  her  urine  has  remained 
entirely  free  of  albumen.  The  csdema  has  now  for  the  most  part  entirely  disap- 
peared, but  still  returns  slightly  after  she  has  been  some  time  in  the  erect  position. 
General  health  good.     Dismissed. 

Commentnnj. — On  succeeding  Dr.  Ciiristison  in  the  charge  of  the 
clinical  wards  on  tlie  1st  of  May  18.54,  I  was  informed  that  this  was  a 
case  of  Bright's  disease.  On  the  Sth  of  the  month,  however,  as  stated 
in  the  report,  on  examining  her  urine,  I  found  it  to  contain  no  albumen 
on  the  addition  of  heat  or  nitric  acid,  while  the  sediment,  carefullv  col- 
lected, exhibited  no  tube-casts  under  the  microscope.  On  lookin<>"  into 
the  history  of  the  case,  however,  as  recorded  in  the  ward-book,  and 
which  is  given  above,  it  became  clear  that  the  woman  had  undoubtedly 
been  labouring  under  albuminuria  and  chronic  renal  disease,  which,  well 
pronounced  March  21st,  had  entirely  disappeared  at  the  beginnino-  of 
May.  But  the  oedema  of  the  feet  continued,  with  stomachic  derano-e- 
lULMits  ;  the  former  symptom  exhibiting  a  tendency  to  return,  on  assum- 
ing the  erect  position  for  any  time ;  and,  in  consequence,  she  was  not 
dismissed  until  the  20th  of  Jnly.  Before  saying  anything  with  regard 
to  the  treatment,  it  will  be  well  to  attend  to  the  facts  exhibited  bv  some 
other  cases. 


Case  CLXVIII.* — Albuminuria — (Eiem/i  of  both  feet  and  legs,  left  arm  and  hand — 

Recovery. 

HiSTOKY.— Bobert  Lindsay,  at.  02,  carder  of  wool— admitted  21st  March,  18.54. 
States  that,  twenty-three  years  ago,  he  had  a  violent  attack  of  rheumatism,  which 
laid  him  up  for  ten  months.  After  his  recovery,  his  health  continued  good,  until  ten 
years  ago,  when  he  began  to  suffer  from  symptoms  of  stone  in  the  bladder.  He 
underwent  the  operation  of  lithotomy,  but  made  a  tardy  recovery,  being  unable  to 

♦  Reported  by  Mr.  Robert  Bird,  Clinical  Clerk. 


bright's  disease.  751 

resume  his  work  until  upwards  of  twelve  months  afterwards,  and  for  two  or  three 
years  subsequently  he  was  subject  to  attacks  of  rigors,  which  compelled  him  to  keep 
within  doors  for  several  days  at  a  time.  He  then  became  tolerably  healthy,  and 
continued  so  until  three  weeks  ago,  when  he  noticed  his  left  wrist  somewhat  swol- 
len, and  in  the  course  of  two  days,  his  lower  extremities  became  likewise  cedeniatous- 
He  sutTered  from  a  dull  heavy  pain  in  the  lumbar  region;  which  has  been  present 
more  or  less  ever  since  he  underwent  the  operation  ten  years  ago.  His  urine,  at  the 
time  tlie  swelling  commenced,  was  scanty  and  high  coloured,  and  he  was  troubled 
with  a  slight  cough.  He  says  that  about  tlie  time  when  his  illness  began,  he  was 
engaged  in  cleaning  machinery,  and  may  have  caught  cold.  He  is  not  aware  of  any 
other  cause  which  might  have  brought  on  his  ailment.  He  acknowledges  that  for- 
merly he  was  a  free  liver,  but  since  the  operation  he  has  been  very  temperate. 

Symptoms  on  Admission. — On  admission,  both  feet  and  legs  are  oedematous,  pit- 
ting on  pressure  There  is  also  shght  swelling  of  the  left  arm  and  hand.  He  com- 
plains of  a  dull  pain  in  the  lumbar  region  on  both  sides,  but  that  on  the  left  is  most 
severe.  Micturition  frequent;  he  is  obliged  to  rise  several  times  in  the  course  of  the 
night  for  that  purpose.  It  is  not  attended  with  pain  or  difficulty.  Sp.  gr.  of  urine 
1011;  coagulable  by  lieat  and  nitric  acid.  He  complains  of  frontal  headaciie. 
Sleeps  badl}^  being  much  disturbed  by  dreams  and  sudden  startings.  Tongue  moist 
and  clean;  complains  of  great  thirst;  appetite  impaired;  bowels  regular;  has  a 
sliglit  cough,  with  very  little  expectoration;  chest  every wliere  resonant  on  perctis- 
sion.  At  the  apices  of  both  lungs  anterioriy,  and  at  the  apex  of  the  left  posterioriy, 
sibilant  rales  are  heard.  He  has  suffered  from  palpitation  for  the  last  three  weeks, 
but  the  cardiac  sounds  are  normal.  ]J  Tinct.  Ftrri  Mur.  |  i.  Ten  drops  to  he  taken 
three  times  a  day.  I^  Pulv.  Doveri  gr.  x.  MMant.  tales,  vi.  One  to  he  taken  morn- 
ing and  night. 

Progress  of  the  Case.— J/arc7i  23d.— This  morning  he  had  violent  vomiting, 
but  it  has  now  abated,  and  he  complains  of  great  thirst.  March  26</i.— Ordered 
pills  of  digitaline,  each  containing  l-74th  of  a  grain.  One  to  be  taken  three  times 
a  day.  March  28th  —After  taking  the  pills  of  digitaline  twice,  excessive  purging 
came  on  ;  their  further  use  was  therefore  abandoned.  The  urine  was  very  sligiitly 
increased  in  quantity.  April  4</l— The  use  of  digitaline  was  resumed  four  days 
ago,  and  now  the  coagulability  of  the  urine  has  entirely  disappeared.  The  oedema 
of  his  lower  extremities  has  abated  greatly.  The  purging,  caused  by  the  digitaline, 
was  counteracted  by  opium  pills.  Maij  3d.— Since  last  report  the  urine  has  been 
several  times  examined,  and  has  been  always  found  to  be  free  of  albumen.  To-day 
only  the  slightest  haze  is  caused  by  heat  and  nitric  acid;  the  urine  is  pale  coloured ; 
sp.  gr.  1014,  transparent,  and  without  sediment  on  standing;  84  oz.  are  passed  in 
the  twenty-four  hours.  The  oedema  has  not  entirely  disappeared  from  the  feet  and 
ankles.  He  continues  to  take  the  digitaline  pills.  His  general  health  is  much 
improved.  May  llth.—Two  days  ago  he  was  ordered  the  following:— IJ  Tinct. 
Ferri  Mur.  3  i.  Fifteen  drops  to  be  taken  thrice  a  day.  To-day  he  has  passed  54 
oz.  of  unne.  The  oedema  of  his  feet  and  ankles  is  abating.  A  few  minute  flakes 
are  produced  on  treating  the  urine  by  heat  and  nitric  acid.  May  Uth.—18  oz  of 
urine  were  voided  during  the  last  24  hours.  5  S^x  ^th.  Nit.  |  iss ;  Aq.  Potwss.  ■ 
Tinct.  Digital,  aa.  3  ij.  M.  A  tea-spoonful  to  he  taken  thrice  a  day.  Contin.  Tinct. 
Mur.  Ferri.  May  lOC/i.— Amount  of  urine  passed  during  the  twenty-four  hours  is 
100  oz.  June  22d.— (Edema  of  legs  almost  entirely  gone;  68  oz.  of  urine  passed 
during  the  last  twenty-four  hours;  sp.  gr.  1014:  quite  unaftected  by  heat  and  nitric 
acid.  June  '26//i.— His  feet  and  ankles  are  slightly  oedematous  at  night ;  60  oz.  of 
urine  passed  during  the  last  twenty-four  hours;  sp.  gr.  1017.  No  coagulum  pro- 
duced by  heat  and  nitric  acid.     July  lUh. — Dismissed  quite  well. 


752  DISEASES   OF   THE   GEXITO-URINARY   STSTEM. 

Commentary. — In  this  case  also,  we  can  have  no  doubt  of  the 
existence  of  Bnght's  disease,  ahhough  on  my  succeeding  Dr.  Christison 
in  the  clinical  wards  I  found  no  aibumen  in  the  urine,  and  that  the 
patient  was  rapidly  recovering.  Digitaline  had  been  tried,  with  the 
effect  of  producing  excessive  purging,  and  slight  increase  of  the  urine. 
The  albumen  shortly  afterwards  disappeare<l  fi-om  that  tinid,  but  here, 
as  in  the  last  case,  the  oedema  continued,  and  he  subsequently  became 
quite  well.  These  two  cases,  therefore,  indicate  that  purgatives  and 
diuretics  are  sometimes  very  efficient  in  entirely  removing  the  disease. 


Case  CLXIX.* — Albuminuria — (Edema — Ascites  and  General  Anasarca — Coma  and 
Conv  uls  ions — Recovery. 

History. — Alexander  Strachan,  wt.  36,  a  joiner — admitted  October  25,  1858. 
He  enjoyed  good  health  up  to  the  2d  October  last,  when,  after  exposvire  to  cold  and 
wet,  he  was  seized  witli  a  rigor,  followed  b}-  severe  cough  and  sliglit  expectoration. 
On  the  6th  he  first  remarked  swelliug  of  the  lower  extremities,  and  in  the  evening, 
on  trying  to  make  water,  he  with  some  difficulty  passed  about  half  a  pint  of  brown, 
smoky -coloured  urine.  On  the  following  morning  this  presented  a  sediment  of  a 
light  colour  and  viscous  consistence.  He  at  this  time  suffered  from  constipation, 
and  was  ordered  a  dose  of  castor  oil  by  his  medical  attendant.  On  the  7th  he  had  a 
copious  evacuation  from  the  bowels,  but  his  legs  continued  to  swell.  On  the  8th 
his  water,  which  was  small  in  quantity,  still  presented  a  white,  viscous  sediment. 
The  legs  became  more  swollen,  the  abdomen  now  began  to  increase  in  size,  and  great 
difficulty  of  breathing  came  on.  He  continued  in  this  state  up  till  the  day  of  his 
admission. 

Symptoms  ox  Admission. — There  is  great  oedema  of  both  legs,  ascites,  and  general 
anasarca.  He  has  a  good  deal  of  cough  and  frothy  expectoration ;  but,  with  the 
exception  of  occasional  fine  moist  rale  and  sibilation  posteriorly,  the  lungs  are  healthy. 
Cardiac  dulness  and  sounds  normal.  Pulse  70,  of  moderate  strength.  He  com- 
plains of  a  dull  pain  over  the  region  of  kidneys.  Urine  of  a  dark,  smoky  colour, 
highly  albuminous,  and  depositing  a  whitish,  tenacious  sediment.  Tube  casts  and 
blood  corpuscles  are  very  abundant,  as  determined  by  the  microscope.  Other 
symptoms  normal.  To  be  dry  cuirped  over  the  kidneys,  and  to  take  3j  doses  of  Pulv. 
Jalapce  Comp.  three  times  a  day. 

Progress  of  the  Case. —  October  29th. — The  cough  and  expectoration  have 
greatly  diminished  since  he  came  into  the  house,  but  little  impression  has  been 
made  upon  the  dropsy.  Xov.  2d. —  Ordered  Pit.  Digitalis  et  Scillce  xij;  one  three 
times  a  day,  in  addition  to  the  powders.  Nov.  7th.— Bas  passed  quantities  of  urine 
varying  from  20  to  44  oz.  daily,  although  generally  it  has  been  deficient  in  quantity. 
The  dropsical  symptoms  have  undergone  no  change.  This  morning  at  four  o'clock 
he  was  seized  with  convulsions  and  loss  of  consciousness.  Had  three  more  fits  at 
intervals  during  the  day.  Urine  of  a  smoky  tint,  containing  tube  casts  and  blood 
corpuscles.  Ordered  to  be  cupped  to  5  ounces  over  the  region  of  the  kidneys.  To  have 
I  j  of  the  Bitartrate  of  Potass  three  times  a  day.  Nov.  8th. — Had  three  fits  to-da}',  and 
has  been  very  drowsy.  Nov.  9th — The  drowsiness  is  nearly  gone  to-day,  and  he  is 
quite  sensible,  though  complaining  of  an  intense  headache.  Pulse  108,  of  fair 
strength.  Urine  40  oz.,  sp.  gr.  101.5,  albuminous  and  containing  blood  corpuscles. 
Dropsy  of  the  legs  has  nearly  disappeared,  and  the  abdomen  feels  softer.     It  measures 

*  Reported  by  Mr.  George  Shearer,  Clinical  Clerk. 


bright's  disease.  753 

36  inches  round  the  most  prominent  part.  Xov.  lOtk. — ffidema  of  legs  entirely  gone ; 
not  the  slightest  pitting  on  pressure.  Complains  of  seeing  objects  distorted,  and 
sometimes  of  a  haze  which  appears  before  his  vision.  He  continues  to  take  the 
Squill  and  Digitalis  pill,  one  four  times  a  day,  and  3  j  doses  of  bitartrate  of  potash. 
Xov.  llih. — Six  dry  cupping-glasses  were  applied  over  the  lumbar  region  this  even- 
ing. The  pupil  of  letl  eye  was  observed  to  be  considerably  dilated.  Nov.  I2(h. — 
Passed  63  oz.  of  urine  free  from  albumen.  Xov.  I3th. — Passed  42  oz. ;  and  Xov.  lith, 
46  oz.  of  urine.  To-day  the  left  pupil  was  observed  to  be  contracted,  the  right 
dilated.  Sees  whatever  object  he  has  been  looking  at  magnified  on  the  opposite 
wall.  Xov.  I9th. — Since  last  report,  has  passed  on  the  different  days,  48,  GO,  135, 
132,  and  98  oz.  of  urine.  To-day  it  shows  a  mere  trace  of  albumen.  Abdomen 
much  les.s  tense,  measures  34  inches.  From  the  19th  to  the  27th  has  been  passing 
about  90  oz.  of  urine  daily.  It  has  still  a  dim,  smoky  tint,  reaction  acid,  sp.  gr.  1018. 
Xitric  acid  imparts  to  it  a  red  tint,  and  after  boiling  flakes  of  albumen  appear.  From 
this  time  he  gradually  recovered.  He  was  for  some  days  troubled  with  muscae 
volitantes.  but  was  dismissed  ou  the  1st  of  December  at  his  own  request,  the  dropsy 
having  completelj'  disappeared,  and  only  the  faintest  trace  of  albumen  existing  in 
the  urine. 

Commentary. — In  this  case  the  amount  of  general  anasarca  was  very 
great,  and  purgatives  and  the  squill  and  digitalis  pill  produced  no  eflfect, 
so  that  poisoning  of  the  blood  with  urea,  caused  coma  and  severe  con- 
vulsions. These  were  of  an  epileptiform  character,  with  foaming  at  the 
mouth,  each  paroxysm  being  of  about  ten  minutes'  duration.  From  this 
state  the  patient  was  roused  by  the  energetic  action  of  the  bitartrate  of 
potash,  which,  by  increasing  the  flow  of  urine  from  the  kidiiey.s,  rapidly 
diminished  the  head  symptoms  and  completely  removed  the  dropsy. 
The  following  case,  which  is  the  most  remarkable  recovery  I  ever  saw, 
still  further  points  out  tlie  value  of  this  drug,  in  Bright's  disease  of 
the  kidnevs. 


Case  CLXX.* — Third  Attack  of  General  Anasarca  tviih  Albuminuria — Enormous 
Dropsical  Distension  of  the  Abdomen^  Scrotum,  and  Inferior  Extremities —  Cmn^ 
plete  Recovery  under  the  Action  of  Supertartrate  of  Potash, 

History. — William  Herdmann,  set.  49,  single,  a  hthographer — admitted  March  31, 
1855.  Patient  admits  that  he  has  been  a  man  of  rather  intemperate  habits,  although 
this  has  not  been  the  case  of  late.  Twelve  years  ago,  without  any  premonitory 
symptoms,  he  was  suddenly  seized  with  general  anasarca  and  with  ascites.  For 
this  he  entered  the  Infirmary,  and  after  treatment  was  dismissed  '•  Cured."  Six 
j'ears  after  the  first,  he  suffered  from  another  attack,  which  Avas  also  cured  in  the 
Infirmar}^  Within  the  last  fortnight  he  has  been  again  attacked  by  "  dropsy," 
which  has  been  gradually  increasing. 

Symptoms  ox  Admission. — On  admission,  the  quantity  of  urine  passed  is  small, 
but  he  is  not  obliged  to  rise  during  the  night  to  pass  his  water.  No  pain  in  loins, 
or  tenderness  on  pressure.  Abdomen  is  considerably  swollen,  especially  at  the  lower 
part.  Circular  measurement  below  umbilicus,  30i  inches.  When  he  lies  on  his 
back,  the  anterior  part  of  the  abdomen  is  tympanitic,  and  the  flanks  dull  on  percus- 
sion.    On  turning  him  to  either  side,  the  one  which  is  uppermost  becomes  clear  ou 

*  Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 
48 


754  DISEASES   OF   THE   GEXITO-URIXARY   SYSTEM. 

percussion,  and  the  undermost  remains  dull.  There  is  slight  oedema  of  the  ankles, 
but  he  notices,  every  morning,  some  puffiness  in  the  cheeks,  especially  on  the  right 
side  (that  on  which  he  usually  lies).  Bowels  rather  costive ;  appetite  very  bad ; 
tongue  foul,  and  covered  with  a  thick  brown  fur ;  considerable  thirst ;  complains  of 
cough  and  shortness  of  breath ;  expectorates  a  little  frothy  mucus.  Percussion  of 
chest  anteriorly  resonant  on  both  sides.  On  auscultation  in  front,  there  is  heard  on 
both  sides  harsh  inspiration,  attended  with  very  prolonged  expiration.  Posteriorly, 
at  both  bases,  there  are  loud  sibilant  and  crepitating  rales.  Heart  sounds  indistinct ; 
no  murmur;  pulse  68,  of  good  strength;  sleeps  well;  has  complained  a  little  of 
drowsiness  for  the  last  few  days ;  skin  dr}-  and  harsh.  Urine  very  scanty ;  has  only 
passed  12  oz.  since  admission.  The  application  of  heat  converts  the  whole  quantity 
in  the  test-tube  into  a  firm  coagulum ;  sp.  gr.  1024.  Casts  of  tubes  and  oil  globules 
are  found  in  the  sediment.  Desctndat  in  balneum  calidum  vespere.  Stimat  Fit. 
Scillce  et  Digitalis  j.  ter  in  die.  5  ^'*-  O^pii  Ammoniaice ;  Sp.  Lavandulce  Co.  ita  §  ss ; 
Mi.$t.  Scilke  3  v.     M.     Surnat  5  j  ter  in  die. 

Progress  of  the  Case. — Api-il  4ih. — Has  pa.ssed  16  oz.  of  urine  during  the  last 
twenty -four  hours.  Swelling  of  abdomen  increased ;  it  measures  below  umbilicus 
33  inches.  He  is  very  thirsty.  Apiil  bth. — Only  9  oz.  of  urine  passed  since  last 
report;  sp.  gr.  1018;  highly  coagulable ;  bowels  costive;  tongue  dry  and  furred; 
cough  still  present,  with  expectoration  of  tough  frothy  mucus ;  sibilant  and  crepi- 
tating rales  still  heard  at  bases  of  both  lungs  posteriorly.  Repeat  the  warm' hatlis. 
Injiciaiur  enema  foetiduia.  Hdbeai  Pulv.  Ipecac.  Co.  gr.  x.  liac  node,  et  repetatiir  eras 
mane.  Aj^ril  Gth. — Obtained  little  relief  from  the  injection;  skin  of  cbe.st,  abdomen, 
and  loins  pits  upon  pressure.  Abdomen  measures  34f  inches  in  circumference ; 
passed  only  9  oz.  of  urine  since  last  report,  of  same  character  as  before.  Breath  has 
a  urinous  odour.  Continuent.  Pil.  ScillcB  et  Digitalis,  et  sumat.  Potass.  Bitart.  3j 
ter  in  die.     Eepeiatur  Pulv.  Doveri.     April  loth. — Urine  passed  daily  has  been  from 

8  to  15  oz.,  of  sp.  gr.  about  1020,  and  highly  coagulable.  Omittantur  Pil.  Scilkn  et 
Digitalis.  To  apply  spongio-piline  constantly  to  the  abdomen,  saturated  loith  a  strong 
solution  ofJnfus.  Digitalis.     Aj>ril  lid. — Urine  not  increased  in  quantity,  varies  from 

9  to  1.5  oz.  per  diem ;  abdomen  measures  37|  inches.  The  Inf.  Digitalis  has  produced 
a  rash  of  a  papular  character  over  the  surface  of  the  abdomen.     IJ  Sp.  jEth.  Xitrici 

3vj;  Aq.  Cinnamomi  §  vss.  M.  Haheat  ^j  ter  in  die.  Ap)ril2oth. — Saj's  that  the 
last  mixture  has  given  him  great  relief;  has  passed  26  oz.  of  urine  after  it.  The 
spongio-piline  to  be  removed,  owing  to  irritation  which  it  has  caused  in  the  skin  of 
abdomen.  May  2d. — Base  of  left  lung  dull  on  percussion  posteriorly ;  no  rale ;  a 
good  deal  of  pain  in  abdomen ;  bowels  costive ;  skin  dry ;  has  passed  25  oz.  of  urine 
to-day.  May  3d — Urine  24  oz. ;  Habeat  Potass.  Bitart.  3j  ter  in  die.  Omittantur 
alia.  May  oth. — Urine  18  oz. ;  swelling  of  abdomen  much  increased,  thighs  and 
legs  greatly  distended.  Abdomen  measures  forty  inches  in  circumference.  Had 
Pil.  Rhei  Co.  gr.  x.  last  night.  To  take  Gin  §  j  daily.  May  7th. — Urine  20  oz. ;  sp. 
gr.  1018;  his  condition  at  present  seems  almost  hopeless.  The  abdomen  is  enor- 
mously distended,  with  a  peculiar  diftuse  indurated  feel  over  the  region  of  the 
epigastrium,  which,  however,  is  tympanitic  on  percussion.  The  scrotum,  thighs,  and 
legs  are  greatly  enlarged ;  appetite  impaired ;  tlie  pulse  86,  weak.  To  be  dry 
cupped  over  the  loins.  To  have  Gin  §  ij  daily.  2Iay  9th. — No  change.  Ilabeat 
Potass.  Bitart.  3ss  ter  in  die.  May  11  th. — Urine  34  oz. ;  sp.  gr.  1015;  still  highly 
coagulable ;  numerous  casts  of  tubes  are  seen  in  the  urine  under  the  microscope. 
May  lath. — Urine  38  oz. ;  sp.  gr.  1014;  is  less  coagulable;  complains  of  severe 
frontal  headache.  To  continue  tvith  the  Bitartrate  of  Potass.  May  IQih. — Urine  64 
oz. ;  sp.  gr.  1010.  May  11th. — Urine  58  oz. ;  sp.  gr.  1013;  no  headache;  bedsore 
on  sacrum  ;  right  side  more  swollen  than  left  (he  lies  on  this  side) ;  bowels  costive. 


bright's  disease.  755 

Haheat  Pil.  Cobcynth.  Co.  gv.  x.  hord  somni.  Afay  18th. — Urine  67  oz. ;  oedema  of 
limbs  very  much  diminished;  swelling  of  abdomen  less.  Mai/  2lsL — Urine  68  oz. ; 
sp.  gr.  1010;  appetite  good ;  pulse  96,  full  and  strong.  May  22d. — Urine  120  oz. 
May  23d. — Urine  128  oz. ;  sp.  gr.  1014;  it  still  contains  albumen  in  considerable 
quantity :  the  abdomen  has  greatly  diminished  in  size,  and  the  thighs  and  legs  are 
of  natural  appearance,  tliough  tiiere  is  some  pitting  on  pressure  at  tlie  ankles ;  every 
second  day  of  late  he  has  been  attacked  about  noon  witli  a  severe  frontal  headache. 
^  Quinoi  SulphaUs  gr.  iij  ter  die  sumend.  3Iay  2-lth. — Urine  107  oz  ;  sp.  gr.  1018; 
still  contains  much  albumen;  no  headache.  May  2oth. — Urine  126  oz. ;  sp  gr. 
1016;  very  slight  headache  to-day;  has  taken  four  of  the  quinine  powders.  Still 
takes  the  Bitartrate  of  Potash.  3fay  2Sth  —Urine  100  oz, ;  sp.  gr.  1020.  May  SOih. 
— Urine  50  oz.  2Iay  Slst. — Urine  80  oz. ;  sp.  gr.  1014;  perfectly  free  from  all 
trace  of  albumen ;  oedema  of  legs  and  ascites  have  completely  disappeared ;  no 
headache;  appetite  good.  June  8th. — No  return  of  albumen  in  urine;  quantity 
varies  from  60  to  114  oz.  daily.  June  9t]t. — A  slight  trace  of  albumen  in  the  urine 
toda}^,  and  feet  sliglitly  (edematous.  June  15th. — Still  a  faint  trace  of  albumen  in 
the  urine;  his  ankles  become  oedematous  if  he  sits  up  long.  June  19ih. — Urine  100 
oz.  in  twenty-four  hours;  sp.  gr.  1010;  contains  an  exceedingh'-  faint  trace  of 
albumen.  June  27th. — The  quantity  of  urine  passed  in  twenty-four  hours  averages 
100  oz. ;  sp.  gr.  varies  from  1010  to  1015  ;  his  ankles  after  he  has  been  long  up  pit 
slightly  on  pressure.  July  2d  — Albumen  has  quite  disappeared ;  bandaging  prevents 
his  ankles  from  swelling.  He  sits  up  the  entire  day.  Tlie  appetite  is  good.  Urine 
passed  daih'  about  40  oz.     In  fact  he  is  quite  well.     July  '3d. — Dismissed  cured. 

Commentnry . — Tn  this  case  the  man  describe<l  liis  dropsy  as  being 
tlie  third  attack  of  the  kind  he  had  experienced,  althougli  it  was  by  far 
much  more  severe  than  the  preceding  ones  I  found  him  in  the  ward 
at  the  same  time  with  Cases  CLXVII.  and  CLXVIIL,  but,  unHke  them, 
the  treatment  seemed  to  have  been  of  no  avaih  The  abdomen  was 
enormously  distended  from  fluid  collected  in  the  peritoneum  and  the 
scrotum ;  the  thighs  and  legs  were  also  so  greatly  swollen  from  dropsy, 
that  to  all  appearance  the  case  was  hopeless.  The  urine,  when  heated, 
presented  almost  a  solid  mass  of  albumen,  as  if  it  had  been  serum  of  the 
blood,  and  the  sediment  exhibited,  under  the  microscope,  numerous  fatty 
cells,  and  casts  of  tlie  tubes,  proving  the  disease  to  be  renal.  A  singular 
circumstance  is,  that  from  his  admission  in  March,  until  May  lltli,  not- 
withstanding a  diaphoretic,  purgative,  and  diuretic  treatment  had  been 
employed,  he  continued  to  get  worse,  and  the  anasarca  increased.  In 
April  also  he  had  taken  the  bitartrate  of  potash  in  drachm  doses  without 
benefit.  But  after  I  resumed  tlie  same  remedy  in  May,  in  half  drachm 
doses,  its  diuretic  effect  was  extraordinary.  From  the  11th  to  the  28th 
of  May,  the  quantity  of  urine  was  greatly  increased,  and  I  ordered  it  to 
be  measured  daily.  On  some  occasions,  120  oz.  of  fluid  were  voided, 
and  coincident  with  this  diuretic  eff"ect,  the  enormously  swollen  abdomen, 
scrotum,  and  inferior  extremities  diminished  in  size,  and  gradually 
returned  to  their  normal  condition.  On  the  31st  of  May  there  was  no 
albumen  in  the  urine.  The  ankles  still  remained  putfy,  especially  after 
sitting  up  for  any  time,  but  on  the  third  of  July  he  was  dismissed 
perfectly  well. 

The  anasarca  in  this  case  had  reached  its  ultimate  limits,  the  scrotum 
was  as  large  as  an  adult  licad,  the  prostration  of  the  patient  was  extreme, 
and  we  daily  feared  the  coming  on  of  coma,  and  sloughing  sores  on  the 


756  DISEASES   OF   THE    GENITO-URINARY   SYSTEM. 

back.  Althongli  dry  cupping  was  tried  over  the  loins,  on  the  *rth  of 
May,  I  have  niyselt'  no  doubt  that  the  good  eftocts  are  entirely  to  be 
attributed  to  the  diuretic  ordered  on  the  9th,  and  the  increased  discharge 
of  tluid  from  the  kidneys  which  followed. 

The  cases  now  recorded,  in  which  advanced  Bright's  disease  was 
perfectly  cured,  exhibit  the  groundlessness  of  the  fears  entertained  by 
some  as  to  the  use  of  diuretics  in  that  disease.  In  all  they  were  freely 
employed,  and  it  may  be  observed  that  improvement  invariably  coin- 
cided with  the  coming  on  of  the  increased  tiow  of  urine.  The  case  of 
Herdmann  (Case  CLXX.)  is  extraordinary  in  this  respect.  Case  LXYII. 
also,  in  which  there  was  a  permanent  cure  of  albuminuria  in  connection 
with  hepatic  disease,  may  be  consulted  with  advantage. 


Case  CLXXI.* — Second  Attack  of  Albuminuria  with  Anasarca — Dismissed  relieved. 

History. — Marv  Donaghan,  xt.  43 — admitted  July  12th,  1854,  out  worker.  She 
states  that  three  weeks  ago,  slie  came  home  from  her  usual  employment  in  the  open 
fields  in  good  health,  but  awoke  next  morning  with  pain  in  the  epigastric  region, 
and  found  her  legs,  arms,  body,  and  face,  much  swollen.  Slie  was  not  aware  of 
having  been  exposed  to  unusual  cold  or  wet  previously,  and  had  no  shivering.  She 
had  no  pain  in  the  loins,  and  passed  her  urine  in  usual  quantity.  Two  years  ago, 
she  was  admitted  into  this  hospital,  suffering  in  the  same  way  as  at  present.  The 
swelling  of  her  body  at  that  time,  however,  was  much  greater. 

Symptoms  ox  Admission. — On  admission,  her  lower  extremities  only  are  cedema- 
tous,  pitting  on  pressure.  Her  skin  is  moist,  and  she  perspires  moderately.  Urine 
passed  in  normal  quantity.  On  standing,  a  thick  white  deposit  subsides,  which, 
under  the  microscope,  is  seen  to  consist  of  epithelial  scales,  numerous  tube-casts 
tilled  with  oily  globules,  and  compound  granular  bodies.  Urine  deposits  a  consider- 
able coagulum  by  heat  and  nitric  acid,  also  an  abundant  precipitate  of  chlorides  by 
nitrate  of  silver;  sp.  gr.  1012.  She  complains  of  pain  on  pressing  firmly  the  left 
lumbar  region.  Her  tongue  is  moist  at  the  edges,  and  furred  in  the  centre.  She 
complains  of  thirst,  and  bad  appetite.  Epigastric  region  somewhat  tender  on  pressure. 
Bowels  constipated.  5  Pulv.  Potass.  Bitart.  ^  ss ;  in  pulv.  xii.  divid.  One  to  be 
taken  three  times  a  day. 

Progress  of  the  Case. — July  2Sd — Conjunctivse  somewhat  inflamed.  Two 
leeches  to  be  applied  to  external  angle  of  both  eyes.  July  2Qth. — Conjunctivitis  less 
acute.  5  ^d.  Argent,  gr.  ij;  Aquoe  §  i;  Ft.  CoUyrium.  August  2d. — Her  eyes  are 
now  nearly  well.  Urine  still  very  coagulable,  and  its  general  characters  are  much 
the  same  as  on  admission.  The  oedema  of  ihe  legs  is  abating  a  little.  Aug.  loth. — 
She  has  been  sweating  profusely  for  the  last  few  days.  The  characters  of  the  urine 
are  much  the  same  as  at  last  report.  The  oedema  disappears  almost  entirely  when 
she  retains  the  recumbent  posture  for  some  time,  but  returns  again  when  she  walks 
about.  She  continues  to  use  the  powders  of  Potass.  Bitart.  Aug.  2lst. — Urine  pale 
coloured;  sp.  gr.  1012.  Yields  a  considerable  coagulum  on  the  application  of  heat 
and  nitric  acid.  The  swelling  of  her  legs  has  abated  very  much.  Scarcely  any 
pitting  can  be  produced,  except  aft:er  she  has  been  walking  about  a  good  deal.  Her 
general  health  is  very  good.  She  is  able  to  be  out  of  bed  during  the  whole  day,  and 
is  now  anxious  to  be  dismissed.     Azig.  2hst. — Dismissed  relieved. 

*  Reported  by  Mr.  James  Thorburn,  Clinical  Clerk. 


BRIGHT  S   DISEASE.  (  O  < 


Commentary. — In  this  case  tbe  same  diuretic  treatment  we  have 
previoiislv  seen  to  be  so  beneficial,  produced  great  relief  and  rapid 
disappearance  of  the  anasarca.  Xo  doubt  every  symptom  would  have 
soon  disappeared,  bad  she  not  insisted  on  leaving  the  Infirmary. 


Case  CLXXIL* — Second  Attack  of  Albuminuria  after  an  interval  of  twenty-nine  years, 
icith  Anasarc<i — Bronchitis — Diamissed  relieved. 

History- — James  M'Kay,  fet.  62,  armourer — admitted  January  6tb,  1853.  He 
states  that  lie  enjoyed  excellent  healtli,  tUl  twenty-nine  years  ago,  when  he  was 
admitted  to  the  Royal  Infirmary  under  Dr.  Spens,  for  swelling  of  the  limbs,  trunk, 
and  face,  supervening  after  exposure  to  cold  and  wet.  He  continued  under  treat- 
ment for  nine  days,  when  he  was  dismissed  cured,  and  since  then,  he  continued  free 
from  any  complaint,  tiU  about  five  weeks  ago,  when  he  observed  that  his  urine  was 
diminished  in  quantitj',  was  of  a  high  colour,  and  deposited  a  thick  white  sediment. 
A  few  days  after,  he  was  exposed  to  cold,  while  perspiring,  having  freely  indulged 
in  spirituous  liquors.  This  was  foUowed  by  distinct  rigor,  lasting  for  a  short  time, 
and  followed  by  general  uneasiness  and  feverishness,  with  headache  and  feeling  of 
soreness  in  the  loina  Ten  days  after  the  rigor,  swelling  appeared  in  the  feet  and 
gradually  increased,  extending  to  the  legs,  thighs,  and  scrotum,  but  during  the  last 
lew  days,  the  oedema  has  considerably  diminished.  He  has  been  a  good  deal 
addicted  to  the  use  of  ardent  spirits  for  the  greater  part  of  his  life. 

Symptoms  ox  Admission. — On  admission,  the  skin  is  soft  and  dry ;  the  legs  are 
somewhat  oedematous,  and  pit  on  pressure.  The  urine  is  passed  more  frequently 
than  usual,  and  in  small  quantities  at  a  time ;  the  whole  amount  of  urine  voided  is 
considerabh'  under  the  normal  standard ;  it  is  of  a  pale  colour;  sp.  gr.  1012  ;  highly 
coagulable  with  heat  and  nitric  acid ;  no  distinct  sediment  is  deposited  on  standing. 
He  has  no  pain  at  present  in  the  situation  of  the  kidneys  or  bladder  ;  tongue  dry ; 
has  no  appetite,  but  troublesome  thirst ;  bowels  regular ;  pulse  96,  natural ;  heart's 
sounds  normal ;  he  has  some  cough  and  dyspnoea  on  exenion,  but  the  chest  is 
otherwise  normal;  other  functions  natural  To  have  warm  bottles  applied  to  the 
limbs  and  feet,  with  twelve  grairis  of  Dover's  powder  at  night,  followed  by  a  draught  of 
twenty  five  minims  of  Morphia  if  he  does  not  sleep. 

Pkogkjess  of  the  Case — January  9th. — Slept  towards  morning  after  the  morphia ; 
no  sweating;  urine  coagulable  as  before;  sp.  gr.  1018;  passed  without  pain  or  dififi- 
culty,  and  in  good  quantity,  viz.,  48  oz.  The  oedema  has  quite  disappeared  from  the 
limbs;  bowels  costive.  Ordered  two  Colocynth  and  Hyoscyamus pHls.  Jan.Vlth. — 
On  the  10th  he  was  much  in  the  same  state ;  no  sweating ;  appetite  bad ;  great  thirst, 
for  which  he  was  ordered  milk  and  lime  water.  Being  no  better  last  night,  he  was 
ordered  the  warm  bath,  followed  by  fifteen  grains  of  Dover's  powder.  To-day  he  states 
that  he  felt  more  weak  after  the  bath,  had  slight  perspiration,  which  was  confined  to 
the  face  and  legs.  To  have  twelve  grains  of  Dover's  powder,  uith  six,  of  James'  powder 
at  bed  time  Jan.  lAth. — The  diaphoretic  has  been  continued  since  last  report,  but 
no  sweating  has  been  produced;  passe<l,  during  the  last  twenty-four  hours,  5S  oz.  of 
urine:  bowels  are  rather  costive.  IJ  BUart.  Potass.  3iss;  Pulv.  Gambog.  gr.  W.  ^. 
To  be  taken  immediately,  and  repeated  in  six  hours  if  necessary.  Jan.  llth. — ^The 
bowels  were  well  opened  on  the  15  th,  the  stools  being  of  thin  consistence  after  the 
second  powder,  which  afibrded  considerable  relief;  but  they  have  not  been  opened 
since ;  appetite  still  bad,  but  less  thirst.     The  urine  to-day  is  of  nearly  natural  colour  ; 

*  Reported  by  Mr.  "Wm.  Calder,  Clinical  Clerk. 


758  DISEASES   OF   THE   GENITO-URINARY   SYSTEM. 

sp.  gr.  1022  ;  quite  as  coagulable  as  before;  the  quantity  passed  in  the  last  twenty- 
four  hours  is  58  oz.,  with  a  shght  sediment  of  urate  of  ammonia  Ordered  a  scrtiple 
of  Bitartrate  of  Potass,  three  times  a  day.  Jan.  \Wi. — Thequantity  of  urine  passed 
yesterday  was  60  oz.,  but  to-day  it  has  diminished  to  36 ;  he  complained  of  much 
thirst,  and  was  ordered  cream  of  tartar  water  as  a  drink;  he  did  not  sleep  well 
during  the  night,  and  is  somewhat  incoherent  in  his  remarks  to-day,  though  quite 
sensible  when  promptly  spoken  to ;  bowels  still  costive ;  repeat  the  powder  of  Bitar- 
trate of  Potass,  and  Gamboge ;  to  have  ten  grains  of  Dover^s  j>owder  after  the  bowels 
have  been  loell  opened.  Jan.  20th. — Was  a  good  deal  better  last  night,  felt  himself 
Avarm  and  comfortable  after  the  Dover's  powder,  but  he  did  not  sweat ;  he  has  had 
three  loose  stools  since ;  the  quantity  of  urine  is  now  50  oz. ;  sp.  gr.  1020 ;  still 
highly  coagulable;  his  thirst  is  considerably  diminished.  Jan.  22d. — The  urine 
examined  under  the  microscope  yesterday  exhibited  a  few  pale  casts  of  the  urinary 
tubes,  which  are  also  present  to-day ;  during  the  last  two  days  he  has  passed  about 
58  oz.  of  urine  in  the  twenty -four  hours,  and  he  states  that  altogether  he  feels  much 
better.  March  5th. — Since  last  report  has  gradually  improved  in  health.  To-day, 
wishes  to  go  out,  as  he  now  has  no  complaint  but  weakness;  voids  from  50  to  60 oz. 
of  urine  daily.  It  is  of  rather  pale  colour ;  sp.gr.  1020;  about  one-sixth  coagulable. 
A  few  sibilant  rales  are  heard  occasionally  over  the  cliest,  but  otherwise  the  systems 
are  healthy.     Is  dismissed  accordingly  much  relieved. 

Commentary. — In  tins  case  tlie  diaphoretic  plan  of  treatment  was 
tried  at  first,  but  with  inconsiderable  success.  It  is  true  the  oedema 
disappeared  from  the  legs,  a  result  probably  as  mucli  owing  to  the 
recumbent  position  and  general  comforts  of  the  hospital,  as  to  the 
medicines  employed.  When  the  bitartrate  of  potash  was  administeied, 
afterwards  combined  with  purgatives,  the  effects  were  more  lapid,  and 
the  anasarca  soon  disappearad.  The  coagulability  of  the  urine,  however, 
still  continued,  though  in  a  diminished  degree,  when  he  left  the  house. 


Case  CLXXIII.* — Third  Attack  of  Albuminuria  icith  Anasarca — Dismissed  relieved. 

History. — James  Smith,  set.  38 — admitted  25th  November,  1852.  States  that  he 
enjoyed  good  health  till  about  three  and  a  half  years  ago,  when,  after  exposure  to  a 
di-aught  of  cold  air,  his  ankles  began  to  swell,  which  swelling  in  four  days  extended 
up  to  the  thighs,  and  induced  him  to  apply  for  admission  to  the  hospital,  where  he 
remained  three  weeks,  and  was  dismissed  cured.  The  same  symptoms  reappeared 
in  twelve  months,  and  he  was  again  admitted  a  patient,  remained  for  a  few  weeks, 
and  went  out,  feeling  quite  well.  He  continued  in  excellent  health  till  four  months 
ago,  when  he  began  to  complain  of  shortness  of  breath  and  palpitation  when  at 
work;  the  palpitation  was  reduced  by  cupping,  but  the  dyspnosa  continued  upon 
taking  exertion.  Four  weeks  ago  the  swelling  at  the  ankles  returned,  and  he  was 
again  admitted  into  the  hospital,  ward  6,  where  he  has  been  under  treatment  till 
tlie  date  of  his  admission  into  the  clinical  ward.  His  habits  were  rather  intempeiate 
previous  to  his  first  attack,  but  since  then  he  has  never  indulged  in  any  kind  of 
intoxicating  liquors. 

Symptoms  on  Admission. — On  admission  there  is  some  oedema  of  the  limbs  and 
trunk,  which  pit  slightly  on  pressure;  the  skin  generally  is  very  dry,  but  of  the  usual 
temperature.     The  quantity  of  urine  voided  in  the  twenty-four  hours  is  66  oz. ;  it  is 

*  Reported  by  Mr.  Alexander  T.  Macarthur,  Clinical  Clerk. 


bright's  disease.  759 

of  a  pale  stra'w  colour,  slightly  turbid,  and  highly  coagulable ;  sp.  gr.  1014.  depositing 
a  slight  sediment  like  thin  whey.  Viewed  under  the  microscope,  it  presents  nume- 
rous fragments  of  desquamative  casts;  some  very  long,  some  containing  nuclei  and 
granular  cells  more  or  less  fatty,  and  some  tilled  with  minute  fatty  molecules.  There 
are  numerous  pus  cells ;  some  epithelium  cells,  isolated  and  in  groups,  from  the  ureter 
or  bladder.  There  are  numerous  columnar  crystals  of  uric  acid,  and  some  mineral 
salts  aggregated  in  masses  of  minute  angular  crystals.  Tongue  clean  and  moist ; 
appetite  good;  bowels  regular;  pulse  68,  of  moderate  strength.  There  is  slight 
irregularity  of  the  heart's  action :  first  sound  prolonged,  and  accompanied  with  a  soft 
blowing  murmur  heard  loudest  at  the  apex.     Other  functions  normal. 

Progress  of  the  Case. — He  was  dismissed  at  his  own  desire  on  the  29/7t  of 
November,  but  returned  with  all  his  former  symptoms  aggravated  on  the  '27th  of 
December.  He  states  that  after  leaving  the  hospital  he  returned  to  his  usual  em- 
ployment for  about  a  week,  when  he  caught  cold,  and  he  has  been  confined  to  the 
house  ever  since.  The  cough  became  very  severe,  with  dyspnoea  and  great  debility 
after  passing  his  urine.  On  examination,  the  quantity  of  urine  excreted  is  50  oz. ; 
it  is  passed  without  pain ;  is  of  pale  colour  resembling  whey,  is  slightly  turbid,  and 
deposits,  on  standing,  a  small  quantity  of  white  sediment,  whicli,  on  examination  by 
the  microscope,  presents  numerous  casts,  as  before  noticed,  but  no  crystals ;  sp.  gr. 
1013,  highly  coagulable.  On  auscultation,  sibilant  rales  are  heard  all  over  the  chest, 
expiration  prolonged,  but  no  dulness  on  percussion.  He  has  a  frequent  cough,  with 
frothy  mucous  expectoration.  ^.  Sol.  Antim.  3  ii ;  J/«t  Camph.  3  iv ;  Misce. 
Sumat  3  ss  quarto,  quaque  hord.  Descendaf  in  baineum  calidura  secunda  qudque  node. 
Dec.  29{h. — Still  rather  feverish,  complains  of  intense  thirst,  constant  craviiag  for 
drink,  which  is  unrelieved  by  water.  To  have  as  drink  5  ^ij  of  milk  mixed  with  §  vj. 
of  lime  water.  January  Yd. — Cough  much  the  same  as  on  admission ;  oedema  of  legs 
much  diminished,  but  the  skin  is  still  dry,  diaphoresis  never  having  been  induced. 
About  90  oz.  of  urine  are  passed  in  the  twenty-four  hours,  still  very  coagulable  with 
heat  and  nitric  acid;  slight  deposit,  still  containing  granular  casts  of  the  urinary 
tubes.  Jan  Qth. — Cough  much  relieved ;  pulse  68,  of  good  strength  ;  swelling  of  the 
legs  now  quite  gone;  urine  passed  in  large  quantity;  still  complains  of  great  thirst. 
Continueniur  medicament.  Jan.  13</i. — Voided  130  oz  of  urine  during  the  last 
twenty-four  hours ;  has  still  considerable  thirst :  pulse  80,  of  good  strength.  Ex- 
presses himself  as  feeling  quite  well.  On  standing  for  twenty-four  hours  the  urine 
deposits  a  slight  sediment,  in  which  casts  of  the  urinary  tubes  are  still  visible,  crowded 
with  fatty  granules.  Jan.  nth  — Feels  better  than  he  has  done  for  several  years,  and 
wishes  to  return  home.     He  is  accordingly  ordered  to  be  dismissed. 

Commentary. — In  this  case  it  was  evident  that  improvement  had 
commenced  on  his  entering  the  clinical  ward,  the  nrine  was  passinor 
copiouslv,  and  diuretics  were  not  directly  indicated.  Under  these 
circumstances  the  diaphoretic  plan  of  treatment  was  persevered  in,  and 
although  not  with  the  result  of  entirely  freein<;  his  urine  of  all  trace  of 
albumen,  yet  with  such  good  effect,  that  he  insisted  on  leavini^the  house, 
which  he  did  nearly  well. 

In  the  last  three  cases  it  will  be  observed  that  great  relief  was  expe- 
rienced, although  perfect  recovery  was  not  established.  The  dropsical 
symptoms  were  removed,  whilst  the  albuminuria  remained,  a  condition 
which  constitutes  the  majority  of  those  cases  which  enter  into  the  hospital, 
and  are  dismissed  as  '•  relieved." 


760  DISEASES   OF   THE   GEXITO-URINARY   SYSTEM. 


Case  CLXXIV* — Albuminuria,  with  general  Anasarca,  terminating  fatally — Waxy 
Kidneys,  Spleen  and  Liver,  iviih  Extensive  Beposition  of  Tubercle. 

History.— Sarah  Wilson,  ret.  7— admitted  November  11th,  1853.  Three  years 
ago  slie  suffered  from  scarlatina,  and  has  ever  since  been  a  weakly  child,  with  a 
capricious  appetite.  In  the  course  of  last  summer  oedema  of  the  feet  and  legs  was 
first  observed,  together  with  diarrhoea,  which  has  continued  more  or  less  ever  since. 

Symptoms  on  Admission. — On  admission,  her  countenance  is  puffy  and  pallid,  and 
the  whole  surface  blanched.  Her  feet  and  legs  are  oedematous,  pitting  on  pressure. 
The  urine  is  of  a  pale  colour ;  sp.  gr.  1006.  On  applying  heat,  and  adding  nitric  acid, 
a  coagulum  is  thrown  down,  which  occupies  a  space  in  the  test-tube  equal  to  that  of 
half  the  quantity  of  urine.  She  has  never  felt  any  pain  in  the  lumbar  region. 
Tongue  moist,  and  covered  by  a  slight  fur;  no  thirst;  appetite  good.  The  abdomen 
is  greatly  distended,  and  there  is  distinct  fluctuation.  Tulse  86,  weak  and  compres- 
sible ;  cardiac  sounds  normal.  She  has  no  headache,  and  sleeps  well  at  night.  ]J 
Acei.  Potass.  3i;  jEili.  Nit.  3ij;  Syrupi  3i;  Aqiioi  §  v.  M.  A  tablespoonful  to  he 
taken  three  times  a-day. 

Progress  of  the  Case. — Xovember  l~t  th. — Diarrhoea  continues,  and  she  lies  in  a 
very  weak  state.  B  J^ist  Creice  §  iv.  An  ounce  to  be  taken  three  or  four  times  a-day. 
To  have  1  oz.  of  Gin  daily.  Nov.  25th. — Urine  passed  in  great  quantity;  sp.  gr.  1002  ; 
not  so  coagulable.  The  diarrhoea,  which  abated  for  a  few  daj-s  after  last  report,  has 
again  returned.  Ordered  an  astririgent  mixture.  Nov.  SOth. — The  puffiness  of  the 
face,  which,  on  some  days  after  her  admission,  abated  considerably,  is  now  as  bad  as 
ever.  Her  urine  has  been  passed  involuntarily  for  the  last  three  days ;  the  diarrhoea 
is  less  severe.  Dec.  lOlh. — Since  last  report,  the  oedema  has  wholly  disappeared. 
The  foeces  and  urine  are  both  passed  involuntarily.  The  constant  dribbling  of  the 
latter  over  the  labia  and  nates  has  produced  excoriation.  She  takes  her  food  pretty 
well,  but  vomits  it  occasionally.  Her  pulse  is  very  feeble,  and  her  strength  much 
impaired.  She  is  at  present  taking  2  oz.  of  gin,  and  an  equal  quantity  of  wine 
daily.  For  the  last  five  or  six  days  she  has  been  verj^  drowsy,  sleeping  almost  con- 
stantly, although  she  can  easily  be  aroused,  and  answers  questions  readily.  Dec.  I3th. 
— The  oedema  has  not  returned,  but  the  drowsiness  gradually  increased  until  this 
morning,  when  slie  expired. 

Sectio  Cadaveris. — Forty  hours  after  death. 

Body  greatly  emaciated ;  slight  oedema  of  feet. 

Thorax. — The  lungs,  which  looked  quite  healthy,  presented  to  the  touch  some 
indurated  points ;  these,  on  being  cut  into,  were  found  to  consist  of  clusters  of  minute 
grey  granulations,  generally  about  the  size  of  small  marbles.  At  the  apex  of  the 
right  lung  was  a  small  cretaceous  concretion.  The  heart  weighed  3  oz.,  and  was 
quite  healthy. 

Abdomen. — There  were  adhesions  between  the  upper  surface  of  the  liver  and  the 
diaphragm.  The  liver  weighed  3  lb.  16  oz.  There  was  a  little  hepatic  congestion, 
but  the  intervening  tissue  was  pale ;  the  whole  presented  the  usual  appearance  of 
the  waxy  degeneration.  The  spleen  weighed  2^  ounces,  specific  gravity  1054.  It 
felt  firm,  and  presented  on  section  a  waxy  appearance.  Throughout  its  substance 
were  numerous  enlarged  semi-translucent,  grey  malpighian  bodies,  closely  aggregated 
together.  Their  average  diameter  was  about  the  16th  of  an  inch.  The  kidneys  were 
enlarged,  weighing  each  6f  oz.     On  stripping  off  the  capsule  they  presented  a 

*  Reported  by  Mr.  Peter  W.  "Wallace,  Clinical  Clerk. 


bright's  disease.  761 

mottled  appearance  from  tlie  presence  of  irregular  vascularity,  contrasting  with  tlie 
pale  cortical  substance.  On  section  they  presented  a  well-marked  waxy  appearance  ; 
the  cortical  portion  was  of  a  pale  yellowish  colour;  the  stria?  generally  absent  or 
indistinct.  At  some  places  there  was  a  number  of  minute  opaque  yellowish  spots. 
On  opening  the  intestines,  tubercular  ulcers  were  found ;  they  occurred  in  the  lower 
third  of  the  small  intestine,  presented  the  usual  characters,  and  occupied  the  whole 
circumference  of  the  gut.  The  mesenteric  glands  were  much  enlarged,  and  were 
infiltrated  with  tubercle. 

Microscopic  Examination.— The  liver  was  found  to  contain  much  fatty  matter, 
both  free  and  contained  in  the  hepatic  cells.  But  the  majority  of  the  cells  were  pale 
and  very  indistinct  (see  Fig.  295,  p.  214).  Thin  sections  of  the  cortical  substance  of 
the  kidneys  presented  a  very  transparent  appearance,  particularly  the  malpighian 
bodies.  At  some  places,  there  were  collections  of  fatty  granules,  but  this  did  not 
occur  very  frequently,  and  only  in  isolated  points.  The  enlarged  malpighian  bodies 
in  the  spleen  contained  a  translucent  matter,  closely  resembling  colloid,  and  which 
presented  the  blue  reaction  of  cellulose,  on  the  apphcation  of  iodine  and  sulphuric 
acid. 

Commentary. — This  case  presented  all  tlie  symptoms  of  Bright's 
disease,  in  a  young-  girl  who  had  been  in  a  state  of  ill  health  for  three 
years,  in  consequence  of  an  attack  of  scarlatina.  On  dissection  alter 
death,  the  kidneys,  liver,  and  spleen  were  found  to  have  undergone  that 
chronic  condition  now  known  as  waxy,  and  which  is  very  commonly 
associated,  as  in  this  case,  with  tuhei'cle.  The  nature  of  this  morbid 
alteration  I  shall  speak  of  subsequently. 

Case  CLKXX .*— Albuminuria  coming  on  during  the  progress  of  PMMsis  Fulmonalis, 
terminating  fatally —Extensive  Deposition  of  Tubercle — Waxtj  Kidney,  Liver,  and 
Spleen. 

History.— William  Sibbald,  set.  31,  clerk— admitted  September  7th,  18.52.  States, 
that  six  months  ago,  after  exposure  to  cold  and  wet,  he  was  seized  with  rigors,  pain 
in  the  .shoulders,  sore  throat,  and  hard  dry  cough.  Has  not  enjoyed  good  health  for 
many  years  past,  having  been  very  liable  to  catch  cold  on  the  slightest  exposure, 
followed  by  slight  cough,  which  was  sometimes  attended  with  expectoration,  and 
pain  in  the  side.  During  the  last  six  months,  the  above  symptoms  have  become 
much  aggravated,  and,  for  some  time  back,  he  has  suffered  from  dyspnoea,  occasional 
night  sweats,  frequent  nausea,  and  loss  of  appetite. 

Symptoms  on  Admission. — On  admission,  there  is  slight  flattening  of  the  chest 
beneath  botli  clavicles.  On  percussion,  there  is  comparative  dulness  below  the  right 
clavicle,  together  with  a  cracked-pot  sound;  chest  elsewhere  appears  resonant. 
Below  the  right  clavicle,  very  tine  but  distinct  moist  rales  are  heard,  chiefly  with 
inspiration ;  there  is  also  loud-pealing  vocal  resonance,  of  a  somewhat  metallic 
character.  Towards  the  base  of  the  lung,  on  the  same  side,  the  respiratory  mur- 
murs are  slightly  exaggerated,  but  otherwise  normal.  Below  the  left  clavicle  also, 
there  are  fine  moist  rales,  but  less  marked  than  on  the  right:  the  breathing  is  harsh, 
and  the  expiration  prolonged,  though  not  to  the  same  extent  as  on  the  right.  Vocal 
resonance  slightly  increased.  There  is  also  considerable  muco-purulent  expectora- 
tion,   but   no   appearance   of  blood.     Pulse  weak,   90.     Tongue  furred;    appetite 

*  Reported  by  Mr.  AVm.  M.  Calder,  Clinical  Clerk. 


762  DISEASES   OF   THE   GEXITO-URIXARY    SYSTEM. 

impaired;  frequent  nausea ;  bowels  rather  costive.  Uriue  normal,  but  he  has  fre- 
quent calls  to  micturition,  obliging  him  to  rise  frequently  during  the  night.  Other 
functions  appear  normal  To  me  the  opiate  Undus,  when  the  cough  is  troublesome.  To 
have  a  dessertspoonful  of  cod-liver  oil  three  times  aday,  and  full  diet.  §  i^'  V  '^i^e 
daily. 

Progress  of  the  Case. —  October  \st. — He  has  been  taking  the  linctu.s.  and  also 
the  oil,  which,  however,  he  has  been  occiisionally  obliged  to  vomit,  owing  to  the 
nausea  and  disagreeable  eructations  which  it  produces.  With  the  exception  of  some 
increa.se  of  harshness  posteriorly,  the  respiratory  sounds  are  unchanged.  Oct.  -list. — 
His  cough  has  been  more  troublesome  for  some  days  back,  for  which  he  had  a  squill 
mixture  and  a  blLster  applied  to  the  chest,  on  the  nth.  His  appetite  is  bad,  and  the 
bowels  costive.  Omit  the  mixture.  Oct.  29///. — His  appetite  is  now  improved ;  he 
complains  of  some  pain  in  the  throat ;  bowels  rather  costive :  takes  the  cod-liver  oil 
without  difficulty.  December  \&th.  Since  last  report  has  been  alternately  better  and 
worse,  in  proportion  to  the  quantity  of  food  and  cod-liver  oil  his  stomach  has  been 
able  to  retain.  The  disease,  however,  has  steadily  made  progress.  The  report  to- 
day is — Cough  still  continues  hard  and  frequent.  Loud  gurgling  rales  are  heard 
under  both  clavicles,  but  dry  throughout  the  rest  of  the  chest,  with  prolonged  expi- 
ration. Yocal  resonance,  and  dulness  on  percu.ssion  same  as  before.  The  appetite 
is  very  bad;  bowels  have  been  rather  loose  durhig  the  last  tiiree  days.  Urine,  of 
specific  gravity  1012,  of  a  dark  amber  colour,  slightly  albuminous.  5  Tinct. 
Colomb.  ?  iss ;  Liquoris  Potass.  %  ss ;  Syrupi  Auraniii  ?  j :  Infus.  Gentiana  Comp. 
§  ix.  M.  An  ounce  to  be  taken  three  times  a-day.  January  \st,  1853. — Continues 
much  in  the  same  state ;  sleeps  ill  at  night,  and  is  frequently  troubled  with  cold  per- 
spiration. Cough  is  very  severe,  with  copious  muco-purulent  expectoration  of  a  num- 
mular character.  Micturition  frequent ;  urine  strongly  coagulable  by  heat  and  nitric 
acid.  (Edema  of  feet  and  legs,  with  puflBness  of  the  face.  Jan.  I2th. — Feels  very 
weak,  and  seldom  leaves  his  bed ;  loud  gurgling  is  heard  beneath  both  clavicles ;  the 
voice  is  very  husky,  and  there  is  some  ulceration  at  the  back  of  the  pharynx.  Appe- 
tite still  very  bad,  and  bowels  costive.  Takes  a  table-spoonful  of  cod-liver  oil  three 
times  a-dav.  To  have  six  ounces  ofioine  daily,  arid  a  Morphia  draught  at  night.  Jan. 
20th. — Is  getting  gradually  weaker  and  more  emaciated.  Pulse  114,  of  moderate 
strength.  He  has  no  pain  in  the  loins,  but  micturition  is  frequent ;  urine  of  a  dark 
amber  colour,  specific  gravity  1012,  very  coagulable  on  the  application  of  heat  and 
nitric  acid.  Jan.  2Gth. — After  last  report  he  continued  gradually  getting  weaker 
and  more  emaciated.  He  could  take  no  food,  except  a  little  chicken  soup,  and  died 
to-day  at  2  p.ir. 

Sectio  Cadaveris. — Forty-six  hours  after  death. 

Body  emaciated  in  the  extreme ;  very  slight  dropsy  of  feet. 

Thor.A-X. — Both  lungs  very  firmly  adherent  throughout,  with  thickening  of  pleurae 
to  i  inch  at  upper  and  back  parts.  On  incising  the  lungs  they  were  found,  on  both 
sides,  to  present,  in  their  upper  portions,  cavities  containing  a  little  pus,  with  thick 
flocculent  membranes.  These  cavities  were  nowhere  larger  than  |  inch  diameter, 
and  invariably  surrounded  by  much  indurated  and  atrophied  tissue,  which,  in  the 
upper  lobes,  almost  entirely  occupied  the  place  of  normal  lung.  In  the  lower  and 
middle  parts  of  the  lung,  there  were  many  miliary  tubercles  quite  semi-transparent, 
but  of  nearly  cartilaginous  hardness.  No  calcareous  masses  were  observed.  Ill 
the  upper  lobe  of  the  left  lung  was  a  cavity  near  the  surface,  about  an  inch  in 
diameter,  filled  with  air,  and  lined  by  a  smooth  membrane.  Several  others,  smaller, 
but  of  the  same  character,  were  discovered  in  other  parts  of  the  lung.  In  the  thick- 
ened pleura?  there  was  found,  at  several  points,  an  atheromatous  debris,  enclosed 


bkight's  disease.  763 

between  the  layers,  having  an  opaque  yellowish  colour,  and  consisting  of  minute 
fatty  granules.  Brondiial  glands  were  large  and  dark-coloured,  and  contained  some 
miliary  tubercles. 

Abdomen'. — Liver  rather  large,  weighed  5j  lbs.,  very  firm  and  dense,  presented 
the  well-marked  "waxy  character,"  but  without  pallor;  hepatic  veins  well  con- 
gested. At  one  of  the  thin  edges  the  organ  was  deformed  by  the  turning  inwards 
of  the  edge  at  an  acute  angle.  Spleen  very  firm  and  waxy  in  character ;  the  mal- 
pighian  bodies  large  and  solid,  but  not  easily  distinguislied  from  the  pulp.  Kidneys 
al.so  very  firm  and  dense,  with  partial  atrophy  of  the  cortical  substance,  presenting  a 
slight  degree  of  the  waxy  degeneration;  surface  irregular  and  dimpled;  cortical 
substance,  however,  exhibited  its  natural  vascularity  at  most  points;  malpighian 
tufts  not  well  injected;  no  granulations.  Intestinal  canal  presented  thicklj-  scat- 
tered tubercles,  and  tubercular  ulcers  throughout  ileum,  and  less  numerous  ulcers  in 
colon.  The  ulcers  were  not  more  numerous  near  the  ileo-colic  valve  than  for  some 
feet  above  it.  The  vermiform  appendix  was  impacted  with  foecal  matter,  and  pre- 
sented a  very  extensive  ulceration  of  its  mucous  membrane,  leaving  only  about  half 
an  inch  at  the  npper  end  quite  intact.  Numerous  mesenteric  glands  were  converted 
into  calcareous  masses  from  tlie  size  of  a  pea  to  that  of  a  bean ;  others  were  large 
and  pulpy,  and  contained  tubercular  matter.  The  pancreas  was  rather  hard,  but 
otherwise  normal. 

Commentari/. — The  albmninuria  and  waxv  deo-eneration  of  the  kid- 
neys were  observed,  in  this  case,  to  come  on  in  the  ward,  as  a  seqiiehi  of 
phthisis  pidinonalis.  Drs.  Christison  and  Peacock  have  pointed  out  how 
frequently  Brioht's  disease  is  a  complication  of  phthisis,  and  I  have  not 
only  confirmed  that  observation,  but  observed  that  this  is,  in  most  cases, 
connected  with  the  waxy  degeneration  of  the  renal  organs.  The  pre- 
sent was  one  of  these  cases  of  phthisis,  in  whicli  derangement  of  the 
alimentaiy  canal  prevented  all  possibility  of  nourishment.  The  waxy 
transformation  of  the  kidneys,  liver,  and  spleen,  tliough  it  had  not 
advanced  so  far  as  it  did  in  the  last  case,  was  sufficient,  when  added  to 
the  more  extensive  tubercular  disease  that  existed,  to  prove  fatal. 


Case  CLXXVI.* — Alhuminuria,  v-itlt  Phthisis  Pulmonalis,  terminating  fatalhj — 
Extensive  Deposition  of  Tubercle  and  Colliquative  Diarrhoea — Atrophied  Fatty 
Kidney —  Ulcerated  Intestines. 

History. — John  Montgomery,  a?t.  60,  weaver — admitted  November  lOtli,  18.52. 
States  that  for  several  years  past  he  has  been  exposed  to  great  privations,  and  that 
he  has  been  frequentlj^  troubled  with  bowel  complaint  during  that  time.  The 
attacks  have  sometimes  been  severe,  and  of  long  duration,  but  have  generally  lasted 
for  a  few  days  only.  About  a  month  before  admission,  the  diarrhoea  became  much 
aggravated,  there  having  been  sometimes  as  many  as  twelve  stools  in  twenty-four 
hours.  This  has  continued  more  or  less  since  that  time,  reducing  him  greatly  in 
flesh  and  strength.  As  far  as  he  has  observed,  he  has  never  passed  blood  by  stooL 
He  has  also  had  a  short  dry  cough,  but  only  for  a  few  weeks  past,  and  unaccom- 
panied with  expectoration  or  dyspnoea.  He  was  brought  into  the  hospital  in  a  state 
of  great  weakness  and  exhaustion,  having  flillen  down  in  the  street,  supposed  to  be 
in  a  state  of  intoxication.      He  states  tliat  he  has  not  taken  any  spirits  for  some 

*  Reported  by  Mr.  "W.  M.  Calder,  Clinical  Clerk. 


764  DISEASES   OF   THE    GEXITO-URINARY   SYSTEil. 

days  past,  although  he  has  been  much  addicted  to  intemperance  during  the  greater 
part  of  his  life. 

Symptoms  on*  Admission. — On  admission,  the  tongue  is  very  dry,  but  not  furred; 
but  there  are  some  sordes  on  the  teeth  and  gums.  He  experiences  difficulty  in 
deglutition,  as  if  there  was  some  obstruction  about  upper  part  of  sternum ;  appetite 
bad;  troublesome  thirst;  no  sickness  or  vomiting;  no  pain  in  epigastrium,  but 
frequent  griping  pains  in  abdomen.  Bowels  are  very  loose;  much  straining  and 
great  tenesmus  wlien  at  stool ;  evacuations  of  an  almost  watery  consistence  and 
reddish-brown  colour.  Tliey  present  no  appearance  of  blood,  but  contain  a  few 
shreds  of  mucus.  Occasionally  he  passes  nothing  but  a  small  quantity  of  frothy 
slime ;  no  haemorrhoids.  On  physical  examination  of  the  abdomen,  the  parietes  are 
tense  and  retracted.  The  liver  is  slightly  enlarged,  the  dulness  measuring  five 
inches  from  above  downwards.  Chest  appeai-s  contracted,  and  does  not  expand 
freely.  There  is  no  comparative  dulness  on  percu.ssion.  The  respiration  is  feeble, 
and  the  expectoration  prolonged;  under  tiie  right  clavicle  it  is  of  a  somewhat 
tubular  character.  Vocal  resonance  is  also  increased  over  tl>e  same  part  At  the 
lower  part  of  right  side  anteriorly  there  is  a  fine  friction  sound.  Sputum  in  very 
small  quantity;  muco-puruleut,  untinged  with  blood.  Pulse  124,  small  and  feeble; 
heart  sounds  normal;  urine  sp.  gr.  1012,  becomes  slightly  clouded  with  heat  and 
nitric  acid,  but  no  distinct  coagulum  is  formed;  other  functions  normal.  5  ^c^- 
Mur.  Morph.  3  ij ;  Tinct.  Catechu  3  vj ;  Mist.  Crttoe,  5^-j.M.  Sumat  ^j  tertia  qudque 
hord.     To  have  6  oz.  of  wine  and  steak  diet. 

Progress  of  the  Case. — yovember  20lh. — TTandered  a  good  deal  during  the 
night ;  is  exceedingly  weak  to-day,  but  tlie  diarrhoea  is  less  severe.  Nov.  22d. — 
Complains  more  of  cough  and  pain  in  right  side,  striking  across  the  chest  to  the 
left;  no  dulness  on  percussion;  still  friction  on  right  side  with  fine  moist  rales; 
marked  increase  of  vocal  resonance;  urine  diminished  in  quantity;  of  natural 
colour,  with  slight  flocculent  precipitate  on  the  application  of  heat  and  nitric  acid. 
Diarrhoea  stopped;  pulse  112,  small  and  weak.  Xov.  IWi. — Was  much  weaker 
yesterday,  and  evidently  sinking ;  too  weak  for  examination  of  the  chest ;  bowels 
were  once  opened;  no  urine  voided  since  last  report.  Died  this  morning  at  four 
o'clock,  comatose. 

Sectio   Cadaveris. — Fifty-six  hours  after  death. 

Body  somewliat  emaciated ;  very  little  subcutaneous  fat ;  muscles  well  nourished. 

Thorax. — Heart  normal;  adhesions  of  both  pleuras  over  limited  space  of  upper 
lobes.  Both  lungs  contained  many  scattered  groups  of  tubercle,  chiefly  miliary ; 
some  few  of  them  softened,  and  with  small  dry  excavations  at  the  apices ;  the 
pulmonary  tissue  around  the  tubercles  mostly  indurated  and  dark  coloured  from 
carbonaceous  infiltration ;  the  bronchial  glands  dark  and  enlarged. 

Abdomex. — Stomach  and  jejunum  and  upper  two-thirds  of  ileum  normal.  In 
lower  third  several  scattered  ulcers,  not  exceeding  eight  or  twelve  in  number,  from 
one-quarter  to  three-quarters  of  an  inch  in  diameter;  some  of  them  slightly  con- 
gested at  edges;  their  characters  in  all  respects  those  of  tubercular  ulcers.  Colon 
contracted  at  lower  part.  In  the  ascending  portion,  there  are  four  or  five  small 
tubercular  ulcers ;  the  largest  half  an  inch  in  diameter,  edges  pale  and  slate-coloured, 
the  floor  somewhat  indurated.  Spleen,  pale,  peritoneal  capsule  thickened,  the  organ 
rather  small,  no  distinct  morbid  appearances.  Liver  slightly  enlarged,  presenting 
very  distinctly,  and  in  a  considerable  degree,  the  fatty  degeneration.  Kidneys 
unusuallj'  small  (dimension  of  right  three  and  a  half  inches  long,  one  and  three- 
quarter  inches  broad,  three-quarters  of  an  inch  thick ;  left  kidney  of  nearly  the 
same  size,  weiglit  not  ascertained) ;   capsule  easily  stripped  off;  surface   slightly 


bright's  disease.  765 

uneven,  not  distinctl}'  tuberculated ;  venous  vascularity  of  surflxce  considerable  but 
irregular;  on  section,  cortical  substance  much  diminished  (average  three-eighths 
of  an  inch  in  diameter  from  base  of  pyramids);  limiting  line  of  pyramids  tolerably 
distinct;  faint  appearance  of  opaque  granulations.  On  examination  with  a  lens, 
many  very  minute  cysts  were  discovered  in  cortical  substance ;  most  of  them 
required  a  power  of  half  an  inch  focal  distance  to  bring  them  into  view.  A  similar 
power,  or  even  the  naked  eye,  distinguished  easily  a  number  of  opaque  light  gam- 
boge yellow  points  in  the  cortical  substance  ;  the  largest  was  about  one-tiftieth  of  an 
inch  in  diameter,  accurately  limited,  and  3'ielding,  on  being  punctured,  a  fluid  of  the 
same  colour.  In  the  cortical  substances  there  were  also  some  minute  hemorrhagic 
petecbiie,  having  the  usual  appearance  of  extravasation. 

Microscopic  Examination. — With  high  magnifying  powers,  the  tubuli  uriniferl 
were  seen  in  some  places  to  be  of  normal  character,  with  the  exception  of  a  very 
few  granules  in  the  epithelium ;  on  the  contrary,  in  others,  the  tubes  were  crowded 
with  fatty  granules.  The  epithelium  generally  was  normal  in  form  and  appearance 
in  the  tubes  which  had  fewest  granules.  In  many  places  the  cortical  substance  of 
the  kidney  was  studded  with  minute  cysts,  constituting  the  third  form  which  they 
present  (see  p.  747).  In  the  fluid  squeezed  from  the  yellow  points,  in  the  cortical 
substance,  there  was  an  immense  number  of  fatty  granules,  partly  loose,  partlj^ 
agglomerated  into  amorphous  collections,  partly  composing  distinct  rounded  granular 
masses  up  to  the  one-ninetieth  of  an  inch  in  diameter,  and  partly  contained  in  cells 
of  a  very  fine  delicate  transparent  character,  presenting  much  of  the  appearance 
of  a  tesselated  epithelium.  The  cells  of  this  epithelium  were  more  transparent,  and 
generally  one-third  smaller  than  those  usuall}*  found  in  the  renal  tubules. 

Commentary. — In  tliis,  as  in  tlie  two  previous  cases,  the  renal 
disease  was  associated  with  phthisis,  but  was  move  chi'onio,  fnrtiier 
advanced,  and  exhibited  the  uUiinate  effects  of  the  fatty  rather  than  of 
the  wa.KV  degeneration.  The  report  states  that  the  nrine  was  not 
highly  coagah^ble,  presenting  only  a  slight  cloud  on  the  addition  of 
heat  and  nitric  acid.  The  tiuids  of  the  body,  however,  seemed  to  Lave 
been  discharged  to  a  great  extent  by  means  of  stool.  Before  death,  the 
urine  was  suppressed,  causing  coma. 

In  the  three  fatal  cases  now  given,  wo  have  seen — 1st,  Extreme  waxy 
degeneration  of  the  kidneys  in  a  child.  2d,  Incipient  waxy  degeneration 
coming  on  in  the  ward  in  an  adult.  3d,  The  last  stage  of  the  fatty  de- 
generation, with  atrojihy.  It  would  be  easy  to  multiply  cases,  where,  on 
dissection,  all  kinds  of  intermediate  conditions  of  the  kidneys  had  been 
observed  ;  but  those  now  recorded,  together  with  the  six  which  recovered 
or  were  relieved,  present  the  leading  characters  illustrative  of  the  patho- 
logy, diagnosis,  and  treatment  of  Bright's  disease.  A  few  words  on  each 
of  these  topics  may  now  be  added  with  propriety. 


Patholoyy  of  Br'igMs  Disease. 


se 
em 


Many  names  have  been  proposed  by  various  pathologists  for  the  diseas 
called  after  Dr.  Bright.  tJp  to  the  present  time,  however,  none  of  ther 
has  been  sufficiently  good  to  comprehend  all  those  lesions  which  occasion 
renal  dropsy,  with  persistent  albuminuria.  Hence  we  still  retain  the  de- 
signation it  has  so  appropriately  borne,  to  express  a  disorder  characterized 


766  DISEASES   OF   THE    GEXITO-URINARY   SYSTEM. 

by  more  or  less  dropsy,  caused  b}'  obstruction  to  the  renal  functions,  and 
accompanied  by  the  presence  of  albumen  in  the  urine. 

The  nature  of  the  obstruction  to  the  renal  function  differs  under  a  great 
variety  of  circumstances,  but  such  as  occasion  dropsy,  with  persistent 
albuminuria,  it  appears  to  nie  may  now  be  classified  under  three  heads — 
1st.  Intiamination,  acute  or  chronic;  2d,  Waxy  degeneration;  3d,  Fatty 
degeneration. 

1.  The  Iiiflammatory  Form. — This  may  be  acute  or  chronic;  the  first 
is  generally  induced  by  all  those  causes  which  excite  inflammation  in 
other  internal  organs,  and  is  ushered  in  bv  rigors  and  febrile  symptoms, 
and  accompanied  by  pains  in  the  lumbar  region,  and  the  phenomena 
generally  described  as  those  peculiar  to  nephritis.  (See  Nephritis.)  The 
chronic  disease  may  follow  tlie  acute,  may  come  on  more  slowly,  as  the 
result  of  the  same  causes,  or  proceed  so  imperceptibly  from  causes  which 
have  escaped  oV)servation,  that  the  occurrence  of  dropsy,  more  or  less 
extensive,  may  be  the  first  symptom  which  excites  att'.'ntion.  On  testing 
the  urine  chemically,  it  is  found  to  be  albuminous,  and  on  examining 
the  sediments  microscopically,  various  kinds  of  casts  with  epithelial  cells, 
blood  corpuscles,  dift'erent  salts,  and  other  morbid  products,  may  be  seen. 
These  casts  of  the  uriniferous  tubes  are  finally  molecular  and  fibrinous 
{exudative  caMs)^  or  mingled  with  the  fibrinous  matter,  there  are  epi- 
thelial cells  and  free  nuclei  of  the  tubes  [desquamative  casts).  Other 
products,  which  vary  according  to  the  period  of  the  disorder  and  the  tissues 
involved,  may  also  be  present,  to  which  we  shall  allude  under  the  head 
of  diagnosis. 

On  examining  the  kidneys  of  individuals  who  have  laboured  under 
this  form  of  the  disease,  we  find  that  in  the  acute  stage  they  are  more 
or  less  congested  and  tinged  of  various  colours,  from  a  bright  red  to  a 
dusky  brown.  The  suiiace  is  not  unfrequently  covered  over  with  minute 
ecchymolic  spots,  dependent  on  the  extravasation  of  blood  into  the  tubes, 
in  tlieir  convoluted  portions.  The  excessive  congestion  and  extravasation 
of  blood,  by  obstructing  the  tubes  and  interfering  with  the  secreting 
function  of  the  organ,  form  the  chief  source  of  danger  in  these  cases. 
There  may  also  be  frequently  observed  a  fibrinous  exudation  filling  the 
tubes,  in  which  are  intermixed  the  epithelial  cells,  and  here  again  the 
extent  of  the  obstruction  so  occasioned  is,  sometimes  without  much 
congestion  (Case  CLX.),  commensurate  with  the  danger  of  the  case. 
As  the  disease  becomes  more  chronic,  the  intense  uniform  coloration 
diminishes,  leaving  irregular  arborizations,  which  mottle  the  surface — 
the  blood  extravasated  is  absorbed — the  exudation,  if  not  dislodged  and 
passed  in  fragments  by  the  urine,  gradually  disintegrates,  and  may  or 
may  not  undeigo  the  purulent  or  fatty  transfoi-mation.  This,  by  long- 
continued  pressure,  causes  permanent  obsti'uction  of  the  tubes  and  atrophy 
of  the  renal  structure,  so  that  at  last  the  organ  becomes  smaller  and 
smaller,  less  and  less  able  to  perform  its  functions,  and  ultimately  causes 
death  (Case  CLXXVI). 

2.  The  Wax;/  Form. — This  form  of  the  disease  is  generally  chi'onic, 
and  for  the  most  part  accompanies  scrofulous  or  tubercular  complications. 
Dropsy,  and  a  peculiarly  cachectic  and  emaciated  look,  constitute  its 
chief  symptoms  ;  and  the  urine,  as  the  disease  slowly  progresses,  becomes 


BEIGHT  S   DISEASE. 


767 


more  and  more  suppressed,  death  taking  place  by  coma.  The  sediment 
is  usually  small,  and  presents  pale  casts  of  the  tubes  {wuxi/  casts),  with  a 
few  epithelial  cells,  unusually  colourless  and  transparent.  Xot  unfre- 
quently,  however,  at  an  early  period,  desquamative  casts,  with  little  fibrin, 
and  composed  of  closely  aggregated  cells,  of  the  tubes,  may  be  seen. 
This  form  of  the  disease  is  so  mixed  up  with  the  various  other  lesions 
which  usually  accompany  it,  as  not  to  admit  of  any  distinctive  description, 
referable  to  the  more  renal  disorder. 

On  examining  kidneys  which  have  undergone  the  waxy  deo-eneration, 
we  generally  find  that  they  are  more  dense  to  the  feel  tlum  natural, 
sometimes  smallei-,  at  others  larger  than  usual,  and  of  a  colour  resembHng 
various  shades  of  dirty  bees'  wax,  or  of  a  liglit  fawn  tint.  On  section  the 
surface  is  smooth,  and  the  edges  more  or  less  translucent ;  a  circumstance 
dependent  on  the  diminished  vascularity  which  everywhere  prevails,  and 
a  peculiar  transparency  which  all  the  structures  of  the  organs  have  under- 
gone. A  thin  slice,  when  magnified  under  a  power  of  250  diani.  linear, 
exhibits  the  vessels  of  the  malpighian  bodies  more  transparent  and  re- 
fractive than  usual  (Fig.  445).  The  tubules  are  colourless,  often  destitute 
of  epithelium,  and  of  a  peculiar  whiteness.  Such  cells  as  are  <Iiscovered 
have  their  nuclei  more  or  less  atrophied,  and  closely  resemble  those  seen 
in  the  liver,  when  similarly  affected  (see 
Fig.  295,  p.  214).  Indeed,  this  change 
in  the  kidney  is  frequently  associated 
with  a  similar  transformation  of  the 
liver  and  spleen.  The  nature  of  this 
waxy  degeneration  of  tissue  is  unknown, 
although  probably  it  is  some  chancre 
in  the  chemical  composition  of  the 
structure  affected.  (Cases  CLXXIV. 
and  CLXX^^) 

3.  The  Fatty  Form. — This,  as  we 
have  seen,  may  be  a  result  of  the  in- 
flammation, but  it  is  not  unfrequently 

produced   independent   of  it.      Here,  Fi.r  44.5. 

again,  the  progress  of  the  disease  is 

chronic,  is  not  so  frequently  associated  with  scrofula  and  tubercle,  but 
occurs  rather  in  individuals  more  advanced  in  life,  suffering  from  cardiac 
and  bronchitic  disorders,  or  who  are  addicted  to  intemperance.  It  is 
also  frequently  associated  with  tatty  degeneration  of  the  heart  and  liver. 
Dropsy  and  persistent  albuminuria  are 'constant  symptoms,  and  the  sedi- 
ment is  loaded  with  casts  of  the  tubes  containing  oil  granules  [fatttf 
casts)  and  granule  cells. 

On  examining  the  kidneys  of  individuals  who  have  died  of  this  form 
of  the  disease,  we  observe  the  tubes  more  or  less  obstiucted  by  fatty 
granules,  which  have  gradually  accumulated  in  the  epithelial  cells  of 
the  tubes.  These  separate,  and  even  burst,  liberating  their  contents, 
and  in   this  way  obstruct  the  tubes,  and  compress  the  secreting  and 


Fig.  445.  Waxv  degeneration  of  a  malpighian  boclr,  with  a  few  granule  cells.- 
( ^^d^-)  '  300  diam. 


768 


DISEASES   OF   THE    GENITO-URINARY   SYSTEM. 


surrounding   textures  (Fig.  446,  a,  and   h).     Gradually  the  vessels  are 

so  compressed,  that  the  or- 
gan affected  looks  bloodless, 
and  though,  on  the  whole,  en- 
larged, is  of  a  light  fawn  or 
dirty  white  colour.  The  fi- 
brous texture  is  occasionally 
hypertrophied,  causing  con- 
tractions round  the  convoluted 
tubes,  thus  producing  irre- 
gularities on  the  surface.  Oc- 
casionally, also,  large  accumu- 
lations of  the  fatty  granules 
take  place,  causing  the  tubes 
^ '"'  ""■  to    burst,    and    presenting    to 

the  naked  eye  light  fawn-coloured  spots  or  granulations,  more  or  less 
numerous,  which  are  scattered  over  and  through  the  cortical  substance. 
It  is  easy  to  conceive  how  such  accumulations  of  fat,  and  consequent 
pressure  and  obstruction,  must  at  length  so  interfere  with  the  kidneys, 
as  to  be  incompatible  with  the  pciformance  of  their  functions  (Case 
CLXXVI.) 

On  scraping  the  surface  of  a  fatty  kidney,  and  adding  a  drop  of  water, 
we  are  enabled  to  see,  under  a  magnifying  power,  fragments  and  cells 
.^.  such  as  are  given  Figs.  446,  447.     Tliey 

exhibit  portions  of  uriniferous  tubes  loaded 
with  free  fat  granules  and  epithelial  cells, 
also  containing  similar  fat  granules.  On 
making  a  thin  section  of  a  fatty  kidney,  we 
not  unfrequently  see  the  tubes  in  situ  loaded 
with  similar  granules,  and  the  fibrous  tissue 
so  increased  and  thickened  between  them, 
as  to  occasion  a  lesion  identical  in  many 
respects  with  the  so-called  cirrhosis  of  the 
liver,  to  which  an  atrophied  and  granular 
kidney  is  strictly  analogous.  Sections  of 
the  cortical  substance  of  such  kidneys  are  represented  Figs.  448,  449. 

Ihe  above  is  a  condensed  description  of  what  appear  to  me  the  three 
pathological  forms  of  Bright's  disease  of  the  kidney.  These  lesioiis, 
although  they  are  met  with  separately  and  distinct,  may,  however,  be 
more  or  less  conjoined.  One  part  of  a  kidney  may  be  congested  or  in- 
flamed, whilst  another  is  fatty ;  or  we  may  have  the  fatty  and  Avaxy 
conditions  united  together.  It  is  only  in  this  way  that  we  can  account 
for  the  various  shades  of  alteration  which  the  kidney  may  at  dift'erent 
times  present  during  the  continuance  of  persistent  albuminuria  with 
dropsy.     All  these  alterations,  by  interfering  with  the  secreting  functions 


,•  0'?' 


Fig.  447. 


Fig.  446  Structures  in  a  fatty  kidney,  a  and  6,  Tubes  tilled  with  fatty  granules, 
having  in  one  of  them  the  transparent  basement  membrane  visible,  c,  Transverse 
section  of  similar  tube,  d,  Fatty  ej)ithelium  of  the  tubes,  e,  Amorplious  fatty  matter 
in  the  tubes.    /  Crystals  of  uric  acid  in  a  tubule. — {Wtdl.)  350  dimn. 

Fig.  447.  Portion  of  fatty  tube,  with  fatty  epithelial  cells,  scraped  from  the  surface 
of  a  fatty  kidney. 


BRIGHT  S   DISEASE. 


7G9 


of  the  cells,  more  or  less  impede  the  excretory  power  of  the  kidneys, 
and,  if  continued,  ultimately  tend  to  overload  the  blood  with  the  effete 


Fi,    44 


elements  which  ought  to  be  discharged  with  the  urine.  At  the  same 
time,  by  causing  more  or  less  congestion  of  the  vessels,  or  by  pressure 
on  the  malpighian  bodies,  and  obstruction  of  the  tubules,  a  serous  effusion 
takes  place,  the  albumen  of  which,  passing  into  the  urine,  communicates 
to  it  that  property  of  coagulability  which  constitutes  its  pathognomonic 
character. 

Diagnosis  of  Bright'' s  Disease. 

The  diagnosis  of  Bright's  disease  of  the  kidney  is  dependent  on  three 
kinds  of  observation  : — 1st,  Symptoms;  2d,  Chemical — and  3d,  Micro- 
scopical examination  of  the  urine. 

1.  Diagnostic  Symptoms. — In  the  acute  forms,  pain  in  the  lumbar 
region,  high-coloured  urine,  and  other  indications  of  nephritis,  followed 
by  dropsy ;  and  in  the  more  chronic  forms,  the  occurrence  of  dropsy, 
frequently  without  the  local  renal  symptoms,  are  the  chief  diagnostic 
symptoms.  But  these  symptoms  must  always  be  very  vague  until, 
by  a  chemical  examination  of  the  urine,  the  presence  of  albumen  is 
determined. 

2.  Chemical  Examination  of  the  Urine. — In  testing  the  urine,  you 
should  be  careful  to  employ  both  heat  and  nitric  acid.  Heat  alone, 
frequently  separates  earthy  salts,  which  to  the  eye  may  resemble  a 
slight  cloud  of  albumen — and  nitric  acid  alone,  frequently  throws  down 
a  precipitate  of  ui'ic  acid,  where  urate  of  ammonia  is  in  excess.  But 
if  the  coagulum  produced  by  heat  also  resist  the  action  of  nitric  acid, 
we  may  be   pretty  sure  that  the  urine  contains  albumen.     The  mere 

Fig.  448.  Longitudinal  section  of  a  fatty  kidaej"-,  showing  the  tubes  loaded  with 
fatty  granules. 

Fig.  449.  Transverse  section  to  the  former  one,  (i)  malpighian  body. — (Christi- 
son.)  250  diam. 

49 


770 


DISEASES   OF  THE   GEXITO-URINARY  SYSTEM. 


presence  of  albumen  in  the  urine  does  not  constitute  Brigbt's  disease. 
It  niav  accompany  cystitis,  or  bsematuria — may  foUow  tbe  action  of  a 
bHsteraftecting  the  kidneys,  or  result  from  mercurialism,  errors  in  diet, 
or  confirmed  dyspepsia.  In  all  such  cases,  however,  it  is  temporary, 
and  does  not  present  the  diagnostic  character  oi  persistence. 

3.  Microscopical  Examination  of  the  Urine. — The  method  I  have  found 
best  for  determining  the  form  and  structure  of  the  organic  matters  dis- 
charged in  the  urine,  is  to  allow  the  fluid  to  repose  for  twelve  hours, 
thenpour  off  the  supernatant  liquid,  and  put  the  turbid  sediment  into 
a  test-tube.  Allow  this  to  repose  for  another  twelve  hours,  Avhen  the 
concentrated  precipitate  containing  the  organic  matters  collects  at  the 
bottom,  and  can  now  easily  be  brought  into  the  tield  of  the  microscope. 
Or  some  ounces  of  the  urine  may  be  put  into  a  conical  glass,  like  an 
ale  glass,  and  the  precipitate  allowed  to  deposit  itself,  as  recommended 
bv  i)r.  Johnson.  From  thence  it  can  easily  be  obtained  by  pouring 
off  the  supernatant  fluid,  or  by  removing  the  sediment  with  a  pipette 
for  microscopic  examination.  The  objects  so  brought  into  view  are 
various,  comprising  diflerent  salts,  cells,  fungi,  and  casts  of  tubes  (see 
pp.  88  to  93,  and  Figs.  75  to  84),  the  discrimination  of  which  necessi- 
tates a  knowledge  of  histology.  The  diagnostic  elements,  however,  in 
Bright's  disease,  may  be  considered  to  be  the  separated  casts  of  the 
tubuli  uriniferi.     These  are  of  four  kinds. 

1.  Exudative   Casts. — These  casts  consist  of  the  coagulated  exuda- 
tion   or   fibrin,  which,  in    the  inflammatory  form,    is 
poured  into  the  tubes,   so  as  to  present   a  mould  of 
their   interior.     They  are    analogous  to  similar  casts 
which    occur  in   the  minute  bronchi,  in  all  cases    of 
pneumonia,  and  are  recognised  under  the  microscope 
by  their  uniform  molecular  structure.      They  mostly 
occur    in  acute  cases,  are  frequently  associated  with 
blood  corpuscles,  and  not  unfrequently  with  desquama- 
tive casts  and  epithelial  cells.     Figs.  816,  and  450. 
2.    Desquamative    Casts. — These    casts     consist    of 
masses  of  the  epithelium    lining   the  tubules,    some- 
times closely  aggregated  together  side  by  side,  at  others  agglutinated 
by    means    of    the    molecular    exudation,    formerly 
alluded  to.     They   result  from   a  separation   of  the 
lining  cell  membrane  from  the  interior  of  the  tube, 
in    patches  of  greater  or  less  extent,   and    may   be 
associated     in     acute    cases   with     exudations,     and 
in    chronic    cases   with    the    fatty   or    waxy    trans- 
formations   next   to    be    mentioned — (See    Fig.    81, 
«,  p.  90,  and  451.) 

3.  Fatty  Casts. — These  casts  consist  also  of  patches 
of  epithelium,  which,  however,  have  previously  under- 
gone the  fatty  transformation,  by  the  accumulation  of 
a  greater  or  less  number  of  fatty  granules  in  their  cells.      Occasionally 


450. 


Fis:.  450.  Exudative  casts,  with  epithelial  cell  and  mass  of  coagulated  exudation. 
Fig.  451.  Desquamative  casts,  SA'itli  blood  corpuscles,  naked  nuclei,  and  cells.  2(i()diam. 


bright's  disease. 


771 


the  cells  burst  and  fill  the  tubes  -with  fatty  granules,  among  which 
no  epithelium  can  be  distinguished. — (See  Fig.  82,  p.  90,  and  Fio-. 
446.)  At  others  the  cells  are  less  changed,  the  fatty  accumulation 
as  it  were  only  commencing  as  in  Fig.  452.  These  fatty  casts 
are  often  associated  with 
fragments  of  desquama- 
tive ones,  with  a  few 
cells,  more  or  less  fatty, 
and  frequently  with  the 
kind  of  cast  to  be  noticed 
(Fig.  452). 

Waxi/  Casts. — These 
casts  present  an  exceed- 
ingly diaphanous  and  struc- 
tureless substance,  which, 
according  to  Dr.  Johnson, 
is  secreted  by  the  basement  membrane  after  the  destruction  of  its 
epithelial  cells.  But  may  it  not  consist  of  the  basement  membrane 
itself  which  has  undergone  some  chemical  transformation,  the  nature  of 
which  has  yet  to  be  ascertained  ?  The  waxy  are  frequently  associated  with 
the  two  kinds  of  casts  last  described,  but  especially  with  the  fatty  ones. 
(Figs.  452,  453.)  Not  unfrequently  all  stages  ot"  transformation  may 
be  seen  in  the  same  demonstration,  between  one  tube  containing 
epithelial  cells,  more  or  less  fatty,  and  another,  which  being  empty, 
presents  the  translucent  or  waxy  appearance.     (Figs.  446,  453.) 

The  exact  signification  of  all  these  various  kinds  of  casts  has  yet  to  be 
fully  determined  by  clinical  investigation.  But  it  appears  to  me  that 
the  exudative  casts  indicate  the  most  acute  form  of  lesion — the  desqua- 
mative a  sub-acute,  the  fatty  a  chronic  lesion,  and  the  waxy  a  lesion 


Fij.  452. 


^  s.  /  ^'  iii^ 


'^: 


.s^ 


Fig.  456. 


Tig.  454.  Fig.  455. 

destructive  of  the  tubular  textures.     But  as  all  these  different  changes 
may  be  going  on  in  the  kidney  at  the  same  moment,  so  we  may  find 


Fig.  452.  Fatty  casts  with  granule  cell. 
Fig.  453.  Waxy  casts  of  various  sizes. 

Fig.  454.  Tyrozin  masses  iu  the  uriuary  sediment  of  a  mau  with  atrophy  of  the 
liver.  — ( Frerichs. ) 

Fig.  455.  Leucia  in  a  drop  of  the  same  urine,  allowed  to  evaporate. — {Frerichs.) 
Fig.  456,  Pure  tyroziu  from  the  same  urinary  sediment. — (Frerichs.)       200  diam 


772  DISEASES   OF   THE    GEXITO-URIXARY   SYSTEil. 

these  various  casts  mingled  with  one  another  in  various  proportions, 
combined  with  other  structural  elements.  The  predominance  in  number 
of  one  kind  of  cast  over  another,  will,  however,  serve  to  indicate  to  the 
pathologist,  with  tolerable  correctness,  the  nature  of  the  change  which  is 
going  on  in  the  renal  organs.  They  undergo  great  varietv  in  size,  often 
being  much  smaller  than  any  kind  of  uriniferous  tubes,  a  circumstance 
indicating  considerable  contraction  of  their  calibres. 

In  addition  to  the  elements  now  and  previously  described  (p.  88),  as 
occasionally  met  with  in  urine,  there  should  not  be  overlooked  two  pro- 
ducts, viz.,  Tyrosin  and  Leucin.  According  to  Frerichs,*  they  occur  in 
that  fluid  iu  certain  diseases  of  the  liver,  and  especially  in  atrophy  of  that 
organ.  Hitherto  they  have  not  been  much  studied,  having  commonly 
been  mistaken  for  fatty,  starchy,  or  mineral  bodies.  But  their  clinical 
history,  in  relation  to  hepatic  and  renal  disease,  having  been  commenced 
by  so  able  an  investigator  as  Frerichs,  justifies  my  placing  before  you  the 
forms  which  they  assume  (Figs.  454,  455,  456). 


Treatment  of  Brighfs  Disease. 

The  acute  forms  of  Bright's  disease  should  be  combated  externally 
by  cupping  over  the  loins,  and  warm  fomentations — internally  by  dia- 
phoretics, and  later  by  diuretics.  I  have  seldom  found  it  necessary  to 
have  recourse  to  general  bleeding,,  and  then  only  as  a  palliative  to  relieve 
pulmonary  congestion.  The  chronic  forms,  in  addition  to  appropriate 
remedies,  require  attention  to  diet  and  exercise.  A  non-fatty  diet  is  evi- 
dently indicated  in  the  fatty  degeneration  of  the  kidney.  Exercise, 
change  of  air,  and  sea  voyages  are  also  beneficial.  Care  also  should  be 
taken  that  the  surface  be  kept  warm,  and  cutaneous  transpiration  favoured. 
The  complications  and  sequelae  must  be  managed  according  to  circum- 
stances, and  the  general  indications  special  to  individual  diseases.  In 
this  place  I  shall  only  allude  to  the  effects  of  two  classes  of  remedies, 
namely,  diaphoretics  and  diuretics. 

Dia^ihoretics. — The  connection  which  necessarily  exists  between  the 
kidneys  and  the  skin  as  excretory  organs,  is  well  known.  In  health, 
impeded  function  in  the  one  is,  to  a  certain  extent,  compensated  for  by 
increased  function  in  the  other;  and  diseases  in  the  skin,  especially 
scarlatina,  or  other  causes  which  tend  to  check  cutaneous  transpiration, 
are  peculiarly  liable  to  induce  renal  disorders.  Such  being  the  case,  it 
seems  highly  judicious,  in  our  efi'orts  at  cure,  to  excite,  by  all  means  in 
our  power,  the  functions  of  the  skin  in  cases  of  Bright's  disease  of  the 
kidney ;  and  with  this  view,  Dover's  powder,  keeping  the  surface  warm, 
hot  air  baths,  warm  water  baths,  and  a  warm  climate,  are  among  the 
means  which  have  been  proved  to  be  most  useful.  Should,  however,  as 
frequently  happens,  these  remedies  be  of  no  avail,  and  the  dropsical 
symptoms  increase,  then  we  must  have  recourse  to  the  next  class  of 
remedies. 

Diuretics. — It  has  been  thought  that  in  the  acute  inflammatory  cases, 
where  the  kidney  is  more  or  less  congested  and  loaded  with  exudation, 

*  Atlas  zur  Klinik  der  Leberkrankheiten.     Ta£  iii. 


bright's  disease.  773 

diuretics,  by  stimulating  the  organs  and  exciting  them  to  increased 
action,  would  add  to,  rather  than  diminish,  the  excitement.  But  wlien 
it  is  considered  that  the  dropsy  is  induced  by  obstruction  in  the  secreting 
tubes,  which  presents  a  mechanical  obstacle  to  the  outward  flow  of  fluid, 
it  seems  probable  that,  by  increasing  that  flow,  the  accumulations  pro- 
ducing the  obstruction  may  be  washed  out.  Besides,  by  augmenting  the 
amount  of  fluid  from  the  malpighian  bodies  through  such  tubes  as  still 
remain  pervious,  a  compensation  is  frequently  to  be  found  for  the 
diminished  flow  which  takes  phxce  in  the  obstructed  ones.  Certain  it  is, 
that  I  have  given  diuretics  in  all  stages  of  the  disease  with  the  best 
eft'ects,  as  soon  as  it  became  manifest  that  the  remedies  formerly  ahuded 
to  were  of  no  avail.  Nor  have  I  ever  seen  any  bad  results  from  the 
practice.  On  this  point  I  fully  coincide  with  the  observations  made  by 
Dr.  Christison,  in  a  most  important  lecture  he  has  published  on  this  sub- 
ject.* Besides,  in  acute  cases  with  diminution  of  urine  and  rapid  dropsy, 
no  other  course  is  left  open  to  us,  as  diaphoretics  under  such  circum- 
stances are  seldom  effectual. 

The  whole  class  of  diuretics  may  be  tried  in  Bright's  disease,  in  com- 
bination with  other  remedies ;  but  the  most  valuable,  so  far  as  I  have 
been  able  to  determine,  is  the  bitartrate  of  potass,  which  I  have  ft-e- 
quently  seen  to  produce  a  most  powei'ful  effect,  when  every  other  had 
failed.  The  spongio-piline,  saturated  in  a  strong  solution  of  infusion  of 
digitalis  applied  externally,  and  digitaline  administered  internally  in 
minute  doses,  both  recommended  by  Dr.  Christison,  are  useful.  But 
here  again  I  have  seen  the  cream  of  tartar  operate  after  both  these  had 
failed.  Sometimes  also,  after  it  has  been  given  without  effect  at  an 
early  period  of  the  disease,  it  has  succeeded  remarkably  well  at  a  later 
one.  Of  this,  the  case  of  Herdmann  (Case  CLXX.)  is  a  remarkable 
example,  which  wari'ants  our  having  recourse  to  the  remedy  again  and 
again  after  certain  intervals,  should  it  not  act.  It  is  very  possible  that 
the  casts  which  obstruct  the  tubes  may  be  more  loosened  at  one  time 
than  at  another,  and  that  a  powerful  diuretic  may,  in  consequence,  have 
a  greater  eft'ect  in  washing  out  the  obstruction  and  restoring  the  func- 
tion of  the  organs.  At  all  events,  I  have  rarely  seen  other  diuretics 
succeed,  when  repeated  attempts  by  means  of  the  bitartrate  of  potass 
had  failed. 

*  Monthly  Journal  of  Medical  Science.     June  1851. 


SECTION  IX. 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


Notwithstanding  the  great  advances  which  have  been  made  in  our 
knowledge  of  diseases  of  the  skin,  it  cannot  be  denied  that  very  inexact 
notions  prevail  I'egarding  this  class  of  disorders.  I  do  not  here  allude 
to  the  eruptive  fevers  which,  from  their  frequency  and  danger,  neces- 
sarily demand  the  attention  of  every  professional  man,  so  much  as  to 
the  lighter  and  more  chronic  disorders  to  which  the  skin  is  subject, 
lo-norance,  however,  here,  although  it  seldom  occasions  danger  to  human 
life,  produces  great  inconveniences,  exasperates  the  progress  of  other 
maladies,  renders  life  miserable,  and  frequently  destroys  those  social  rela- 
tions and  ties  which  constitute  happiness. 

A  ladv  was  seized  with  an  eruption  on  the  genital  organs,  which  ren- 
dered the  slightest  contact  unbearable.  Her  husband  suspected  that  she 
laboured  under  syphilis,  and  accused  her  of  infidelity.  A  medical  man, 
who  was  consulted,  pronounced  her  disease  venereal — a  separation  took 
place  between  the  parties  ;  the  lady  always  maintaining  her  innocence, 
but  anxious  to  escape  the  unfounded  suspicions  and  ill-treatment  of  her 
husband.  Mercury  and  an  anti-venereal  treatment  was  continued  for 
some  time,  but  the  disease  increased  in  intensity.  At  length  another 
physician,  skilled  in  the  diagnosis  of  skin  diseases,  was  consulted,  who 
pronounced  it  to  be  an  eczema  ruhrum,  quite  imconnected  with  syphilis ; 
and  on  the  application  of  appropriate  remedies,  a  speedy  cure  confirmed 
his  diagnosis. 

x\.  lady  in  the  country  sent  one  of  her  servants  into  town,  to  obtain 
advice  for  an  eruption  which  had  broken  out  on  her  body,  and  which 
she  was  afraid  might  be  communicated  to  her  children.  The  practitioner 
consulted  was  much  puzzled,  and  asked  me  to  see  the  patient,  who,  ac- 
cording to  him,  was  labouring  iinder  a  rare  form  of  skin  disease.  I  found 
a  her2)es  zoster  extending  round  one  half  the  trunk,  and  told  him  it 
would  disappear  spontaneously  in  a  few  days,  which  it  did. 

Nothino-  is  more  common  in  practice  than  to  meet  with  cases  among 
servants,  where  prurigo  has  been  mistaken  for  itch,  causing  great  alarm 
to  the  family,  and  much  injury  to  the  servant.     The  various  diseases  of 


CLASSIFICATION   OF  SKIN   DISEASES.  775 

the  scalp  also  are  continually  confounded  together.  Indeed,  examples 
might  easily  be  accumulated,  proving  the  inconvenience  which  an  unac- 
quaintance  with  skin  diseases  may  occasion  both  to  patient  and  prac- 
titioner. A  young  medical  man  is  especially  liable  .to  be  consulted  in 
cases  of  trifling  skin  eruptions  ;  and  nothing  is  so  likely  to  establish  his 
credit,  as  the  ready  diagnosis  and  skilful  management  of  such  disorders, 
especially  when  (as  frequently  happens)  they  have  been  of  long  standing, 
and  baffled  the  efforts  of  older  practitioners.  Conceiving,  then,  that 
this  subject  deserves  more  careful  consideration  than  it  usually  meets 
with  in  a  clinical  course,  I  propose  directing  your  attention  to  the 
classification,  general  diagnosis,  and  treatment  of  these  disorders  as  an 
introduction  to  the  studv  of  individual  cases  in  the  wards. 


CLASSIFICATIOX  OF  SKIX  DISEASES. 

Skin  diseases  are  so  various  in  appearance  and  in  their  nature,  that 
many  experienced  practitioners  have  endeavoured  to  facilitate  their  studv 
by  arranging  them  in  groups. 

There  are  three  kinds  of  classification  which  deserve  notice: — 1st, 
The  artificial  classification  of  ^Yillan ;  2d,  The  natural  arrangement  of 
Alibert ;  and  3d,  A  pathological  arrangement  founded  on  the" supposed 
morbid  lesions. 

Of  these,  the  best,  and  the  one  which  most  facilitates  the  study  of  cuta- 
neous diseases,  is  certainly  that  of  "NTillan.  Xo  doubt  it  has  its  faults 
and  inconveniences,  but  many  of  them  have  been  removed  by  Biett. 
This  classification  is  founded  upon  the  character  presented  bv  the  erup- 
tion, which,  when  once  known,  determines  the  disease.  It  is  an  old 
saying,  that  it  is  much  easier  to  play  the  critic  and  to  find  fault,  than  to 
construct  something  better.  This  remark  may  be  well  applied  to  those 
who  have  ventured  to  set  aside  the  principle  on  which  Lilian's  arrano-e- 
ment  is  founded,  and  to  bring  forward  others.  The  natural  classification 
of  Alibert  can  never  be  followed  by  the  student,  and  presupposes  a  con- 
siderable knowledge  of  the  subject.  The  pathological  arrangement 
again  is  decidedly  faulty.  The  morbid  anatomy  and  pathology  of 
many  skin  diseases  are  unknown  ;  how,  then,  can  we  found  a  classifica- 
tion upon  them  ?  Indeed,  the  very  foundation  on  which  such  clas- 
sifications are  based,  is  continually  undergoing  changes  as  patholoo-y 
advances. 

On  the  whole,  therefore,  the  arrangement  best  suited  to  the  student 
and  for  practical  purposes  is  that  of  Willan  and  Bateman,  with  the 
modifications  subsequently  to  be  noticed. 

Definitions. — Before  we  can  proceed  to  refer  any  particular  disease 
to  its  appropriate  class,  we  must  be  acquainted  with  the  characteristic 
appearances  which  distinguish  the  different  orders.  They  are  as  fol- 
lows : — 

1.  Exanthema  (Rash). — Variously  formed,  irregular-sized,  superficial 
red  patches,  which  disappear  under  pressure,  and"  terminate  in  desqua- 
mation. 

2.  Vesicula  (Vesicle). — A  small,  acuminated,  or  orbicular  elevation  of 


776 


DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 


the  cuticle,  containing  lymph,  which,  at  first  clear  and  colourless,  becomes 
often  opaque  or  pearl-coloured.  It  is  succeeded  either  by  scurf  or  a 
laminated  scab. 

3.  Bulla  (Bleb). — This  differs  from  the  vesicle  in  its  size,  a  large  por- 
tion of  the  cuticle  being  detached  from  the  skin  by  the  interposition  of  a 
watery  fluid,  usually  transparent. 

4.  P'ustula  (Pustule). — A  circumscribed  elevation  of  the  cuticle,  con- 
taining pns.  It  is  succeeded  by  an  elevated  scab,  which  may  or  may  not 
be  followed  by  a  cicatrix. 

5.  Papula  (Pimple), — A  small,  solid,  acuminated  elevation  of  the 
cuticle,  in  appearance  an  enlarged  }mpilla  of  the  skin,  commonly  termi- 
nating in  scurf,  and  sometimes,  though  seldom,  in  slight  ulceration  of  its 
summit. 

6.  Squama  (Scale). — A  lamina  of  morbid  cuticle,  liard,  thickened, 
whitish,  and  opaque,  covering  cither  small  papular  red  elevations,  or 
larger  deep-red,  diy  surfaces. 

7.  Tuhcrcula  (Tubercle). — A  small  hard,  indolent,  primary  elevation 
of  the  skin,  sometimes  suppurating  partially,  sometimes  ulcerating  at  its 
summit. 

8.  Macula  (Spot). — A  permanent  discoloration  of  some  portion  of  the 
skin,  often  with  a  change  of  its  structure.  Tliese  stains  may  be  white 
or  dark-coloni'ed. 

The  different  appearances  thus  described  characterise  the  eiglit  orders 
of  AYillan  and  Bateman,  viz.,  1.  Exanthemata;  2.  Vesiculae  ;  3.  Bullae  ; 
4.PustuliE;  5.  Papulae  ;  6.  Squamae  ;  V.  Tuberculae  ;  8.  Maculae.  The 
principal  modifications  made  by  Biett  consist  in  removing  from  these 
groups  certain  diseases  which  have  no  affinity  with  them,  and  forming 
them  into  extra  orders  of  themselves.  Thus  he  makes  altogether  fifteen 
orders,  as  seen  in  the  following  classification  given  by  liis  pupils  Schcdel 
and  Cazenave,  which  also  indicate  the  subdivisions  into  which  each  order 
is  divided  : — 


Order  I. — Exanthemata. 

Eubeola. 

Scarlatina. 

Erythema. 

Erysipelas. 

Roseola. 

Urticaria. 
Order  II. —  Vesiculce. 

Eczema. 

Herpes. 

Scabies. 

Miliaria. 

Varicella. 
Order  III. — Bzdlce. 

Pemphigus. 

Rupia. 
Order  IV. — Picsfuke. 

Variola. 

Vaccinia. 


Ecthyma. 

Impetigo. 

Acne. 

Mentagra. 

Porrigo. 

P]quinia. 
Order  V. — Papulce. 

Lichen. 

Prurigo. 
Order  VI. — Squamce. 

Psoriasis. 

Pityriasis. 

lehthj'osis. 
Order  VII. — Tuhercula. 

Lepra  Tuberculosa. 

Lupus. 

Molluscum. 

Eramboesia. 

Cheloidea. 


Order  VIII. — Maculce. 
Lentigo. 
Ephelides. 
Najvi  and  Vitiligo. 
Order  IX. — Purjmra. 
X. — Pellagra. 
XI. — Padesyge. 
XII. — Lepra  As- 
trachauica. 
XIIL— T/te  Aleppo 
Evil,  or  Malwra 
Alepporum. 
XIV. — Elephantiasis 

Arahica. 
XV. — Sypli  ilidiv    or 
Syphilitic  Erup- 
tions. 


Even   this   classification  is  very  complicated,  and  appears  to  me   to 
admit  of  still  further  modifications,  which  will  render  the  subject  more 


CLASSIFICATION   OF   SKIN  DISEASES.  777 

simple  and  practical  at  the  bed-side.  I  shall  point  out  to  you,  in  the 
first  instance,  the  reasons  which  have  induced  me  to  make  these  modifi- 
cations, and  then  give,  in  a  tabular  form,  the  classification  -which  we 
shall  in  future  adopt. 

In  the  orders  Exanthemata  and  Fustulcc,  we  find  several  diseases 
which  are  characterised  by  excessive  fever,  so  that  they  have  long  been 
spoken  of  under  the  terra  of  eruptive  fevers,  as  well  as  nnder  that  of 
febrile  eruptions.  AVith  them,  in  short,  fever  is  the  characteristic,  and 
they  are  influenced  by  laws  of  a  peculiar  character,  altogether  different 
from  those  which  regulate  the  production  of  other  cutaneous  aft'ections. 
I  propose,  then,  to  I'cmove  these  disorders  from  the  category  of  skin 
diseases  altogether,  and  to  leave  only  three  in  the  first  order,  namely, 
erythema,  roseola,  and  urticaria.  I  am  aware  that,  strictly  speaking, 
these  may  be  accompanied  by  slight  fever,  Avhich  may  also  occur  in 
several  other  skin  diseases.  But  1  do  not  pretend  to  form  a  classifica- 
tion which  is  perfect,  or  even  pathological,  but  one  which  some  experi- 
ence in  the  teaching  of  these  diseases  has  convinced  me  is  useful  and 
practical  for  the  student. 

In  the  order  Vesicidce  we  find  five  diseases.  I  propose  cutting  out 
miliaria,  as  being  very  unimportant,  and  a  trifling  sequela  of  fevers. 
Varicella  I  believe  to  be  a  modified  small-pox,  and  I  omit  it  for  the  same 
reasons  as  I  do  variola.  Scabies,  on  the  other  hand,  though  dependent 
upon  the  presence  of  an  insect,  the  Acarus  Scabiei,  presents  such  distinct 
characters,  as  to  warrant  its  retention. 

I  propose  expunging  the  order  Bullce  altogether.  "\Ve  find  in  it  two 
diseases.  The  first  oi  these,  pemphigus  or  pompholyx,  is  a  vesicular 
disease  in  every  point,  appearing  sometimes  in  successive  crops,  and 
forming  a  laminated  scab.  Paipia,  on  the  other  hand,  is  evidently  a  pus- 
tular disease,  forming  a  prominent  scab,  producing  ulceration,  and  leaving 
a  cicatrix.  I  shall  therefore  add  pemphigus  to  the  order  vesicula',  and 
rupia  to  that  of  the  pustular. 

From  the  Pustula;,  for  the  reasons  formerly  stated,  I  expunge  variola, 
vaccinia,  and  equinia.  Mentagra,  so  far  as  I  have  been  able  to  study  it 
in  this  country,  has  always  consisted  of  eczema  or  impetigo  on  the  chin 
of  the  male.  In  syphilitic  cases  it  is  more  or  less  tubercular,  and  it  has 
been  described  also  as  consisting  of  a  vegetable  parasite.  Although  I 
have  never  seen  the  appearance  figured  by  Cazenave  (Plate  16),  I  can 
understand  that  such  a  mentagra  might  really  consist  of  vegetable  fungi. 
At  all  events,  mentagra  is  nota  special  pustular  disease.  Porrigo  means 
any  eruption  on  the  head,  whether  vesicular,  pustular,  or  squamous. 
Favus,  to  which  it  has  long  been  applied,  is  undoubtedly  a  vegetable 
parasite,  and  ought,  with  others  of  a  like  nature,  to  constitute  a  distinct 
class.  Moreover,  it  is  neither  vesicular  nor  pustular.  Hence  the  class 
of  pustulse  will  with  us  contain  only  impetigo,  ecthyma,  acne,  and  rupia. 
The  orders  Pajndce  and  Squamce  remain  the  same.  The  strophulus 
of  many  English  writers  is  certainly  only  lichen  occurring  in  the  child  ; 
and  what  has  been  called  lepra,  as  distinguished  from  psoriasis,  is  the 
latter  disease  presenting  an  annular  form. 

From  the  class  Tuberculce  I  cut  out  framboesia,  as  being  a  disease 
unknown  in  this  country,  together  with  cheloidea,  which,  as  1  understand 
it,  means  either  cancer  or  tubercle  of  the  skin. 


778  DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 

As  regards  the  order  Macuhe,  I  place  purpura  in  it,  as  did  Willan, 
because,  although  sometimes  it  may  depend  on  constitutional  causes 
of  an  obscure  nature,  and  at  others  be  allied  to  scurvy,  it  still,  in  an 
arbitrary  classification  of  this  kind,  constitutes  an  undoubted  spot  or 
macula. 

All  the  other  orders  of  Biett  I  shall  take  the  liberty  of  expunging — 
pellagra,  lepra  Astrachanica,  and  malum  Alepporum,  are  unknown  in  this 
country.  I  agree  with  llebra,  in  thinking  that  Radesyge  is  only  a  modi- 
fied form  of  lupus.  The  elephantiasis  Arabica  is  an  hypertrophy  of  the 
areolar  tissue  or  chorion,  and  belongs  more  to  the  subject  of  fibrous 
growths  than  that  of  skin  diseases.  Syphilitic  diseases  I  do  not  regard 
as  a  distinct  order,  but  as  any  of  the  ordinary  skin  aftcctions,  more  or 
less  modified  by  a  peculiar  state  of  the  constitution. 

Whilst  I  have  cut  out  many  diseases  from  the  eight  orders  originally 
established  by  Willan,  and  subsequently  modified  by  Biett,  I  find  it 
necessary  to  add  two  orders,  which  the  advance  of  patliology  and  histo- 
logy shows  ought  to  be  considered  apart.  I  allude  to  those  which  depend 
on  the  presence  of  parasitic  animals  and  plants,  and  which  may  be 
called  respectively  Dermatozoa  and  Dermatophyta.  It  has  now  been 
shown  by  M.  Bourguignon,  that  scabies  is  dependent  on  the  presence  of 
an  acarus,  but  that  the  insect  is  only  indirectly  the  cause  of  the  eruption. 
Hence  I  put  acarus  among  the  dermatozoa,  although  it  ceitainly  forms, 
when  present,  a  constituent  of  itch.  Among  the  dermatophytes  will  be 
placed  favus  and  mentagra, — both  removed  fiom  the  class  pustulse. 
Other  diseases,  such  as  plica  Polonica,  and  pityriasis,  have  been  con- 
sidered as  parasitic,  but  the  former  is  unknown  in  this  country,  and 
the  latter,  when  it  presents  epiphytes  among  the  scales,  constitutes  a  form 
of  favus. 

The  classification,  then,  we  shall  in  future  adopt  is  as  follows  : — 

Order  I. — Exanthemata.       Order  IY. — Papulce.  Navi. 

Erythema.  Lichen.  Purpura. 

Roseola.  Prurigo.                       Order  YIII. — Dermatozoa. 

Urticaria.  Order  Y. — Squamce.  Entozoon     folliculo- 

Order  II. —  Vesiculce.  Psoriasis.  rum. 

Eczema.  Pityriasis.  Acarus. 

Herpes.  Ichthyosis.  Pedicuhis. 

Scabies.  Order  YI. — Tuberculce.       Order  IX. — Dermatophytce. 

Pemphigus.  Lepra  Tuberculosa.  Achorion  Schonleini 

Order  III. — PustuUe.  Lupus.  (Favus). 

Impetigo.  Molluscum.  Acliorion     Gmbii 

Ecthyma.  Order  YII. — Maculce.  (Mentagra).* 

Acne.  Lentigo. 

Rupia.  Ephelides. 

*  It  has  been  objected  to  the  words  porrigophyte  and  mentagraphyte,  introduced  by 
Grub}-,  that  they  are  unclassical ;  and  as  the  celebrated  botauist  Link,  after  carefully 
examining  these  vegetations,  has  described  the  former  as  a  new  genus,  under  the 
head  of  Achorion  (from  aclior,  the  old  term  given  to  a  favus  crust  by  Y'illan).  I  have 
thought  it  best  to  adopt  that  term.  To  mark  the  variety  in  favus,  he  has  added  the 
name  of  its  discoverer,  Schonlein  ;  and  I  have  ventured,  at  all  events  provisionally, 
to  distinguish  the  one  described  as  existing  in  mentagra,  by  adding  to  it  also,  that 
of  its  discoverer,  Gruby. 


DIAGNOSIS   OF  SKIN  DISEASES.  779 


DIAGNOSIS  OF  SKIN  DISEASES. 

The  recognition  of  skin  diseases,  and  the  separating  of  one  class  from 
another,  is  of  essential  importance  to  a  proper  treatment.  On  this  point 
I  fully  agree  Avith  a  writer,  who  says,  "The  treatment  of  a  great  many 
cutaneous  diseases  is  but  of  secondary  importance,  compared  with  their 
differential  diagnosis.  Many  of  them  will  get  well  without  any  treat- 
ment, provided  they  are  allowed  to  pursue  their  natural  course ;  and,  on 
the  contrary,  a  mild  and  simple  eruption  by  being  mistaken,  fi'om  a  simi- 
larity of  external  appearances,  for  one  of  a  severe  or  rebellious  character, 
and  treated  accordingly,  may  be  aggravated  and  prolonged  for  an  inde- 
finite period."  (Burgess.)  This  diffei'ential  diagnosis,  however,  to  the 
inexperienced,  is  a  matter  of  great  difficulty,  because  not  only  is  con- 
siderable tact  generally  necessary  to  discover  the  original  element  each 
disease  presents,  such  as  a  rash,  vesicle,  pustule,  scale,  and  so  on ;  but 
often  this  is  impossible.  Under  such  circumstances  the  diagnosis  is  fre- 
quently derived  from  the  scab,  or  other  appearances  presented,  such  as 
the  cicatrix.  The  whole  subject  has  been  rendered  very  confused  and 
complicated  by  systematic  writers,  who  have  often  given  different  names 
to  the  same  disease,  or  unnecessarily  divided  them  into  forms  and  vari- 
eties. I  advise  you  not  to  pay  any  attention  to  these  forms  and  varieties 
for  the  present,  and  to  confine  your  efforts  only  to  the  detection  of  the 
diseases  enumerated  in  the  table  under  each  order;  and  with  a  view  of 
facilitating  your  endeavours,  the  following  short  diagnostic  characters 
and  definitions  should  be  attended  to. 

I.  Exanthemata. 

1.  Erythema. — A  slight  continuous  redness  of  the  skin  in  patches  of 
various  shapes  and  sizes. 

2.  Roseola. — Circumscribed  rose-red  patches,  of  a  circular,  serrated, 
or  annular  form. 

3.  Urticaria. — Prominent  red  patches  of  irregular  form,  the  centre 
of  which  is  often  paler  than  the  surrounding  skin. 

II.  Vesicul.e. 

Eczema. — Very  minute  vesicles  in  patches,  presenting  a  shining  ap- 
pearance, yielding  a  fluid  which  di'ies  into  a  laminated  or  furfuraceous 
crust.     The  skin  is  of  a  bright  red  colour. 

Herpes. — Clusters  of  vesicles,  varying  in  size  from  a  millet  seed  to 
that  of  a  pea,  surrounded  by  a  bright  red  areola.  They  yield  a  fluid 
which  dries  into  a  thin  incrustation,  that  drops  off  between  the  eighth  and 
fifteenth  day. 

Scabies. — Isolated  vesicles  of  an  acuminated  form,  commonly  seated 
between  the  fingers  and  flexor  surfaces  of  the  arms  and  abdomen — never 
on  the  face. 

Pemphigus. — Large  vesicles  or  blebs  (bullse),  surrounded  by  an  ery- 
thematous circle,  the  fluid  of  which  forms,  when  dry,  a  laminated  crust. 
When  chronic,  they  appear  in  successive  crops,  and  the  disease  is  called 
pompholyx. 


780  DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 


III.    PeSTCL.E. 

Impet'tgo. — Small  pustules,  commonly  occurring  in  groups,  and  form- 
ing an  elevated  crust. 

Ecthyma. — Large  isolated  pustules,  depressed  or  umbilicated  in  the 
centre,  and  leaving  a  cicatrix. 

Acne. — Isolated  pustules  situated  on  a  hardened  base,  which  form  and 
disappear  slowly.     They  only  occur  on  the  face  and  shoulders. 

Rupia. — Large  pustules,  followed  by  thick  prominent  crusts,  and  pro- 
ducing ulcerations  of  various  depths. 

IV.  Papul.e. 

Lichen. — ^Minute  papulfe  occurring  in  clusters  or  patches. 
Prurif/o. — Larger  and  isolated  papulte  generally  seated  on  the  extensor 
surfaces  of  the  body. 

V.  Squamae. 

Psoriasis. — Whitish  laminated  scales  slightly  raised  above  the  red- 
dened surface  of  the  skin.     Lepra  is  psoriasis  occurring  in  rings. 

Pityriasis. — Very  minute  scales,  like  those  of  bran,  seated  on  a  red- 
dened surface. 

Ichthyosis. — Induration  of  the  epidermis,  and  formation  of  square  or 
angular  prominences,  not  seated  on  a  reddened  surface. 

VI.  Tl'bercul.e. 

Lepra  Tuberculosa. — (Elephantiasis  of  the  Greeks.) — Tubercles  vary- 
ing in  size,  preceded  by  erythema  and  increased  sensibility  of  the  skin, 
and  followed  by  ulceration  of  their  summits. 

Lupus. — Induration  or  tubercular  swelling  of  the  skin,  which  may  or 
may  not  ulcerate.  In  the  former  case,  ulceration  may  occur  at  the  sum- 
mit or  at  the  base  of  the  tubercles,  and  frequently  extends  in  the  form 
of  a  circle  more  or  less  complete. 

MoUuscum. — Pedunculated,  globular,  or  flatfish  tubercles,  accompanied 
by  no  erythema  or  increased  sensibility,  occurring  in  groups.  They  are 
filled  with  atheromatous  matter. 

VII.  Macul.e. 

Lentigo  or  Freckle. — Brownish-yellow  or  fawn-coloured  spots  on  the 
face,  bosom,  hands,  or  neck. 

JEphelis. — Large  patches  of  a  yellowish-brown  colour,  accompanied  by 
slight  desquamation  of  the  cuticle. 

Ncevi  or  Moles. — Spots  of  various  colours  and  forms,  sometimes  ele- 
vated above  the  skin.     They  are  congenital. 

Purpura. — Red  or  claret-coloured  spots  or  patches,  which  do  not  dis- 
appear under  pressure  of  the  finger. 

VIII.  Dermatozoa. 
These  minute  animals  require  a  lens  of  considerable  power  to  ascertain 


DIAGNOSIS   OF   SKIN   DISEASES.  781 

their  characters,  which  need  not  he  particularised  here,  as  they  will  be 
subsequently  described  and  tigured.     (See  p.  789,  et  seq.) 

IX.  Dermatophyt.e. 

These  minute  plants  require  a  high  magnifying  power  to  distinguish 
them  with  exactitude.  But  they  communicate  peculiar  characters  to 
certain  cutaneous  diseases  as  follows  : — 

Faviis. — Bright  yellow,  umbilicated  crusts,  surrounding  individual 
hairs,  which  agglomerate  together  to  form  an  elevated  friable  crust,  of  a 
peculiar  musty  or  mousy  smell. 

Mcntugm. — Grayish  or  yellowish  dry  crusts,  of  irregular  form,  origi- 
nating in  the  hair  follicles  of  the  beard. 

In  forming  your  diagnosis,  therefore,  you  will  be  guided  principally 
by  three  characters: — 1st,  The  primitive  and  essential  appearance — that 
is,  whether  a  rash,  vesicle,  pustule,  and  so  on.  2d,  The  crust, — whether 
laminated  or  prominent,  composed  of  epidermis  only,  etc.  3d,  Ulcer- 
ation,— whether  present  or  absent;  and  if  so,  the  kind  of  cicatrix. 
These  and  other  characters  I  shall  point  out  at  the  bed-side,  so  as  to 
familiarise  you  with  their  appearances. 

You  will  remember  that  the  classification  formed  by  Willan  is  wholly 
artificial.  It  is  like  the  Linncean  classification  of  plants.  The  difficulty 
for  the  learner  is  to  recognise  the  essential  character,  the  more  so  as  many 
diseases  pass  through  various  stages  before  this  is  formed.  Thus  herpes 
presents,  1st,  a  rash ;  2d,  papules ;  -Sd,  vesicles ;  4th,  pustules ;  yet  the 
disease  is  considered  vesicular.  Ecthyma  passes  through  the  same  stages, 
yet  it  is  considered  pustular.  In  the  vesicular  disease,  how^ever,  the  crust 
is  laminated, — in  the  pustular,  it  is  more  or  less  prominent. 

Again,  it  not  unfrequently  happens  that  two  or  more  diseases  are  com- 
bined together  in  one  eruption.  Thus  it  is  very  common  to  meet  eczema 
and  impetigo  combined,  when  the  disease  is  called  Eczema  impetiginodes. 
Favus  occasionally  causes  considerable  irritation,  producing  a  pustular 
or  impetiginous  margin  around  it.  The  vesicles  of  scabies  are  often  ac- 
companied by  the  pustules  of  ecthyma,  and  so  on. 

In  very  chronic  skin  diseases,  it  may  happen  that  it  is  impossible  to 
say  what  the  original  disorder  was,  whether  vesicular,  pustular,  scaly,  or 
papular.  In  such  cases  the  skin  assumes  a  red  colour,  the  dermis  is 
thickened,  the  epidermis  rough  and  indurated,  and  a  morbid  state  is 
occasioned,  in  which  all  trace  of  the  original  disease  is  lost,  and  what 
remains  is  a  condition  common  to  various  disorders. 

As  regai"ds  varieties,  little  need  be  said,  and  as  formerly  stated  I  advise 
you  to  postpone  their  study  until  you  are  acquainted  with  the  diseases 
themselves.  Even  then  an  acquaintance  with  them  is  of  secondary  im- 
portance. These  varieties  have  been  formed  on  account  of  the  most 
varied  circumstances,  such  as, — 1st,  Dukation,  most  of  them  may  be  acute 
or  chronic ;  2d,  Obstinacy,  hence  the  terms/w^'a.r,  invetej'ula,  acrius,  etc. ; 
3d.  Intensity,  hence  the  terms  mitis,  maligna,  etc. ;  4th,  Situation,  hence 
the  terms  capitis,  facialis,  labialis,  palmaris,  etc. ;  5th,  Form,  hence  the 
terms  circinnatus,  scutulata,  iris,  gyrata,  larvalis,  Jigurata,  tuberosa,  gut- 
tata, etc. ;  6th,  Constitution,  hence  the  terras  cachectica,  scorbutica, 
syiyhilitica,  etc. ;  7th,  Age,  hence  the  terms  infantilis,  senilis,  etc. ;  8th, 


782  DISEASES   OF   THE   INTEGUMENTARY   SYSTEil. 

Colour,  hence  the  terms  album,  nigrum,  rabrum,  versicolor,  etc. ;  9th, 
Density,  hence  the  terms  Sjxirsa,  diffusa,  concentricus,  etc.;  10th,  Feel, 
hence  the  terms  Icsve,  indurata  ;  11th,  Sensatiox  produced,  hence  the 
terms  formicans,  pruritus,  urticans,  etc. ;  12th,  Geographical  distri- 
bution, hence  the  terms  tropicus,  ^riyptiana,  y^orwegiana,  etc. 

Porrigo. 

There  was  a  period  in  the  history  of  skin  diseases  when  they  were 
arranged  in  two  great  divisions,  viz.,  those  atFecting  the  scalp,  and  those 
affectmg  the  rest  of  the  cutaneous  surface.  All  the  disorders  compre- 
hended in  the  first  of  these  divisions  received  the  name  of  Porrigo,  a 
word  said  by  some  to  be  derived  from  porrum,  on  account  of  the  scales 
or  concretions  of  the  scalp  resembling  the  layers  of  an  onion  ;  by  others 
it  is  derived  from  porrigo,  to  spread.  Willan  described  six  kinds  of 
Porrigo,  viz.,  P.  larvalis,  P.furfurans,  P.  scutulata.  P.  favosa,  P.  lupi- 
nosa,  P.  decalvans.  It  is  now  ascertained  that  none  of  these  diseases  are 
necessarily  peculiar  to  the  scalp, — and  that,  although  they  are  more  or 
less  modified  by  being  connected  with  and  aft'ecting  the  hairs  of  that 
region,  they  may  also  occur  on  other  parts  of  the  skin.  There  can  be 
little  doubt,  however,  that  the  employment  of  the  term  Porrigo,  as  well 
as  the  corresponding  word  Teigne  in  France,  has  thrown  great  confusion 
over  the  subject  of  eruptions  on  the  scalp.  But  as  this  term  is  still  in 
pretty  general  use,  it  will  be  well  to  explain  to  you  what  diseases  these 
difierent  kinds  of  Porrigo  really  are. 

Porrigo  larvalis  (larva,  a  mask)  is  really  Impetigo,  or  Eczema  impe- 
tiginodes,  of  the  scalp.  The  former  is  recognised  by  crusts  more  or  less 
prominent  or  nodulated  ;  the  latter,  by  the  circumstance  that,  in  addition 
to  these  nodules,  there  is  between  them  a  laminated  or  brittle  crust, 
spread  more  or  less  equally  over  the  surface.  They  are  both  very 
common  in  infants  and  children  ;  and  as  the  disease  sometimes  extends 
over  the  face,  concealing  the  features,  hence  the  term  larvalis.  A  very 
characteristic  representation  of  Impetigo  capitis,  is  given  in  Wilhm  and 
Bateman,  Plate  xli.,  erroneously  called  Porrigo  favosa.  (See  also  the 
disease  on  the  face,  ibid.  Plate  xxxvii.     Alibert,  Planches  13  and  15.) 

Porrigo  furfurans  {furfur,  bran)  is  really  Pityriasis  of  the  scalp, 
although  Psoriasis  of  that  region  has  also  received  the  same  appellation. 
There  is  also  a  peculiar  form  of  Eczema,  or  Eczema  impetiginodes,  in 
which  the  crust  is  friable,  and  breaks  up,  or  crumbles  into  minute  frao-- 
ments,  to  which  the  term  furfurans  has  been  erroneously  applied.  The 
true  Porrigo  furfurans  (Pityriasis)  is  well  represented. —  Willan  and 
Bateman,  Plate  xxxviii.  Alibert,  Planches  14  and  15.  It  is  often  a 
form  of  favus.     (See  Favus.) 

Porrigo  scutulata  (scutulum,  a  small  shield). — The  nature  of  this 
disease  has  been  much  disputed.  By  some,  it  is  said  to  be  Favus 
(Erasmus  Wilson),  by  others  a  form  of  Herpes  (Cazenave).  The  disease 
is  described  by  AVillan  and  Bateman,  and  more  recently  by  Burgess,  as 
consisting  of  oval  or  rounded,  slightly  elevated  patches,  covered  with 
fiirfur,  and  having  stunted  or  filamentous  hair  projecting  from  the  sur- 


THE   TREATMENT   OF   SKIN   DISEASES.  783 

face.  It  is  a  form  of  skin  eniption  exceedingly  rare  in  Edinburgh.  It 
seems  to  be  represented,  Willan  and  Bateman,  Plate  xxxix.  Willis 
(Trichosis  scutulata). 

Porrigo  favosa  [favtis,  a  hone3'comb)  is  a  disease,  the  true  nature  of 
Avhich  has  been  only  lately  determined.  It  consists  essentially  of 
an  exudation  on  the  skin,  in  which  fungi  or  phytaceous  plants  grow. 
Round,  isolated,  bright  yellow  crusts  are  formed,  which,  when  compressed 
together,  assume  an  hexagonal  shape — hence  the  term  favosa.  It  is  well 
represented.  Willis  (Trichosis  lupinosa).  Erasmus  Wilson,  Fasciculus 
I.     Alibert,  PJanche  17. 

Porrigo  lupinosa  (lujiinuw,  the  lupine). — This  is  the  same  disease  as 
the  last.  The  lound  or  oval  crusts  when  isolated,  and  at  an  early  stage, 
present  a  concavity  and  form,  resembling  that  of  the  lupine  seed — hence 
its  name. 

Porrigo  decalvans  {calvus,  bald). — Baldness  is  so  common  among  the 
aged,  that  it  can  scarcely  be  called  a  disease ;  but  when  it  occurs  in 
young  persons,  and  is  circumscribed,  it  constitutes  the  Porrigo  decalvans 
of  Willan.  It  is  said  by  Gruby  to  depend  on  a  vegetable  parasite  grow- 
ing in  the  hair.  It  is  well  represented,  Willan  and  Bateman,  Plate  xl. 
Willis  (Trichosis  decalvans). 

From  this  analysis  of  the  difterent  kinds  of  the  so-called  Porrigo, 
you  observe  that  there  is  nothing  peculiar  with  regard  to  them.  With 
the  exception  of  baldness,  none  essentially  belong  to  the  hairy  scalp. 
True  favus  is  far  more  common  on  the  head  than  elsewhere  ;  but  I 
have  frequently  seen  it  on  various  parts  of  the  cutaneous  surface,  and 
occasionally  on  the  cheeks  or  shoulders,  without  being  on  the  scalp  at 
all.  It  follows  that  instead  of  the  term  Porrigo,  you  should  designate 
the  disease  as  Eczema,  Impetigo,  Pityriasis,  Psoriasis,  or  Favus  of  the 
scalp,  as  the  case  may  be. 

Notwithstanding  I  have  endeavoured  to  place  this  subject  before  you 
in  as  simple  and  uncomplicated  a  form  as  possible,  I  am  conscious  that 
at  first  you  will  still  experience  considerable  ditticulty  in  the  diagnosis 
of  skin  affections.  This  can  only  be  removed  by  practical  experience 
at  the  bed-side,  and  by  constantly  exercising  your  powers  of  observation 
in  detecting  the  essential  elements  which  theirvaried  forms  present.  At 
the  same  tiuje,  I  think  the  modified  classification  and  short  characters  I 
have  given,  will  materially  assist  your  studies  in  this  important  depart- 
ment of  practical  medicine.  It  must  be  remembered,  however,  that  they 
only  refer  to  those  cutaneous  diseases  which  you  are  liable  to  meet  with 
in  this  country.  Should  you  ever  be  called  upon  to  j^ractise  in  the 
tropics,  or  in  other  places  where  peculiar  skin  disorders  prevail,  it  will, 
of  course,  be  your  duty  to  study  them  in  an  especial  manner.  Here,  as 
they  cannot  be  made  the  subject  of  clinical  observation,  they  are  alto- 
gether removed  from  our  consideration. 

THE  TREATMENT  OF  SKIN  DISEASES. 

Since  the  addition  of  a  ward  for  skin  diseases  to  the  clinical  department 
of  the  Royal  Infirmary,  I  have  had  ample  opportunities  of  determining 


78-i  DISEASES   OF   THE    INTEGUMENTARY   SYSTEM. 

what  are  the  more  common  forms  of  cutaneous  eruption  met  with  in 
Edinburgh,  and  of  trying  various  kinds  of  remedies.  As  the  iUustration 
of  so  many  foruis  of  integumentary  disease  by  reports  of  cases  is  in  this 
work  impossible,  I  propose  now  to  give  a  condensed  account  of  the  treat- 
ment I  have  found  most  successful. 

Exanthemata. 

Few  cases  labouring  under  erythema,  roseola,  or  urticaria,  enter  the 
Infirmary,  and  in  sucli  as  occasionally  present  these  eruptions  during 
their  residence  there,  the  mildest  remedies  suffice  for  their  removal.  In 
the  severer  cases,  a  saturnine  lotion  to  diminish  local  irritation,  with  a 
saline  purgative,  generally  suffices  for  the  cure. 

Yesicul^e. 

Eczema  is  by  far  the  most  common  disease  met  with,  both  in  the  acute 
and  chronic  forms.  The  local  treatment  I  have  found  most  effiacious  is 
that  which  I  first  recommended  in  1849.*  It  consists  in  keeping  the 
affected  part  moist,  with  lint  or  linen  saturated  in  a  very  weak  alkaline 
solution,  consisting  of  3  ss  of  the  common  carbonate  of  soda  dissolved  in 
a  pint  of  water.  For  this  purpose  it  is  necessary  to  cover  the  moistened 
lint  with  oil  silk,  or  gutta  percha  sheeting,  which  should  well  overlap  the 
lint  below,  so  as  to  prevent  evaporation.  The  usual  effect  is  soon  to 
remove  all  local  irritation,  and  especially  the  itching  or  smarting  so 
distressing  to  the  patient.  It  also  keeps  the  surface  clean,  and  prevents 
the  accumulation  of  those  scabs  and  crusts,  which  in  themselves  often 
tend  to  keep  up  the  disease.  After  a  time,  even  the  indurated  parts 
begin  to  soften,  the  margins  of  the  eruption  lose  their  fiery  red  colour, 
and  merge  into  that  of  the  healthy  skin,  and,  finally,  the  whole  surface 
assumes  its  normal  character. 

In  private  practice,  it  is  often  a  matter  of  great  difficulty  to  secure  a 
proper  application  of  the  lotion.  Individuals  are  slow  to  accept  the  idea 
that  constant  moisture  of  the  part  is  absolutely  necessary  for  the  treat- 
ment, and  hence  vigilant  superintendence  and  frequent  visits  are  requisite, 
in  order  to  watch  the  progress  of  the  case.  Even  in  the  hospital  constant 
care  is  necessary,  to  see  that  nurses  properly  cover  the  eruption  ;  and 
when,  as  sometimes  happens,  this  task  is  given  to  the  patients  themselves, 
it  almost  always  fails.  Then  there  are  some  portions  of  tlie  surface 
which  it  is  very  difficult  to  keep  moist  and  well  covered,  such  as  the  f;ice 
and  axillse.  But,  by  carefully  adapting  lint  and  gutta  percha  sheeting, 
attaching  strings  to  the  edges  of  the  latter,  so  as  to  keep  the  whole 
in  its  place,  I  have  never  failed  in  ultimately  carrying  out  my  object. 
In  the  Infirmary  I  treat  vesicular  eruptions  of  the  face  in  this  way  by 
means  of  a  mask,  having  apertures  for  the  eyes,  nostrils,  and  mouth. 
If  the  eruption  be  very  general,  long  soaking  in  slightly  alkaline  baths 
is  useful. 

In  addition  to  stating  what  I  have  found  to  be  beneficial,  it  is  import- 
ant to  say  what  I  have,  on  careful  trial,  ascertained  to  be  useless  or 
iniurious.  Perhaps  no  remedy  is  more  generally  employed  in  this  and 
a  Variety  of  other  skin  diseases  than  citrine  ointment,  an  application  that 
*  Monthly  Journal  of  Medical  Science,  August  1849. 


THE   TREATMENT   OF   SKIN   DISEASES.  785 

I  have  always  found  to  irritate  and  make  eczematous  eruptions  worse. 
At  the  same  time,  there  are  some  very  chronic  forms  of  tlie  disease,  which 
I  have  been  told  are  cured  by  this  preparation,  but  what  these  are  I 
have  never  been  able  to  ascertain.  Indeed,  all  greasy  applications  what- 
ever, in  acute  cases,  are  useless,  and  the  patients  themselves  sav,  are  very 
"heating."  I  have  tried  the  freezing  process  recommended  by  Dr. 
Arnott,  but  the  salt  of  the  frigoi'ific  mixture,  and  the  cold  itself,  has 
caused  apparently  so  much  agony,  that  I  have  been  deterred  from 
using  it,  especially  Avhen  the  emollient  moist  alkaline  application  is  so 
efficacious. 

In  some  rebellious  chronic  cases  I  have  occasionally  found  the  oil  of 
cade  a  useful  remedy,  and  in  others  the  oxide  of  zinc  ointment.  They 
are  most  beneficial  after  a  prolonged  use  of  moist  alkaline  application. 
In  the  same  way,  friction  with  the  hand  or  a  soft  flesh  brush  favours  the 
disappearance  of  the  chronic  induration  and  vascularity  of  chronic 
eczema  of  the  inferior  extremities,  which  should  be  kept  as  much  as 
possible  in  the  recumbent  position.  These  stimulating  applications, 
whilst  useful  in  the  very  chronic  and  non-irritative  forms  of  the  disease, 
or  to  remove  what  an  emollient  treatment  tails  to  accomplish,  are  most 
injurious  in  the  acute  forms. 

Herpes. — This  disease  generally  runs  its  course  in  about  fourteen  days, 
and  requires  no  treatment  whatever,  further  than  an  acetate  of  lead 
lotion  to  allay  the  smarting.     It  is  not  very  common. 

Scabies  occurs  very  frequently,  and  is  cured  by  a  host  of  remedies. 
A  strong  lather,  made  of  common  soft  soap  and  warm  water,  twice  a  day, 
answers  very  well.  The  question  with  scabies,  is  not  what  remedy  is 
useful,  but  which  will  cure  it  in  the  shortest  period.  The  most  extensive 
experience  at  St.  Louis  has  shown,  that  the  sulphur  and  alkaline,  or 
Helmerinch's  ointment,  cures  itcli,  on  an  average,  in  seven  days.  That 
sulphur,  however,  is  not  the  active  remedy,  I  have  satisfied  mvself  bv 
experiment.  Soft  soap,  as  we  have  seen,  wliich  contains  alkali,  and  eveii 
simple  lard,  if  pains  be  taken  to  keep  the  parts  constantly  covered  with 
it,  will  cure  the  disease  as  soon  as  sulphur  ointment.  I  have  tried  the 
Stavesacre  ointment,  recommended  by  ]\I.  Bourguignon,  in  only  a  few 
cases,  but  found  it  to  answer  very  well.  Its  superiority,  however,  over 
other  applications,  I  am  not  yet  prepared  to  admit.     (See  Dermatozoa.) 

Pempliifius. — This  is  rather  a  rare  disease,  and  Avhen  chronic,  comino- 
out  in  successive  crops,  is  very  rebellious.  I  liave  cured  several  acute, 
and  some  tolerably  chronic  cases  in  tVom  one  to  three  weeks,  by  the 
weak  alkaline  wash,  applied  as  in  the  case  of  eczema,  combined"  with 
generous  diet. 

PuSTUL.E. 

Impefif/o. — This  affection  in  all  its  forms  is  very  common,  and  is  best 
treated  by  the  weak  alkaline  wash,  exactly  the  same  as  in  eczema.  In 
the  chronic  foi'ms  which  attack  the  chin  of  men,  constituting  one  of  the 
varieties  of  mentagi-a,  the  same  treatment  cures  the  most  rebellious  cases, 
if  the  moisture  be  constantly  preserved.  For  this  purpose  the  hair  must 
be  cautiously  cut  shoit  with  sharp  scissors,  and  the  razor  carefully 
avoided.  If  the  side  of  the  cheek  covered  by  the  wliisker  be  attacked, 
removal  of  the  hair  from  thence  also  is  essential  to  the  treatment.     A 

50 


786  DISEASES   OF   THE   INTEGUMEXTART   STSTE3I. 

bag  or  covering  accurately  adapted  to  the  part  aflFected  must  be  made  of 
gutta  percha  slieeting,  and  tied  on  with  strings.  This  may  be  covered  with 
a  piece  of  black  silk,"to  allow  the  individual  to  go  about  and  carry  on  his 
usual  occupations.  In  this  way  I  have  frequently  seen  chronic  impetigo 
of  the  chin,  of  from  eight  to  ten  years'  standing,  which  has  resisted  all 
kinds  of  ointments  and  heroic  remedies,  completely  removed  in  a  few 
weeks.  But  then  the  surface  must  be  kei^t  constanihj  moist,  a  circum- 
stance requirino-  great  care  and  determination  on  the  part  of  the  patient. 
When  it  becomes  necessary  to  shave,  flour  and  warm  water,  or  paste, 
should  be  used,  and  not  soap.  Alkalies  applied  from  time  to  time  only, 
as  in  the  form  of  wash  or  soap,  always  irritate,  although,  when  employed 
continuously,  they  are  soothing. 

Ecthyma  is  not  a  common  disease,  and  usually  presents  itself  con- 
joined with  Eczema  or  Impetigo,  and  is  treated  successfully  in  the  same 
manner  as  those  diseases.  The  E.  cachectkum  requires,  in  addition  to 
the  alkaline  wash  locally,  a  generous  diet. 

Acne  is  a  disease  always  requiring  constitutional  rather  than  local 
remedies.  Although  not  uncommon  in  private,  it  is  rare  in  hospital 
practice.  Careful  "regulation  of  the  diet,  abstinence  from  wine  and 
stimulating  articles  of  food,  watering-places,  baths,  etc.,  etc.,  constitute 
the  appropriate  treatment. 

Bdp'td. — This  disease  I  have  never  seen  occur  but  in  individuals  who 
have  been  subjected  to  the  influence  of  mercurial  poisoning.  Hydriodate 
of  potassium  and  tonic  remedies,  with  careful  avoidance  of  mercury  in 
all  its  forms,  is  the  general  treatment  I  have  found  most  successful.  If 
the  pustules  be  few1n  number,  the  scabs  may  be  removed  by  poulticing, 
and  the  sores  treated  locally  with  water  dressing  or  red  wash.  But  it 
thev  are  numerous,  great  caution  should  be  exercised  in  exposing  so 
main-  ulcerated  surfaces,  and  it  is  better  to  let  the  crusts  remain. 

Papula. 

Lichen  and  Prurigo. — In  both  these  affections,  constant  inunction 
with  lard  is  as  beneficial  as  constant  moisture  in  the  eczematous  and 
impeticrinous  disorders.  In  the  prurigo  of  aged  persons,  the  Ung.  Hyd. 
Preci'p.  All),  is  a  useful  application,  although  the  disease  is  not  unfie- 
quentlv  so  rebellious  as  only  to  admit  of  palliation.  The  chronic  papular 
diseases  often  constitute  the  despair  of  the  physician. 

Sqlam^. 

Psoriasis,  and  that  modification  of  it  known  as  lepra,  is  a  very 
common  disease,  and  has  been  uniformly  treated  by  me  externally  with 
pitch  ointment.  I  have  satisfied  myself  by  careful  trials  that  it  is  the 
pitch  applied  to  the  part  that  is  the  beneficial  agent,  as  1  have  given 
pitch  pills  and  infusion  of  pitch  largely  internally,  without  benefit. 
With  tbe  hope  of  obtaining  a  less  disagreeable  remedy,  I  have  frequently 
tried  creosote,  and  naphtha  ointment,  and  washes,  but  also  without 
benefit.  Lastly,  I  have  caused  simple  lard  to  be  rubbed  in  for  a 
lengthened  time,  but  without  doing  the  slightest  good.  The  oil  of  cade 
is  occasionally  useful,  especially  in  psoriasis  of  the  scalp.  Internally,  I 
give  jive  drops  of  Fowler's  solutioii,  and  as  many  of  the  tr.  cantharidis. 


THE    TREATMENT   OF   SKIX   DISEASES.  787 

It  is  rare  that  tlie  internal  treatment  alone  produces  any  effect  on  a 
case  of  psoriasis  of  any  standing.  If  a  case  resists  this  conjoined 
external  and  internal  treatment,  I  have  always  found  it  incurable. 
Some  years  ago  I  carefully  treated  a  series  of  cases  iuternallv  with 
Donovan's  solution,  without  producing  the  slightest  benefit. 

True  Piti/riasis  frequently  disappears  of  itself  In  chronic  cases 
the  treatment  by  pitcli  is  useful,  and  sometimes  the  application  of  the 
Ung.  Zinci  Oxyd.  or  Ung.  Hyd.  Precip.  Alb.  The  form  of  pityriasis 
that  is  dependent  on  a  vegetable  fungus  is  identical  with  favus.  (See 
Favus.) 

Ichtlvjosis. — I  have  treated  several  chronic  cases  of  ichthyosis.  But 
while  in  some  cases  the  skin  has  become  a  little  softer  from  a  course  of 
pitch  treatment,  no  permanent  cure  was  effected. 

TCBERCCL^E. 

Lupus  is  the  only  kind  of  tubercular  skin  disease  I  have  seen  in 
the  skin  ward  of  the  Infirmary,  and  that  is  pretty  common.  It  is  a 
constitutional  disorder,  and  must  be  treated  by  cod-liver  oil,  and  all 
those  remedies  useful  for  scrofula,  of  which  it  is  a  local  manifestation. 
The  external  treatment  is  surgical,  consisting  of  the  occasional  appli- 
cation of  caustics,  red  lotion,  water  dressing,  ointments,  etc.,  accordino- 
to  the  appearances  of  the  sore.  I  agree  with  Hebra  in  thinkim*-  lupus 
and  the  radesyge  of  the  Norwegians  to  be  the  same  disease.  Manv 
years  ago  I  found  lupus  of  the  legs  and  thighs  to  exist  among  the  fisher- 
women  of  Xewhaven,  who  assisted  their  husbands  in  hauling  in  their 
boats,  or  who  were  accustomed  to  wade  for  any  length  of  time  in 
salt  water. 

Macul.e. 

Lentir/o  I  have  never  found  to  be  benefited  by  any  kind  of  treat- 
ment, local  or  general.  It  is  evidently  connected  with  season  and  the 
intensity  of  the  sun's  rays,  as  it  often  disappears  in  winter  and  returns 
in  summer. 

Ephdis  o.nd  x^cevi  are  alike  incurable.  Bronzino-  from  exposure  to 
the  sun,  as  in  hot  climates,  frequently  disappears  on  returning  to  a 
temperate  latitude. 

Purpura  is  a  constitutional  disorder,  for  the  most  part  allied  to 
scurvy.  It  consists  of  an  alteration  of  the  blood,  with  tendency  to 
disintegration  of  the  coloured  corpuscles  and  diffusion  of  haematozine. 
Under  such  circumstances,  ecchymoses  occur  in  the  skin,  sometimes 
confined  to  round  spots  varying  in  size,  at  others  existing  in  patches. 
It  is  for  the  most  part  associated  with  weakness,  and  requires  rest  and 
time  to  permit  absorption  of  the  extravasated  blood,  conjoined  with 
tonics,  anti-scorbutics,  and  generous  diet.  In  sea  scurvy,  lemou  juice 
and  fresh  vegetables  are  the  true  remedies.     (See  Scorbutus.) 

Scalp  diseases  must  be  treated  according  as  they  depend  on  eczema, 
impetigo,  psoriasis,  or  favus,  in  all  cases  first  removing  the  crusts  with 
poultices,  then  keeping  the  head  shaved,  and,  lastly,  applying  alkaline 
washes,  pitch  ointment,  or  oil,  according  to  the  directions  formerly 
given.      Ringworm  is   a  disease  I  have  never  seen  in  Edinburgh,  and 


788  DISEASES   OF    THE   INTEGUMENTARY   SYSTEM. 

of  what  it  consists  I  am  ignorant.  Some  writers  apparently  consider 
it  to  be  favus,  and  others  a  form  of  herpes.  On  two  or  three  occasions 
I  have  seen  a  scaly  disease  of  the  scalp,  in  the  form  of  a  ring — that  is 
lepra,  which  I  have  cured  by  pitch  ointment,  or  oil  of  cade.  Dr. 
Andrew  Wood  informed  me  some  time  ago,  that  he  banished  it  from 
the  Heriot's  Hospital  school  of  this  city  by  condensing  on  the  eruption 
the  fumes  of  coarse  brown  paper,  and  thus  causing  an  empyrcumatic 
oil,  or  kind  of  tar  to  fall  upon  the  part.  This  at  one  time  led  me  to 
suppose  that  it  might  be  a  scaly  disease,  and  a  form  of  lepra  or  psoriasis. 
On  the  whole,  I  am  inclined  to' think  it  a  form  of  favus,  which  has  com- 
monly been  mistaken  for  a  scaly  disease  of  the  scalp.     (See  Favus.) 

So-called  Si/philitic  diseases  of  the  skin  are,  in  my  opinion,  the 
various  disorders  already  alluded  to,  modified  by  occurring  in  individuals 
who  have  suffered  for' periods  more  or  less  'long  from  the  poisonous 
action  of  mercurv.  A  longer  time  will  be  required  for  their  cure,  but 
the  same  remedies  locally^  conjoined  with  hydriodate  of  potassium  in 
small  doses,  with  bitter  i'nfusions,  tonics,  and  a  regulated  diet,  offer  the 
best  chance  of  success. 

The  great  difficulty  in  the  treatment  of  skin  diseases,  generally  con- 
sists in  their  having  been  mismanaged  in  the  early  stages — a  circum- 
stance I  attribute  to  the  little  care  with  which,  until  a  recent  period, 
clinical  students  have  studied  them.  Many  chronic  cases  of  eczema 
are  continually  coming  under  my  notice,  which,  in  their  acute  forms, 
have  been  treated  by  "citrine  ointment,  or  other  irritating  applications, 
that  almost  invariably  exasperate  the  disorder.  1  shall  not  easily 
forget  the  case  of  one  gentleman,  covered  all  over  with  acute  eczema, 
who  had  suffered  excessive  torture  from  its  having  been  mistaken  for 
psoriasis,  and  rubbed  for  some  time  with  pitch  ointment.  In  the  same 
way  I  have  seen  a  simple  herpes,  which  would  have  readily  got  well 
if  left  to  itself,  converted  into  an  ulcerative  sore  by  the  use  of  mercurial 
ointment.  Nothing  is  more  common  than  to  confound  chronic  eczema 
of  the  scalp  with  favos,  although  the  microscope  furnishes  us  with  the 
most  exact  means  of  diagnosis.  I  have  seen  one  case  in  which  a 
chronic  eczema  of  the  clieek  was  cut  out  by  a  surgeon,  under  the  idea 
that  the  disease  was  malignant.  I  presume  that  acne  must  frequently 
have  been  mistaken  for  tubercular  disease.  In  no  other  ^yay  can  I 
account  for  some  very  distressing  cases,  where  the  patients'  faces  have 
been  painted  over  wi'th  butter  of  antimony.  I  need  scarcely  say,  that 
the  correct  application  of  the  remedies  I  have  spoken  of  can  only  be 
secured  bv  an  accurate  discrimination,  in  the  first  instance,  of  the  dis- 
eases to  which  they  are  applicable. 

The  general  constitutional  treatment  in  all  these  cases  seldom  demands 
aperient  or  lowering  remedies  except  in  young  and  robust  individuals 
with  febrile  symptoms.  In  the  great  majority  of  cases,  cod-liver  oil, 
o-ood  diet,  and  tonics  are  required.  In  a  few  instances  sedatives,  both 
focally  and  internally,  are  necessary  to  overcome  excessive  itching  or 
irritation.  These  the  judicious  practitioner  will  readily  understand  how 
to  apply  according  to'  circumstances.  Baths  in  all  their  various  forms 
are  useful  in  skin  diseases,  although,  since  I  have  applied  a  kind  of  con- 
stant local  bath  in  the  form  of  moist  application,  formerly  alluded  to 
(see  Treatment  of  Eczema),  they  are  comparatively  seldom  used  by  me 


DERMATOZOA. 


789 


in  the  Infirmary.  The  natural  baths  and  mineral  springs  of  watering 
places  in  Great  Britain,  France,  and  Germany,  are  undoubtedly  beneficial 
in  appropriate  chronic  cases. 

DERMATOZOA. 

The  skin  may  be  attacked  by  certain  animal  parasites.  Of  these  the 
pediculi,  or  lice',  are  too  well  known  to  need  description.  But  we  may 
shortly  allude  to  the  Acarus  scabiei,  and  the  Eutozoon  folliculorum. 

AcARUS  Scabiei. 

This  insect  has  been  proved  by  the  researches  of  M.  Bourguignon*  to 
be  the  undoubted  cause  of  itch.  The  male  is  about  a  third  smaller  than 
the  female.  lie  has  suckers  on  two  of  his  hind  feet,  and  possesses  on  the 
abdominal  surface  genital  organs,  all  of  which  characters  are  absent  in 
the  female.  She,  on  the  other  hand,  in  addition  to  her  size,  and  the 
negative  marks  alluded  to,  is  characterised  by  the  three  kinds  of  horny 


spines  which  are  scattered  over  the  back.     The  suckers,  or  ambulacria, 

are  organs  of  locomotion ;  the  mandibles  enable  it  to  cut  the  epidermis, 

*  Traite  entomologique  et  pathologique  de  la  gale  de  I'liomme.    4to.    Paris,  1852. 


Fig.  457.  Dorsal  surface  of  the  female  Acarus  Scabiei. 

Fig.  458.  Ventral  surface  of  tlie  same. 

Fig.  459.  Ventral  surface  of  the  male  Acarus. — {Bourguignon). 


100  diam. 


790  DISEASES   OF   THE    INTEGUMENTARY    SYSTEM. 

and  extract  fluid  from  the  tissues,  which  passes  through  a  delicate  oeso- 
phagus, the  inteinal  termination  of  which  is  unknown,  the  body  of  the 
animal  being  appaiently  filled  with  an  unorganized,  very  finely  molecu- 
lar pulp.  A  short  delicate  tube  may  also  sometimes  be  observed  at  the 
anus — a  supposed  rectum.  No  respiratory  appai'atus  can  be  discovered, 
although  the  ci'cature  may  be  seen  to  swallow  minute  bubbles  of  air, 
which  pass  down  the  oesophagus,  and,  like  the  nutritive  juices,  dift'use 
themselves  through  the  interior.  At  all  events,  animal  juice  and  air  are 
both  necessary  to  the  life  of  the  Acarus. 

The  disease  called  scabies  has  been  conclusively  shown  by  M.  Bour- 
guignon  to  be  entirely  owing  to  the  presence  of  the  insect,  and  to  be 
communicated  from  one  person  to  another,  eight  times  out  of  ten,  by 
their  sleeping  together.  The  female  seldom  quits  her  burrow  but  at 
night,  and  if  impregnated,  not  even  then,  unless  distui'bed  mechanically, 
as  by  scratching.  Once  in  motion,  she  crawls  over  the  surface  with  gi'eat 
rapidity,  and  readily  passes  from  one  person  to  another,  where  the  skins 
are  in  contact.  Communication  is  not  readily  occasioned  by  holding  the 
hands  of  those  affected,  or  by  coming  in  contact  with  them  during  the 
day.  The  disease  cannot  be  communicated  by  inoculating  with  the 
serum  of  the  vesicles,  by  the  pus  of  the  pustules,  or  by  any  principle 
contained  in  the  dead  body  of  the  insect  itself.  Neither  can  the  Acarus 
of  one  species  of  animal,  as  of  the  horse,  or  sheep,  inhabit  the  body  of  a 
different  one.  Still  the  disease  is  not  purely  local,  inasmuch  as  papular, 
vesicular,  or  pustular  eruptions  often  occur  in  parts  which  the  Acarus 
has  not  infested,  so  that  the}'  seem  to  originate  from  some  cause  indepen- 
dcTit  of  its  mere  presence. 

The  Acarus  has  a  predilection  for  youth  and  a  tender  skin,  and  has  a 
hatred  of  hair  bulbs.  Hence  why  it  frequents  young  persons  more  com- 
monly than  old  ones,  and  why  in  children  it  occurs  indiscriminately  all 
over  the  body,  while  in  adults  it  is  most  often  found  between  the  fingers 
and  toes,  inside  of  the  thighs  and  genital  organs.  Seventy  times  out  of 
a  hundred,  scabies  is  confined  to  the  hands,  and  in  the  other  thirty, 
occurs  also  on  the  trunk  and  genitals.  The  only  proof  of  the  existence 
of  itch,  is  the  presence  of  the  Acarus,  and  this  is  easily  to  be  detected 
by  a  microscope  adapted  for  the  purpose  by  M.  Bourguignon.  It  con- 
sists of  a  body  with  eye-piece  and  lenses  magnifying  seventy  diameters 
linear,  with  a  condensing  lens,  the  whole  placed  on  a  moveable  arm  with 
several  joints,  attached  to  a  firm  stand.  With  this  instrument  the  entire 
surface  of  the  body  may  be  explored,  and  the  movements  and  doings  of 
the  insects  observed  with  the  utmost  facility.  The  associated  papules, 
vesicles,  and  pustules  are,  in  the  opinion  of  M.  Bourguignon,  in  no  way 
diagnostic. 

M.  Biett  made  a  series  of  experiments  at  the  Hopital  St.  Louis,  to 
determine  what  substance  would  cure  itch  in  the  shortest  space  of  time. 
He  employed  forty-one  different  applications  and  modes  of  treatment. 
The  result  was,  that  frictions  with  the  following  ointment  occasioned 
recovery  on  the  average  in  the  smallest  number  of  days  : — Take  of 
sublimed  sulphur,  two  parts  ;  of  subcarbonate  of  potash,  one  part;  and 
of  lard,  eight  parts. 

M.  x\lbin  Grass  endeavoured  to  ascertain  what  substances  would  most 
quickly  destroy  the  Acarus  just  removed  from  its  burrow.     It  survived 


DERMATOZOA.  791 

three  hours  in  water ;  two  in  olive  oil ;  one  in  a  solution  of  acetate  of  lead  ; 
four-tifths  of  an  hour  in  warm  water ;  twenty  minutes  in  vinegar  and  an 
alkaline  solution  ;  twelve  minutes  in  a  solution  of  sulphuret  of  potash  ; 
nine  minutes  in  turpentine ;  and  from  four  to  six  minutes  in  a  solution 
of  tlie  hvdriodate  of  potash.  It  survived  sixteen  hours  in  the  vapour  of 
sulphur  under  a  watch  glass;  and  one  hour  in  the  flowers  of  sulphur. 
According  to  these  researches,  therefore,  hvdriodate  of  potash  would  be 
the  best  remedv.  He  removed  three  living  insects  from  a  patient  who 
had  taken  three  sulphur  baths,  whereas,  after  a  single  application  of 
Helmerinch's  ointment,  that  is,  where  sulphur  and  potash  are  combined, 
he  frequently  found  them  dead. 

M.  Bouriruignon  with  his  microscope  watched  with  great  care  the 
effect  of  the  frictions  made  at  St.  Louis  with  the  sulphuro-alkaline  oint- 
ment. After  the  first  day,  in  which  there  had  been  two  frictions  and  a 
simple  bath,  the  Acari  were  in  no  way  disturbed.  In  two  days,  after 
four  frictions,  they  were  still  active,  but  burrowed  d.^ep  in  their  grooves. 
In  three  days  they  still  lived,  but  were  unusually  flat ;  but  their  eggs 
could  be  hatched  by  artificial  heat,  and  produced  larv»,  possessing  great 
activitv.  In  four  days  the  insects  in  the  superficial  parts  were  shrivelled 
up  and  dead;  the  deeper  ones,  though  Ww'mg^,  tres  malades.  Many  of 
the  eggs  now  aborted.  In  five  days  all  the  insects  were  dead ;  and  in 
six  even  the  e^gs  had  lost  their  vitality.  The  eruptions,  on  the  other 
liand,  often  remained  stationary,  and  not  unfrequently  became  worse 
from  the  irritation  of  the  ointment  and  frictions,  but  after  a  time  they 
disappear  also.  Uence  it  is  common  at  St,  Louis,  after  seven  or  eight 
days'  friction,  to  send  out  the  patients  though  still  covered  with  erup- 
tion, and  in  most  cases  they  get  well.  About  three  in  ten,  however, 
return  with  the  disease  again  established,  a  circumstance  that  Mons.  B. 
attributes  to  the  fact,  that  the  frictions,  which  were  only  applied  to  the 
superior  and  inferior  extremities,  had  not  destroyed  the  insects  which 
were  present  on  the  trunk. 

"S\.  Bourguignon,  on  considering  the  structure  of  these  Acari,  and  the 
facilitv  with  which  a  poisonous  fluid  could  penetrate  their  delicate  integu- 
ment, was  led  to  make  a  series  of  observations  to  determine  how  long 
they  would  live  after  the  application  of  various  toxic  solutions.  He  found 
those  which  possessed  the  most  energetic  action  on  these  creatures  were 
solutions  of  the  ioduret  of  potassium  and  of  the  ioduret  of  sulphur, 
Avhich  killed  them  in  eight  minutes.  A  solution  of  the  alcoholic  extract 
of  staphisagria  was  the  next  in  virulence,  destroying  the  animals  in 
fifteen  minutes.  The  hands  of  an  itch  patient  were  immersed  in  a  solu- 
tion of  the  two  former  for  two  hours,  so  as  strongly  to  impregnate  and 
colour  the  integuments.  On  examining  the  insects  immediately  after- 
wards, they  were  as  lively  as  ever,  but  on  the  next  day  they  were  all 
dead,  and  the  eggs  destroyed.  The  epidermis  was  greatly  shrivelled, 
and  in  three  davs  complete  desquamation  occurred,  carrying  with  it 
Acari,  grooves,  and  eggs,  and  leaving  the  cutis  raw  and  tentler.  The 
action  on  the  skin  was  evidently  too  strong.  A  bath  of  a  solution  ot 
the  alcoholic  extract  of  staphisagria  was  then  made,  and  immediately 
after  a  two  hours'  immersion  of  the  hands,  all  the  insects  were  found 
dead,  and,  with  one  exception,  the  eggs  destroyed.  So  far  from  irritating 
the  integument,  this  application  at  once  caused  the  itching  to  cease,  and 


792 


DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 


produced  such  calmative  effects,  that  M.  B.  proposes  it  as  a  local  remedy 
for  inflammation.  The  eruptions  also  appeared  to  be  rapidly  cured  by 
it.  After  various  experiments,  he  adopted  an  ointment  of  the  staphisa- 
gria  as  the  most  generally  useful  preparation,  prepared  as  follows : — 
Recent  grains  of  staphisagria  in  powder,  300  grammes ;  boiling  lard, 
500  grammes.  Digest  for  24  hours  at  the  temperature  of  100°  in  a 
sand  bath,  and  strain.  Four  days  of  friction  with  this  ointment,  instead 
of  seven  with  sulphuro-alkaline  ointment,  not  only  destroys  the  insects 
and  their  eggs,  but  completely  cures  and  prevents  the  integumentary 
irritation  and  eruptions. 

Entozoon  Folliculorum. 

This  insect  inhabits  the  sebaceous  follicles  of  the  skin  and  is  very 
common  in  the  face,  more  especially  when  the  seat  of  acne.  In  the 
follicles  of  the  nose  they  are  present  in  the  majority  of  living  persons, 
and,  according  to  Simon,  are  almost  universal  in  dcp.d  bodies.     He  fre- 


Fis.  460. 


Fis.  4G1. 


quently  found  them  living  six  days  after  the  death  of  the  individual  in 
whom  they  were  found.  The  animal  measures  from  1-1 35th  to  1-G4th 
of  an  inch  in  length,  and  from  l-155th  to  l-555th  of  an  inch  in  breadth. 
It  is  composed  of  a  head,  a  thorax,  and  abdomen. 


Fig.  460.  Three  follicles  of  the  skin  of  the  dog  containing  entozoa.  100  diam. 

Fig.  461.  Cul-de-sac  of  a  sebaceous  follicle,  containing  three  animalcules  in  differ- 
ent positions,  and  two  eggs — {after  Ch-uby.)[\  350  diam. 


DERMATOZOA. 


793 


Tlie  head  represents  in  form  a  truncated  cone,  flattened  from  above 
downwards,  and  directed  obliquely  downwards  from  the  anterior  part 
of  the  trunk.  The  existence  of  an  eye  has 
not  been  determined.  The  head  is  furnished 
■with  two  maxillary  palpi,  which  admit  of  ex- 
tensive motion.  The  thorax  is  the  broadest 
part  of  the  animal,  and  is  composed  of  four 
segments.  In  each  of  these,  on  each  side, 
are  two  legs — eight  in  all.  The  abdomen 
varies  in  length,  is  annulated  in  structure,  and 
admits  of  certain  movements.  Internally,  Dr. 
Erasmus  Wilson  has  traced  out  an  alimentary 
canal,  and  its  termination  in  an  anus,  together 
with  a  brownish  mass  which  he  considers  to 
be  the  liver.  No  sexual  difterences  have  been 
discovered  in  them,  and  they  possess  no  respi- 
ratory organs. 

The  animalcule  is  easily  found  by  compressing 
with  two  fingers  the  skin  we  wish  to  examine, 
until  the  sebaceous  matter  is  squeezed  out,  in 
the  form  of  a  little  worm.  This  matter  should 
be  placed  in  a  drop  of  oil  previously  heated, 
then  separated  with  needles,  and  examined 
with  a  microscope  magnifyino-  250  diameters. 
Their  movements  are  slow,  whilst  the  confor- 
mation of  their  articulations  only  permits 
them  to  move  forwards  and  backwards,  like 
lobsters.  (Gruby.)  They  are  nourished  by 
the  sebaceous  secretion  of  the  follicles. 

Thev  most  commonly  occupy  the  excretory 
duct  of  the  follicles,  which  are  often  dilated 
in  the  places  where  they  are  lodged.  Their 
head  is  always  directed  towards  the  base  of 
the  gland.  When  there  are  many  together, 
tliey  are  placed  back  to  back,  and  their  feet 
are  applied  against  the  walls  of  the  duct. 
When  very  numerous  they  are  compressed 
closely  together,  and  are  found  deeper  in  the 
ducts.  They  rarely  exist,  however,  at  the  base  of  the  gland.  In  young 
persons  they  generally  vary  in  number  from  two  to  four ;  in  an  aged 
individual,  they  may  be  from  ten  to  twenty.      (Gruby.) 

Though  this  entozoon  may  occasionally  be  associated  with  acne,  it 
seldom  gives  rise  to  great  inconvenience.  According  to  ilrasmus  Wilson, 
the  difficulty  seems  not  to  be  to  find  these  creatui'es,  but  to  find  any  indi- 
vidual, with  the  exception  of  newly-boi-n  cliildi-en,  in  whom  they  do  not 
exist. 


Fig.  462. 


Fig.  462.  Hair  and  its  follicle,  in  which  may  be  seen  the  auimalcules  descending 
towards  the  root  of  the  hair,  and  cul-de-sac  of  the  follicles. — (Ch-uby.)        100  diam. 


'94:  DISEASES   OF   THE   IXTEGUMENTAEY   SYSTEM. 


DERMATOPHYTA. 

Tlie  fji'owtli  of  parasitic  t"ang-i  on  the  surface  of  the  skin,  has  now 
been  observed  under  a  variety  of  circumstances,  and  constitutes  occa- 
sionallv  in  man  three  forms  of  skin  disease,  which  I  believe  to  be  essen- 
tially the  same,  viz. — tyenia  favosa,  a  certain  form  of  pityriasis  of  the  scalp 
and  of  mentagra.  The  latter  is  very  rare  in  this  country ;  and  I  have 
never  seen  a  case  of  it.  All  these  disorders,  howevei-,  may  be  classified 
under  the  head  of  favus,  under  which  I  shall  consider  them. 

Fay  us. 
Case  CLXXYII.* — Favus  of  the  Scal2)  in  an  adult — Incurable. 

History. — Isabella  Fergusson,  a>t.  22,  a  somewhat  stout  servant  girl,  with  fair 
skin,  and  scrofulous  aspect,  was  admitted  into  tlie  clinical  ward  of  the  Royal  Infir- 
mary, Mav  6,  1849.  She  states  that  there  has  been  au  eruption  on  her  head  for  the 
last  twelve  years.  Four  months  ago  the  catamenia  ceased,  since  whicli  time  she  has 
been  subject  to  occasional  headache,  constipation,  and  slight  dyspepsia. 

Symptoms  on  Admissiox. — Nearly  the  whole  of  the  scalp  is  covered  with  a  thick 
yellow  friable  crust,  of  uneven  surface,  and  irregular  margin,  emitting  a  highly 
offensive  odour,  like  cat's  urine,  and  causing  great  itching  and  irritation.  Up  to 
the  middle  of  July  she  was  treated  with  various  internal  remedies,  which  subdued 
the  constipation  and  dyspepsia,  and  caused  return  of  the  catamenia.  The  crusts  on 
the  scalp  Avere  removed  by  poultices,  and  au  ointment,  composed  of  ammon.  mur. 
3  j ;  and  umj.  sulphuris  §  j,  applied  locally.  Dr.  Bennett  first  took  charge  of  the 
ease  ou  the  14th  of  June.  The  head  was  then  again  covered  with  favus  crusts,  some 
isolated,  others  compressed  together,  and  forming  au  elevated  scab.  A  small  portion 
examined  under  the  microscope,  presented  the  branches  and  sporules  of  the  crypto- 
gamic  plant  so  characteristic  of  the  disease.  Tlie  crusts  vjere  again  removed  by 
2)ouUices  of  linseed  meal,  the  head  shaved,  and  cod-liver  oil  ordered  to  be  applied  to  the 
scalp  morning  and  evening — the  whole  to  be  covered  with  an  oilrsilk  cap.  This  treat- 
ment was  continued  for  six  weeks,  but  on  suspending  it  the  favus  crusts  returned. 
During  the  mouths  of  August  and  September,  iodine  and  pitch  ointments  were 
applied ;  portions  of  the  scalp  were  even  blistered,  but  without  eflect. 

Progress  of  the  Case. — At  the  commencement  of  October,  the  scalp  being  at 
the  time  perfectly  clean  and  closely  shaved,  all  local  treatment  was  suspended,  and 
the  reappearance  of  the  disease  carefully  watched.  In  three  da3-s  the  eutue  surface 
presented  a  scaly  eruption,  the  epidermis  being  raised,  cracked,  and  broken  up  over 
the  whole  scalp,  which  was  exceedingly  dry  and  harsh.  The  furfuraceous  con- 
dition of  the  scalp  continued,  becoming  more  and  more  dense,  until  the  fourteenth 
day,  when  there  were  first  perceived  minute  bright  sulphur-coloured  spots  in  it. 
These,  on  being  examined  microscopically,  were  seen  to  be  composed  of  fine  mole- 
cular matter,  mingled  with  epidermic  scales,  from  which  delicate  branched  tubes 
were  apparenth'  growing.  The  crusts  were  now  once  more  removed  by  repeated 
poulticing,  and  cod-liver  oil  applied  as  formerly.  The  scalp  continued  fi-ee  from 
eruption  until  the  20th  of  November,  when  she  was  seized  with  febrile  symptoms, 
which  ushered  in  a  very  severe  attack  of  typhus,  that  ran  its  usual  course.  She 
was  not  considered  fully  convalescent  until  the  %ih  of  December.      During  this 

*  Reported  by  Mr.  "William  Johnson,  Clinical  Clerk. 


DERMATOPHYTA.  795 

period,  no  local  application  was  made  to  the  scalp,  with  the  exception  of  tlie  cold 
douche  to  alleviate  the  head  sj-niptoms,  delirium  and  coma  having  been  severe. 
The  surface  latterly  once  more  became  covered  with  furfuraceous  scales ;  and  on  the 
nth  December  the  bright  yellow  minute  spots  again  made  their  appearance.  As 
her  strength  improved,  tlie  favus  crusts  increased  in  size  and  number,  and  the  pro- 
gress of  this  very  singular  disease  was  again  very  carefully  watched.  Each  individual 
crust,  at  Urst  the  size  of  a  small  pin's  head,  gradually  flattened  out  and  became 
circular.  Its  centre  was  cupped  and  umbilicated,  and  many,  which  were  more 
isolated  than  the  rest,  grew  until  they  measured  a  quarter  of  an  inch  in  diameter. 
More  generally,  however,  they  came  in  contact  with  others,  and  groups  of  twos,  or 
threes,  and  sometimes  a  dozen,  became  compressed  together  and  presented  the 
hexagonal  form  of  the  honey-comb.  Gradually  the  concavity  disappeared.  Each 
crust  presented  an  external  dark  ring,  and  an  internal  lighter  centre,  which  became 
considerably  elevated.  The  various  groups  became  aggregated  together,  and  she 
complained  of  great  itching  and  irritation,  and  it  was  evident  that,  if  allowed  to 
proceed  further,  the  condition  she  presented  on  admission  would  be  soon  produced. 
The  crusts  were,  therefore,  again  removed  by  poultices,  cod-liver  oil  once  more 
applied,  and  the  scalp  remained  clean  and  free  from  irritation  until  \1ih  January, 
when  the  cure  appearing  to  be  hopeless  she  was  dismissed.  She  was  enjoined  to 
continue  the  use  of  the  oil,  which,  whilst  applied,  and  covered  with  the  oil-sOk  cap, 
had  the  power  of  preventing  the  formation  of  fresh  crusts  on  the  scalp. 

Case  CLXXTIII.* — Favus  of  the  Scal2)  of  three  years'  standing — Cured. 

History. — Margaret  Bryer,  a?t.  12,  of  scrofulous  and  cachectic  appearance,  was 
admitted  June  19tb,  1849,  with  favus  crusts  on  the  scalp.  The  crusts  are  most 
numerous  and  dense  on  the  crown  of  the  head;  but  others,  isolated  or  in  small 
groups,  are  scattered  over  the  temples,  forehead,  and  occiput.  The  scalp  is  bald 
here  and  there  in  patches,  varying  in  diameter  from  half  an  inch  to  an  inch.  Oa 
examining  the  crusts  microscopically,  they  are  seen  to  contain  the  cryptogamic 
branches  and  sporules  pathognomonic  of  favus.  The  disease  is  of  three  years'  .stand- 
ing, and  is  attributed  to  the  use  of  a  comb,  belonging  to  another  girl  who  had  a  sore 
head.  The  crusts  have  been  several  times  removed  by  means  of  pitch  plasters  and 
a  variety  of  ointments,  but  have  always  returned. 

Progress  of  the  Case  — At  first,  the  crusts  were  removed  and  the  scalp  kept 
moist  by  means  of  an  alkaline  lotion,  which  succeeded  in  removing  the  irritation. 
Early  in  July  she  was  ordered  3  ss  of  cod-liver  oil  three  times  a  day.  Tlie  oil  was  also 
directed  to  be  applied  to  the  shaved  scalp  ttvice  daily,  tvhich  v:as  to  be  kept  constantly 
covered  tvifh  an  oil-silk  cap.  This  treatment  was  persevered  in  until  August  10<7j. 
when  she  was  dismissed  cured.  This  girl  was  re-admitted  September-  5th,  and 
remained  in  the  Infirmary  five  days,  under  observation.  Up  to  this  time  the  disease 
had  not  re  appeared,  so  that,  wlien  dismissed  on  the  lOih,  a  permanent  cure  was 
undoubtedly  produced. 


Case  CLXXIX.f — Favus  caught  in  the  Ward  from  Case  CLXXTII. —  Cured. 

History. — Margaret  Cameron,  set.  5,  an  ill-nourished  cachectic-looking  child — 
admitted  July  23d,  1849,  on  account  of  an  eruption  on  the  scalp.     In  some  places 

*  Reported  by  Dr.  J.  Smith,  Clinical  Clerk. 

■]•  Reported  by  Mr.  Alexander  Struthers,  Clinical  Clerk. 


796  DISEASES   OF   THE   INTEGUMENTARY  SYSTEM, 

the  hair  was  matted  together  b}"-  a  recent  pustular  eruption ;  groups  of  impetiginous 
pustules  and  eczematous  vesicles  being  scattered  here  and  there.  In  others,  where, 
tlie  disease  was  more  chronic,  hard,  nodulated,  elevated  masses,  and  friable  crusts 
existed.  The  disease  was  eczema  impetiginodes.  No  favus  was  present,  as  was 
proved  by  careful  examination,  and  micro.scopic  demonstrations  of  the  scabs.  Poul- 
tices loere  ordered  to  the  scalp,  to  remove  the  crusts ;  and  afterwards  an  alkaline  wash, 
with  cod- liver  oil  internally. 

Progress  of  the  Case. — My  colleagues  taking  charge  of  the  ward  during  the 
months  of  August  and  September,  I  lost  sight  of  this  patient;  but  on  resuming  duty 
in  the  beginning  of  October,  I  was  surprised  to  find  the  child's  head  covered  with 
favus  crusts,  with  the  branches  and  sporules  fully  developed,  as  proved  by  the  micro- 
scope. It  appeared  that  the  girl  was  a  great  favourite  with  Isabella  Fergusson 
(Case  CLXXVII ),  and  frequently  slept  in  her  bed,  and  there  can  be  little  doubt  she 
had  caught  favus  from  her.  The  child's  general  health,  however,  had  greatly 
improved ;  and  the  crusts  vjere  ordered  to  he  reinoved  by  poultices,  the  head  shaved,  and 
cod-liver  oil  applied  locally  twice  daily,  and  an  oil-silk  cap  to  be  worn  constantly.  This 
treatment  was  continued  for  seven  weeks.  At  the  end  of  that  time  all  treatment 
was  suspended,  and  the  scalp  watched  daily.  In  fifteen  days  the  head  was  covered 
with  a  slight  furfuraceous  desquamation;  but  the  hair  was  abundant.  Another 
week  elapsed  without  any  return  of  favus ;  and,  her  health  being  now  good,  she  was 
discharged,  December  Gth. 

Case  CLXXX.* — Favus  of  the  Scalp  of  four  years'  standing,  cured  hy  a  Sulphuric 

Acid  Lotion. 

History.— Helen  Goodall,  vet  15 — admitted  November  3d,  1853.  She  has  been 
affected  with  favus  of  the  scalp  for  four  years,  and  frequently  been  in  the  Infirmarj', 
and  subjected  to  various  kinds  of  treatment,  under  different  physicians,  without  any 
permanent  benefit.  On  admission,  a  great  portion  of  the  scalp  was  bald,  from 
destruction  of  the  hair  bulbs,  but  the  other  portions  were  covered  with  a  prominent 
yellow  friable  crust,  of  mousy  odour,  crowded  with  pediculi.  On  the  Ith  of  November 
a  lotion  composed  of  one  part  of  sulphurous  acid  and  three  parts  of  water,  was  con- 
stantly applied  by  means  of  lint  saturated  in  it,  and  covered  with  an  oil-skin  cap.  It 
was  suspended  December  23d,  leaving  the  scalp  parti}'  bald,  but  quite  clean.  On  the 
15th  of  January,  1854,  the  disease  had  not  returned.  The  scalp  was  then  rubbed 
over  with  the  oil  of  cade,  twice  daily,  to  remove  the  squamous  eruption,  and  she  was 
dismissed  apparently  quite  cured,  February  oth. 

Case  CLXXXI.f — Limited  Favus  of  the  Cheek,  cured  by  Cauterization  with  Nitrate  of 

Silver. 

History. — James  Scott,  aat.  15,  a  painter,  applied  for  advice,  January  27.  1850. 
He  states  that,  a  week  ago,  without  any  known  cause,  he  observed  a  small  spot 
about  the  size  of  a  pin's  head,  over  the  external  angle  of  the  left  malar  bone.  On 
examination,  a  circular  reddened  spot,  about  the  size  of  a  shilling,  is  seen  over  the 
external  angle  of  the  left  malar  bone,  in  the  centre  of  which  were  several  favus 
crusts,  aggregated  together.  These  examined  under  the  microscope,  presented 
the  branches  and  sporules  pathognomonic  of  the  disease.  TJie  whole  was  then  luell 
cauterized  with  nitrate  of  silver,  and  was  cured  at  once. 

*  Reported  by  Mr.  P.  "^.  Wallace,  Clinical  Clerk. 
f  Reported  by  Mr.  Hugh  Balfour,  Clinical  Clerk. 


DERMATOPHYTA,  797 

Commentary. — Of  the  five  cases  of  favus  now  given,  tlie  first  was 
that  of  an  adult,  and  was  of  twelve  years'  standing.  By  means  of 
poultices  and  excluding  the  air  with  oily  applications,  the  scalp  could 
easily  be  freed  from  the  eruption  and  kept  so;  but  as  soon  as  these 
means  were  discontinued,  the  disease  returned.  The  second  and  third 
cases  were  permanently  cured  by  the  constant  application  of  oil  to  the 
scalp  for  six  or  seven  weeks.  They  were  children  of  the  ages  of  twelve 
and  five  years  respectively  In  the  former  the  disease  was  of  three 
years'  standing;  in  the  latter,  it  was  altogether  recent,  and  caught 
from  another  case  in  the  ward.  The  fouith  case  was  cured  by  using 
a  sulphurous  acid  lotion  instead  of  oil— a  practice  recommended  by  Dr. 
Jenner,  in  consequence  of  the  powerful  efiect  possessed  by  this  acid,  in 
destroying  vegetable  growths.  In  the  fifth  case,  the  disease  was  limited, 
and  was  at  once  destroyed  by  means  of  caustic.  It  is  rare  that  favus 
can  be  watched  through  its  entire  progress  in  tlie  wards  of  a  hospital — 
first,  because  the  disease  commonly  lasts  months — often  years,  and 
charitable  institutions  cannot  support  individuals  so  long  ;  and,  secondly, 
because  it  always  happens,  that  when  urgent  cases  demand  admission, 
and  beds  are  required,  these  are  just  the  parties  who  are  discharged  to 
make  room  for  them.  At  the  same  time,  the  disease  is  so  common  in 
Edinburgh,  that  the  wards  are  seldom  free  of  one  or  more  examples  of 
it  in  various  stages.  Besides,  by  poulticing  off  the  crusts,  and  allowing 
the  eruption  to  come  back,  its  commencement  and  progress  may  be 
studied  in  any  individual  case. 


Case  CLXXXII.* — Parasitic  Pityriasis — Incuralik. 

History.— Charlotte  Clerk,  xt.  18— admitted  June  20,  1857— a  Hiudoo  girl  from 
Bombay.  She  has  had  an  eruption  on  her  head  ever  since  she  can  remember.  On 
admission  the  hair  was  found  clipped  short ;  the  scalp  was  bald  in  patches,  especially 
over  the  crown  of  the  head.  The  hair  is  filled  with  scales,  easily  detached,  resem- 
bling desquamated  epidermis.  Towards  the  back  of  the  head  these  scales  are 
embedded  in  a  dittused  friable  yellowish  matter,  which,  on  examination  under  the 
microscope,  presents  the  thalli  and  sporules  of  favus.  July  Qth. — To  determine  more 
certainly  the  character  of  the  disease,  poultices  have  been  applied  to  the  head,  the 
hair  has  been  shaved,  and  the  disease  allowed  to  return.  To-day,  being  the  seventh 
since  the  head  was  clean,  two  bright  yellow  favus  spots,  each  perforated  by  a  hair, 
were  observed.  These  rapidly  increased  and  amalgamated  with  others,  never  form- 
ing distinct  favus  crusts,  but  causing  a  scaly  eruption  over  the  surface,  together  with 
a  few  pustules  of  impetigo.  On  removing  the  scales  a  friable  yellow  mass  can  be 
generally  seen  below,  presenting  on  examination  the  vegetable  structure  of  the 
Achorion  Schoenleini.  The  sporules  and  thalli  were  unusually  large  and  well 
developed.  This  girl  was  treated  by  constant  oleaginous  and  other  applications ; 
was  dismissed  and  re-entered  the  house;  but  when  I  last  saw  her  in  December, 
1857,  the  disease  still  existed  as  bad  as  ever. 

Commentary. — This  eruption  presented  to  the  naked  eye  all  the 
appearance  of  pityriasis  of  the  scalp.  The  only  suspicious  circumstance 
was  the  baldness.     I  had  previously  seen  two  similar  cases,  and  was  in 

*  Eeported  by  Mr.  W.  Guy,  Clinical  Clerk. 


798  DISEASES    OF   THE   IXTEGUirEXTARY   SYSTEM. 

no  way  surprised  to  find  that  the  disease  was  a  parasitic  one.  All 
chronic  scalp  eruptions,  especially  if  there  be  Alopaecia,  should  be 
examined  microscopically,  in  order  to  arrive  at  an  exact  diagnosis. 
E>seiitially  the  fungus  is  the  same  as  that  of  favns,  although  it  may 
present  occasional  modifications  as  to  the  size  of  the  sporules  and  thalli. 
In  the  present  case  they  were  remarkably  well  developed  and  larger 
than  usual ;  in  one  case  I  found  all  the  sporules  perfectly  globular,  and 
only  half  the  size  of  the  usual  oval  corpuscles.  In  tliis,  as  in  Case 
CLXXVIL,  all  the  remedies  tried  were  of  no  avail. 


History  of  Fai'us  as  a  Vegetable  Parasite. — [Achorion   Schanleini  of 

Link.) 

The  demonstration  by  Bassi*  of  the  vegetable  nature  of  the  disease 
named  muscardine  in  silk  worms,  which  causes  so  great  a  mortality 
amongst  those  animals,  opened  up  to  pathologists  a  new  field  for  observa- 
tion, and  led  to  the  discovery,  that  certain  disorders  in  the  hio;her 
animals,  and  even  in  man  himself^  were  connected  with  the  growth  of 
parasitic  plants  of  a  low  type.  SchonIein,f  of  Berlin,  was  the  first  to 
detect  them  in  favus  crusts — an  observation  confirmed  by  Remak,;};  Fuchs, 
and  Langenbeck.§  Gruhy||  gave  a  very  perfect  description  of  these 
vegetations  in  1841,  and  made  numerous  researches  as  to  their  seat, 
origin,  and  mode  of  propagation.  These  were  repeated  by  mvselt^  and 
further  extended  in  1842.«r  In  1845  I  succeeded  in  inoculating  the 
disease  in  the  human  subject.  Since  then  tiiey  have  been  made  the 
subject  of  further  investigation  by  Lebert,*'  Remak,!"  Robin,J^  and 
numerous  other  inquirers,  to  whose  observations  I  shall  have  occasion 
to  allude  subsequently. 

Mode  of  Development  and  Symptoms  of  Favus. 

By  most  writers,  amongst  whom  may  be  cited  Willan,  Bateman,  Biett, 
and  fiayer,  favus  is  described  as  commencing  in  a  pustule,  which  breaks 
and  forms  the  peculiar  scab.  Others,  such  as  Baudelocque,  Alibert,  and 
Gibert,  deny  its  pustular  nature,  and  state  that  it  commences  in  a  crust. 
But  numerous  observations  have  satisfied  me  that  the  formation  of  pus- 
tules is  not  essential  to  the  disease,  although  they  are  often  present. 
Hence  the  mistake  of  those  pathologists  who  classified  favus  amongst 
the  pustulse.  M.  Gruby  says  that  they  are  never  present,  which  is 
equally  erroneous,  although  they  appear  to  be  a  secondary  result,  attri- 

*  Del.  MaL  del  Segno  Calcinaccio  o  Muscardino.     MUano,  1837. 

f  MuUers  Archives.     1836.  \  Mediciniscbe  Zeitung.     1S40. 

y  Comptes  Readus  de  la  Polyclinique  de  Gottingen. 

I  Comptes  Rendus,  torn.  xiii.  pp.  72  and  .309.     1841. 

•[  On  Parasitic  Vegetable  Structures  found  Growing  in  Living  Animals.  Edin- 
burgh PhUosophical  Transactions,  vol.  xv.  p.  277.  1S42.  Monthlv  Journal,  June 
1842. 

*^  Physiologie  Pathologique,  torn,  iu     1845. 

\"  Diagnostische  und  Pathogenische  Untersuchungen.     1845. 

X^  Des  Vegetaux  qui  croissent  sur  THomme,  eta     1847. 


DERilATOPHYTA.  799 

billable  to  the  irritation  the  disease  produces  in  some  individuals.*  On 
the  other  hand,  I  have  never  seen  this  atlection  produced,  without  hav- 
ing; been  preceded  by  desquamation  of  the  cuticle,  an  observation  which 
appears  to  me  of  some  importance  in  explaining  the  origin  of  the 
disease,  as  we  shall  subsequently  see.  Occasionally,  also,  the  scales  form 
a  thick  mass,  and  the  favus  matter  is  more  disseminated,  and  does  not 
form  the  distinct  umbilicated  crusts.  This  constitutes  the  parasitic  pity- 
riasis of  some  writers. 

After  removing  the  favus  crusts  by  poulticing,  and  then  watching  from 
day  to  day  how^  the  disease  returns,  it  will  be  seen  that  the  first  morbid 
change  is  increased  vascularity  of  the  skin,  accompanied  with  a  desqua- 
mation of  the  cuticle  ;  and  that  in  a  period  varying  from  twelve  to  four- 
teen days,  small  spots  of  a  bright  yellow  colour,  like  that  of  sulphur, 
may  be  detected.  These  gradually  augment  in  size,  but  even  at  the 
earliest  period  may  be  observed,  Avith  a  lens,  to  have  a  centi'al  depres- 
sion, through  which  a  hair  may  generally  be  observed  to  pass.  The 
crust  or  capsule  may  enlarge  to  about  the  size  of  a  shilling,  and  if  it  be 
isolated,  still  retain  its  rounded  form.  Usually,  however,  its  edges 
come  in  contact  with  other  capsules,  and  then  it  loses  its  rounded  shape, 
and  assumes  the  hexagonal  and  honey-combed  appearances  described  by 
authors.  I  consider,  then,  that  the  so-called  Porrigo  Inpinosa,  and  Por- 
rigo  favosa,  constituting  distinct  forms  or  varieties  of  some  writers,  are 
merely  different  stages  of  the  same  disease,  and  dependent  upon  the 
greater  or  less  aggregation  of  the  crusts.  On  the  first  appearance  of  the 
capsule,  its  edges  are  somewhat  depressed  below  the  surface  of  the 
cuticle ;  but  as  it  increases  in  size,  the  margins  become  more  and  more 
elevated  and  prominent,  whilst  a  series  of  concentric  rings  or  grooves 
may  be  observed  in  them.  At  first,  also,  the  whole  capsule  appears  of  a 
homogeneous  bright  yellow,  but  when  further  developed,  its  centre 
assumes  a  whiter  colour.  This  arises  from  the  aggregation  of  the  spo- 
rules  of  the  plant,  which  are  more  abundant  in  this  situation.  As  the 
development  proceeds,  this  central  whitish  yelloAv  mass  assumes  a  mealy, 
powdery  consistence,  and  encroaches  upon  the  edges  of  the  capsule, 
which  gradually  disappear,  whilst  its  upper  concave  form  becomes  con- 
vex, as  Gruby  pointed  out.  In  general,  an  inflammatory  ring  is  seen 
round  tlie  crust,  which,  as  the  capsule  becomes  elevated  above  the  skin, 
enlarges,  and  assumes  a  deeper  colour,  indicative  of  the  increased  local 
irritation.  At  length  the  whole  cracks  or  splits  np  ;  all  regular  form  is 
lost ;  a  dense  thick  crust  covers  the  scalp ;  an  odour,  like  the  urine  of 
cats  or  mice,  is  evolved ;  and  in  chronic  cases,  vermin  deposit  their  eggs 
in  the  inteistices,  and  ci'awl  in  lai'ge  numbers  over  the  suriace. 

I  have  satisfied  myself  that  occasionally  the  disease,  instead  of  pre- 
senting distinct  capsules  round  hair  bulbs,  becomes  diflused  under  the 
epidermis,  which  then  assumes  the  appearance  of  pityriasis,  and  not 
unfrequently  of  chronic  eczema.  A  microscopic  examination,  however, 
will  in  such  cases  always  detect  groups  of  sporules  and  thalli  more  or 
less  developed.     In  one  instance  I  found  the  sporules  smaller  than  usual, 

*  This  explanation  of  the  origin  of  pustules  and  purulent  matter,  wheu  present, 
has  been  adopted  by  Lebert,  Remak,  and  Simon. 


800  DISEASES   OF   THE    IXTEGUMEXTARY   SYSTEM. 

and  perfectly  globular  instead  of  oval.  In  others  I  have  seen  tlie 
sporiiles  three  or  four  times  laro-er  than  those  of  ordinary  favns,  with 
included  nuclei,  muUiplying  fissiparously.  Hence  the  so-called  para- 
sitic pityriasis  of  the  scalp,  I  believe  to  be  a  modification  of  favus,  and 
consider  it  a  good  rule,  in  all  chronic  eruptions  on  the  head,  to  examine 
the  crusts  microscopically. 

The  other  local  symptoms  are  merely  those  which  result  from  the 
greater  or  less  degree  of  irritation  produced  in  difterent  persons  by  the 
changes  above  referred  to.  At  first,  scarcely  any  uneasiness  is  felt; 
perhaps  occasional  slight  itching  of  the  part.  As  the  disease  progresses, 
however,  the  itching  becomes  more  intolerable,  and  induces  the  patient 
to  rub  and  scratch  the  scalp.  By  these  means,  several  of  the  crusts  are 
forcibly  torn  from  their  attachments,  and  considerable  effusion  of  serous 
fluid  and  blood  is  produced.  Sometimes  inflammation  is  thus  occasioned. 
Impetiginous  pustules  are  frequently  formed,  or  suppuration  produced, 
terminating  in  ulceration,  and  the  discharge  of  an  ichorous  fluid  from 
beneath  the  crusts.  At  an  advanced  stage  of  the  disease,  the  peculiarly 
offensive  odour  exhaled  is  insupportable  to  those  who  surround  the 
individual,  and  the  ichorous  discharge,  vermin,  and  crusts,  which  cover 
the  aftected  parts,  present  a  most  disgusting  appearance. 


e^ 


d 
Fig.  463. 


Although  the  disease  most  commonly  attacks  the  hairy  scalp,  it  may 
occur  on   the  forehead,    temples,  cheeks,    nose,   chin,   ears,    shoulders, 


Fig.  463.  a.  Isolated  crusts  of  Favus,  presenting  the  lupine  seed-like  depression 
in  different  stages  of  growth  (so-called  Porrkfo  lupinosa) ;  some  are  arranged  in 
groups  of  twos  and  threes,  h,  A  larger  group  of  these  crusts,  somewhat  compressed 
at  the  sides,  like  a  honeycomb  {Porrigo  favosa),  c,  Another  group,  which  occurred 
on  the  shoulder  of  a  young  girl.  Xo  hairs  passed  through  the  centre  of  these  crusts. 
rf.  Large  isolated  crusts  in  an  advanced  stage  of  growth,  "the  external  ring  is  cracked, 
and  the  friable  centre  is  enlarged  and  elevated,  e.  Xumerous  crusts'^  aggregated 
together,  so  as  to  form  an  irregular  elevated  mass.  Traces  of  the  original  form°may 
be  observed  iu  the  cracked  rings  round  the  margin.     {Natural  size.). 


DERMATOPHYTA.  801 

arms,  abdomen,  lumbar  region,  sacrum,  knees,  and  legs.  Alibert  gives 
a  plate  in  ^Yhicll  it  is  figured  in  all  these  situations.  I  have  myself 
seen  it  on  the  cheek,  shoulders,  back,  arms,  and  interior  extremities,  and 
in  some  of  these  situations  I  could  detect  no  hairs  perforating  the 
capsules.     (Fig.  463,  c.) 

The  constitutional  symptoms  are  of  the  utmost  importance,  but, 
general Iv  speaking,  receive  little  attention  from  practitioners.  In  most 
of  the  iiidividualsatiected,  who  have  come  nuder  my  notice,  the  general 
health  has  been  greatly  deranged,  and  a  scrofulous  or  cachectic  con- 
stitution more  or  less  evident.  In  some  the  fades  scrofulosa  of 
authors  has  been  well  marked;  in  others  there  were  engorgements  of 
the  lymphatic  glands  of  the  neck ;  and  in  the  only  fatal  case  which  has 
come"  under  my  observation,  there  were  found  tubercular  depositions 
in  the  lungs,  mesenteric  glands,  and  other  textures.  Indeed,  the 
o-enerality  of  individuals  who  die  labouring  under  favus,  perish  from 
phthisis,  "or  other  forms  of  tubercular  disease.  The  beautiful  plates  pub- 
lished bv  Alibert,  are  in  this  respect  far  from  being  true  to  nature;  for 
whilst  tiie  capsules  and  crusts  are  accurately  drawn,  the  individuals 
atfected  seem  to  be  ideal  personages,  enjoying  the  most  robust  health, 
and  possessing  even  the  utmost  beauty  of  form  and  feature.  In  the 
o-eneralitv  of  cases,  on  the  contrary,  the  patient  is  thin,  the  countenance 
is  of  a  dirtv  yellow  colour,  and  the  whole  aspect  betrays  depression  of 
the  vital  powers.  The  appetite  is  often  impaired,  the  alvine  evacuations 
irregular,  and  the  functions  of  digestion  and  nutrition  are  impeded. 
Xuruerous  writei-s  have  observed  the  physical  and  mental  development 
of  the  individual  to  be  retarded ;  and  Alibert  gives  instances  where  the 
epoch  of  puberty  was  considerably  delayed. 

Bv  those  not  well  accustomed  to  the  diagnosis  of  skin  diseases,  favus 
has  often  been  confounded  with  other  eruptions  of  the  scalp,  more  espe- 
cially eczema  and  impetigo,  or  the  combination  of  these  diseases  known 
as  the  eczema  impetiginodes.  In  none  of  these  eruptions,  however,  do 
the  yellow  crusts  or  scales  present  traces  of  vegetations  when  examined 
microscopically.  This,  therefore,  furnishes  the  real  diagnostic  and 
pathognomonic  character  of  the  disease.*  Occasionally,  as  has  been 
stated,  favus  presents  a  scaly  character.  It  has  then  been  called  Pityriasis. 
On  examination  of  the  scurf,  however,  the  epidermic  scales  will  be  found 
associated  with  the  Achorion  Schcenleini,  in  various  stages  of  develop- 
ment. 

Causes. 

Alibert  considered  the  disease  hereditary,  and  gives  cases  confirmatory 
of  this  view.  As  regards  age,  it  is  by  far  most  common  in  children 
between  the  ages  of  three  and  twelve  years.      In  infancy,  and  after 

*  I  am  not  aware  that  this  peculiar  disease  has  ever  been  observed  in  any  of 
tlie  lower  animals.  I  may  therefore  mention,  that  I  have  seen  it  on  the  face  of 
a  common  house  moused  in  which  animal  the  same  cryptogamic  vegetations 
were  to  be  detected  as  in  man.  '  Dr.  Carter  has  confirmed  tliis  observation 
in  a  communication  he  brought  before  the  Eoyal  Mediaxl  Society  of  this  city, 
during  the  session  18.56-57.  Prof  Gluge  of  Brussels  has  also  described  and 
fiirured  the  same  fact  (Bulletins  de  TAcademie  Royale  de  Belgique.  2me.  serie. 
Tom.  iiL,  Xo.  12). 

61 


802  DISEASES   OF   THE   INTEGUMEN'TARY   SYSTEM. 

pvibertj',  it  is  more  rare,  although  sometimes  present;  and  in  a  few 
instances  it  has  been  observed  in  persons  advanced  in  years.  In  ahnost 
all  the  cases  which  have  come  under  my  notice,  the  individuals  have 
been  exposed  to  causes  which  depress  the  vital  powers,  and  are  well 
known  excitants  of  tuberculous  disease.  Close  questioning  will  usually 
elicit  that  they  are  of  a  scrofulous  family;  have  been  exposed  for  some 
time  to  infected  or  corrupted  air;  inhabited  small  rooms,  or  confined 
streets,  or  dwellings  situated  in  unhealthy  situations;  that  the  aliment 
has  not  been  verynutritive,  etc.,  etc.  Hence  why  the  disease  is  common 
in  workhouses  and  jails,  and  most  prevalent  amongst  the  poorer  classes 
of  the  population,  and  individuals  wlio  obtain  a  precarious  subsistence. 

Almost  every  writer  on  the  disease  considers  it  to  be  contagious. 
Batenian,  Guersent,  and  others,  speak  of  its  spreading  amongst  school- 
boys, from  the  employment  of  the  same  towels,  combs,  caps,  etc.  Gibert 
has  seen  it  propagated  in  the  wards  of  St.  Louis  from  tlie  same  cause. 
It  has  been  observed,  he  says,  two  or  three  times  to  be  communicated 
by  young  people  kissing  each  other,  when  it  has  appeared  in  the  chin  or 
neighbourhood  of  the  mouth.  Mahon  even  pretends  to  have  contracted 
favus  incrustations  on  his  fingers,  from  having  neglected  to  wash  them 
after  dressing  the  heads  of  those  affected.  Alibert,  in  his  early  writings, 
also  thought"  it  to  be  contagious.  In  his  later  works,  however,  he  evi- 
dently doubts  it,  says  that  much  exaggeration  has  been  made  use  of  on 
this  subiect,  and  states  that  the  amour  j^ropre  of  parents  usually  induces 
them  to  ascribe  the  origin  of  so  disgusting  a  disease  to  external  com- 
munication, lie  further  observes,  "  Mes  eleves  ont  souvent  tente  d'inocu- 
ler  en  notre  presence,  le  produit  de  I'incrustation  faveuse,  sous  plusieurs 
formes,  et  en  variant  le  procedes.  Le  plus  souvent  il  n'est  rien  resulte, 
dans  d'autres  cas  est  survenue  une  infiammation  passagere,  qui  s'est 
bientot  evanouie — pai-fois  une  suppuration  semblable  qui  pourrait  s'eta- 
blir  par  tout  irritant  mecanique,  ou  par  I'insertion  d'une  substance 
ctrano-ere  dans  le  tegument."*  Gruby  also,  on  discovering  its  vegetable 
nature,  inoculated  tliirty  phanerogamous  plants,  twenty-four  silk-worms, 
six  reptiles,  four  birds,  and  eight  mammifera,  but  only  produced  the  dis- 
ease once,  and  then  in  a  plant.  The  human  arm  was  inoculated  five 
times,  but,  independent  of  a  slight  infiammation  and  suppuration,  no 
eff'ect  was  produced. 

Sixteen  years  ago  I  inoculated  myself  and  others  many  times  with  a 
view  of  determining  whether  favus  was  or  was  not  contagious.  But  in 
none  of  these  experiments,  performed  in  various  ways,  and  frequently 
repeated  so  as  to  avoid  fallacy,  could  I  succeed  in  causing  the  plant  to 
germinate  on  parts  different  from  those  on  which  it  was  originally  pro- 
duced. In  other  words,  I  could  not  communicate  the  disease  to  other 
individuals,  or  from  one  part  of  the  same  individual  to  another. 

At  the  time  I  did  not  consider  these  experiments  (performed  in  1841- 
42)  as  decisive  of  the  question,  although  they  show  that  it  is  with  great 
difficulty  inoculation  succeeds.  Shortly  after,  Dr.  Kemak,  of  Berlin, 
comnmnicated  the  disease  to  his  own  arm  in  the  following  way : — He 
fastened  portions  of  the  crust  upon  the  unbroken  skin,  by  means  of 
plaster.  In  fourteen  days,  a  red  spot,  covered  with  epidermis,  appeared, 
and  in  a  few  days  more  a  dry  yellow  favus  scab  formed  itself  upon  the 
*  Traite  des  Maladies  de  la  Peau,  foL  p.  443. 


DERMATOFHYTA.  803 

spot,  which,  examined  microscopically,  presented  the  mycodermatous 
veijetations  characteristic  of  favus.*  Mentioning  this  fact  to  my  polyclini- 
caf  class,  at  the  Roval  Dispensary,  in  the  snmmer  of  1845,  one  of  the 
ixentlemen  in  attendance  volunteered  to  permit  his  arm  to  be  inoculated. 
A  bov,  called  John  Bangh,  a?t.  8,  labouring  under  the  disease,  was  at  the 
time  the  subject  of  lecture,  and  a  portion  of  the  crust,  taken  directly  from 
this  bov's  head,  was  rubbed  upon  Mr.  M.'s  arm,  so  as  to  produce  erythe- 
matous redness,  and  to  raise  the  epidermis.  Portions  of  the  crust  were 
then  fastened  on  the  pait  by  strips  of  adhesive  plaster.  The  results  were 
reii'ularlv  examined  at  the  meetings  of  the  class  every  Tuesday  and  Friday. 
The  friction  produced  considerable  soreness,  and,  in  a  few  places,  super- 
ficial suppuration.  Three  weeks,  however,  elapsed,  and  there  was  no 
appearance  of  favus.  At  this  time,  there  still  remained  on  the  arm  a 
superficial  open  sore  about  the  size  of  a  pea,  and  Mr.  M.  suggested  that  a 
portion  of  the  crust  should  be  fastened  directly  on  the  sore.  This  was 
done,  and  the  whole  covered  by  a  circular  piece  of  adhesive  plaster  about 
the  size  of  a  crown  piece.  In  a  few  days,  the  skin  surrounding  the  inocu- 
lated part  appeared  red,  indurated,  and  covered  with  epidermic  scales. 
In  ten  davs  there  were  first  perceived  upon  it  minute  bright  yellow- 
coloured  spots,  which,  on  examination  with  a  lens,  were  at  once  recog- 
nised to  be  spots  of  favus.  On  examination  with  the  microscope,  they 
were  found  to  be  composed  of  a  minute  granular  matter,  in  which  a  few 
of  the  crvptogamic  jointed  tubes  could  be  perceived.  In  three  days 
more,  the  vellow  spots  assumed  a  distinct  cupped  shape,  perforated  by  a 
hair;  and  in  addition  to  tubes,  numerous  sporules  could  be  detected. 
The  arm  was  shown  to  Dr.  Alison  ;  and  all  who  witnessed  the  experiment 
being  satisfied  of  its  success,  I  advised  Mr.  M.  to  destroy  each  favus  spot 
Avith  nitrate  of  silver.  With  a  view  of  making  some  fuilher  obser\ations, 
however,  he  retained  them  for  some  time.  The  capsules  were  then 
squeezed  out,  and  have  not  since  returned.  Mr.  M.  had  light  hair,  blue 
eves,  a  white  and  very  delicate  skin.  There  is  every  reason  to  believe 
that  the  strips  of  plaster  employed  in  the  first  attempt  shifted  their  posi- 
tion, and  that  the  crust  was  only  properly  retained  by  the  circular  piece 
of  plaster  employed  in  the  second  experiment. 

That  the  disease,  therefore,  is  inoculable,  and  capable  of  being  com- 
municated by  contagion,  there  can  be  no  doubt,  a  result  which  accords 
with  the  observations  of  most  practitioners,  and  with  numerous  recorded 
facts.  (Case  CLXXIX.)  It  must  also  be  evident  that  it  does  not 
readilv  spread  to  healthy  persons,  and  that  there  must  be  either  a  pre- 
disposition to  its  existence,  or  that  the  peculiar  matter  of  favus  must  be 
kept  a  long  time  in  contact  with  the  skin  previously  in  a  morbid  condi- 
tion. 

Patholoyy. 

"We  have  seen,  when  describing  the  symptoms  and  mode  of  develop- 
ment of  the  disease,  that  it  is  not  essentially  pustular,  and  that  the 
pustules  occasionally  present  are  accidental.  On  the  other  hand,  it  has 
been  shown  that  the  peculiar  favus  crust  is  composed  of  a  capsule  of 
epidermic  scales,  lined  by  a  finely  granular  mass ;  that  from  this  mass 
*  ilediciniscbe  Zeitung,  August  3,  1S42. 


804 


DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 


millions  of  cryptogamic  plants  spring  np  and  fructify;  and  that  the 
presence  of  these  vegetations  constitutes  the  pathognomonic  character  of 
the  disease. 

In  order  to  examine  the  natural  position  of  these  vegetations  micro- 
scopically, it  is  necessary  to  make  a  thin  section  of  the  capsule,  com- 
pletely through,  embracing  the  outer  layer  of  epidermis,  amorphous 
mass,  and  light  friable  matter  found  in  the  centre.  IlAvill  then  be  found, 
on  pressing  this  slightly  between  glasses,  and  examining  it  with  a  magni- 
fying power  of  300  diameters,  that  the  cylindrical  tubes  (thalli)  spring 
from  the  sides  of  the  capsule,  proceed  inwards,  give  off  branches  dicho- 
tomously,  which,  when  fully  developed,  contain,  at  their  terminations 
{inyceUa),  a  greater  or  smaller  number  of  round  or  oval  globules  [sjyo- 
ridia).  These  tubes  are  from  the  ji^  to  g^o  of  a  millimetre  in  thick- 
ness, jointed  at  irregular  intervals,  and  often  contain  molecules,  varying 
from  yo.Voo  to  ToVo  of  a  millimetre  in  diameter.  The  longitudinal 
diameter  of  the  sporulesis  generally  from  ^\-^  to  yio,  and  the  transvei-se 
from  3!-^  to  y4^  of  a  millimetre  in  diameter  (Gruby).  I  have  seen  some 
of  these,  oval  and  round,  twice  the  size  of  the  others.  The  long  diameter 
of  the  former  measured  ^W  of  a  millimetre.     The  mycelia  and  sporules 


M^S-sh^ 


Fig.  465. 

agglomerated  in  masses  are  always  more  abundant  and  highly  developed 
in  the  centre  of  the  crust.  The  thalli,  on  the  other  hand,  are  most 
numerous  near  the  external  layer.  There  may  frequently  be  seen  swell- 
ings on  the  sides  of  the  jointed  tubes,  which  are  apparently  commencing 
ramifications. 

On  examining  the  hairs  which  pass  through  the  favus  crusts,  it  will 
often  be  found  that  they  present  their  healthy  structure.  At  other 
times,  however,  they  evidently  contain  long,  jointed  branches,  similar  to 
those  in  the  crust,  running  in  the  long  axis  of  the  hair,  which  is  exceed- 
ingly brittle.  I  have  generally  found  these  abundant  in  very  chronic 
cases ;  and  on  adding  w  ater,  the  fluid  may  be  seen  running  into  these 

Fig.  464.  Branches  oi  the  Achorion  Schcmkini,  in  an  early  stage  of  development, 
growing  from  a  molecular  matter,  and  mingled  with  epidermic  scales,  from  a  very 
minute  Favus  crust. 

Fig.  465.  Fragments  of  the  branches  more  highly  developed,  with  numerous 
sporules  and  molecular  matter,  from  the  centre  of  an  advanced  Favus  crust. 

300  diam. 


DERMATOPHYTA.  805 

tubes  bv  imbibition,  leaving  here  and  there  bubbles  of  air,  more  or  less 
long.    There  can  be  ver}-  little  doubt  that  the  tubes  and  sporules,  after  a 


--^^ 


«-  b 


time,  completely  fill  up  the  hair  follicle,  and  from  thence  enter  the  hair, 
causing  atrophy  of  its  bulb,  and  the  baldness  which  follows  the  disease. 
The  various  steps  of  this  process,  however,  I  have  been  unable  to  follow, 
never  having  had  an  opportunity  of  observing  favus  in  the  dead  scalp, 
and  of  making  proper  sections  of  the  skin. 

Several  writers  on  favus  have  treated  its  vegetable  nature  as  a  mere 
hypothesis.  At  first  it  was  considered,  as  by  Mr.  Erichsen,*  to  be 
"founded  merely  upon  the  outward  appearance,  sufficiently  strong,  cer- 
tainly, which  the  cup-shaped  crust  of  favus  offers  to  lichens,  or  vegetations 
of  a  similar  description."  Subsequently  favus  was  supposed  to  consist 
of  a  mass  of  cells  ;  and  it  was  argued  by  Dr.  Carpenterf  that  the  vesicular 
oro-anization  is  common  to  animals  as  well  as  plants;  and  hence  "to 
speak  of  Porrirjo  favosa,  or  any  similar  disease,  as  produced  by  the 
growth  of  a  vegetable  within  the  animal  body,  appears  to  the  author  a 
very  arbitrary  assumption."  Mr.  Erasmus  Wilson,  in  his  work  on 
"Diseases  of  the  Skin"  (p.  430),  as  well  as  in  a  special  "Treatise  on 
Rino-worm,"  is  also  opposed  to  the  idea  of  favus  owing  its  essential 
characters  to  a  vegetable  growth.  He  considers  that  the  peculiar 
branches  and  oval  bodies  previously  described  are  mere  modifications  of 
epidermic  cells,  which  in  some  cases  he  is  of  opinion  may  be  transformed 
into  pus  cells — in  others,  into  those  observed  in  favus.  The  branches  of 
the  plant  he  calls  "cellated  stems,"  and  the  sporules,  secondary  cells;  and 
argues,  that  mere  resemblance  to  a  vegetable  formation  is  not  sufficient 
to  constitute  a  plant.  He  says,  "  The  statement  of  the  origin  of  the 
vegetable  formations  by  roots  implanted  in  the  cortex  of  the  crust  is  un- 
founded ;  the  secondary  cells  bear  no  analogy  to  sporules  or  seeds ;  and 
it  is  somewhat  unreasonable  to  assign  to  an  organism  so  simple  as  a  cell 
the  production  of  seeds,  and  reproduction  thereby,  when  each  cell  is 
endowed  with   a  separate  life,  and  separate   power  of  reproduction.'''^ 

*  Medical  Gazette,  December  1851,  p.  415. 
■)•  Principles  of  Physiology,  p.  453. 
X  Ou  Riugworm,  i847,  p.  23. 

Fio-.  4G6.  a.  A  light  hair  containing  branches  of  the  Achorion  Schoenkini  (magnified 
300  diameters  linear).  The  wood-cutter  has  made  the  branches  too  beaded,  b,  A 
darker  coloured  hair,  containing  branches  of  the  plant.  800  diam. 


806  DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 

Lastly,  M.  Cazenave,*  altliongh  he  acknowledges  liimself  to  be  no 
histologist,  says  lie  has  sought  for  the  spornles  many  times,  and  believes 
himself  authorised  to  conchule  that  their  detection  is  not  always  so  easy 
as  is  supposed  (p.  225).  Finally,  he  denies  that  favus  is  a  vegetable 
parasite,  and  maintains  it  to  be  a  peculiar  secretion,  originating  in  the 
sebaceous  glands  (p.  236). 

With  the  exception  of  Mr.  Wilson,  who  ajtpears  carefully  to  have 
examined  the  favus  crust,  the  opposition  to  the  vegetable  nature  of  this 
production  seems  to  have  originated  in  very  imperfect  notions  as  to  its 
intimate  structure  on  the  one  hand,  and  that  of  certain  cryptogamic 
plants  on  the  other.  For  if  long  hollow  filaments,  with  partitions  at 
intervals,  containing  molecules  within  their  cells,  springing  from  an 
unoro'anized  gi'anular  mass,  and  giving  off  towards  their  extremities  round 
oval  bodies,  or  spoiules,  arranged  in  bead-like  rows,  be  not  vegetables, 
what  are  they  ?  The  animal  tissues  present  nothing  similar,  while 
numerous  plants,  long  known  to  botanists,  present  the  same  identical 
structure.  But  not  only  must  they  be  referi'ed  to  the  vegetable  kingdom, 
but  to  a  considerably  elevated  position  among  the  cryptogamic  plants. 
The  'protoroccus  viralis  and  iorula  cei-evisia;  universally  considered  as 
plants,  together  with  the  nuixina  voifriculi,  described  by  Goodsir,  are 
immeasurably  beneath  them  in  complexity  of  structure  ;  and  many  of  the 
mucores  or  mouMs  growing  in  damp  places  are,  as  I  have  satisfied  myself 
by  repeated  examination,  much  more  simple  in  their  organism.  Any  one 
who  looks  over  the  cryptogamia  of  Greville  will  at  once  detect  the  strong 
analogy  between  the  structures  found  in  favus  and  the  jjcnicilium  glaucum 
of  Link,  the  uspergillns  penicillatus,  acrosporiura  monilioides,  sporoiorium 
minuticm,  nostoc  cierideum,  and  other  plants  therein  figured.  Indeed,  it 
seems  to  me  surprising  how  the  vegetable  nature  of  these  structures  can 
for  a  moment  be  doubted  by  any  one  who  has  personally  examined  them, 
especially  under  powers  of  from  six  to  eight  hundred  diameters  linear. 

In  considering  whether  the  structures  described,  and  now  by  every  one 
acknowledged  to  exist  in  the  favus  crusts,  really  belong  to  the  vegetable 
kino;dom,  we  should  remember  that  they  are  not  the  onlv  formations  of 
this  kind  which  have  been  found  to  grow  parasitically  in  living  animals. 
In  my  original  paper,t  I  described  others  growing  in  phthisical  cavities, 
in  the  sordes  on  the  gums  and  teeth  of  typhus  patients;  and  pointed  out 
that  they  had  been  observed  in  the  living  tissues  of  mollusca,  insects, 
reptiles,  fishes,  birds,  and  mammiferous  animals.  These  observations 
have  subsequently  been  confirmed  by  numerous  pathologists  and  natur- 
alists. Lastly,  we  cannot  overlook  the  opinion  of  botanists  themselves 
concerning  this  question.  The  most  eminent  mycologists,  so  far  as  I  am 
aware,  have  no  doubt  of  the  vegetable  nature  of  favus.  Dr.  Greville,  to 
whom  I  exhibited  them,  was  quite  satisfied  of  the  fact.  Brongniart, 
according  to  Gruby,  and  Messrs.  Link  and  Klotzsch,  to  whom  they  were 
shown  by  Remak,  expressed  a  similar  opinion.  Brongniart  considers  them 
to  belong  to  the  genus  Mycoderraa  of  Persoon.  J.  Miiller  places  them 
among  the  genus  Oidium  ;  but  both  Link  and  Klotzsch  consider  that 
they  ought  to  constitute  a  distinct  genus.  The  former,  in  consequence, 
has  given  it  the  name  of  Achorion   (from  achor,  the  old  term  for  favus), 

*  Traite  des  Maladies  du  Ciiir  Clievelu,  1S50. 
f  Ediu.  Philosophical  Trans.  1842. 


DERMATOPHYTA. 


807 


and  added  to  it  the  designation  of  the  discoverer,  Scboulein.  The  fol- 
lowing is  his  description  of  the  plant  : — 

^*  Achorion  Schanleirti  7iobis  orbicuIare,f.avum^coriaceum,  cuti  Jiiimanae 
praeserdm  capitis  insidens ;  rhizopodion  moUe,  pellucidum,  Jioceosum 
Jloccis  tenuissimis,  vix  articulatis,  rumosis.'iimis,  anastomoticis  {?)  ;*  myce- 
lium Jloccis  crassioribus,  subiatnosis,  distincte articulatis,  articulis  inaequa- 
libus  irregularibus  in  sporidia  abeuntibus ;  sporidia  rotunda,  ovalia  vel 
irrer/ularia.  in  uno  vel  pluribus  latcribus  r/erminaniia." 

The  mode  of  development  from  sporiiles  has  now  been  determined 
with  considerable  exactitude.  Remak  made  small  grooves  on  the  cut 
surface  of  a  fresh  apple  ;  placed  portions  of  the  favus  crust  in  them ; 
then  laid  the  apple,  with  the  cut  surface  turned  upwards,  in  moist  sand  ; 
and  covered  the  Avhole  with  a  glass  bell.  Under  these  circumstances, 
he  found  that  the  sporules  developed  themselves,  and  he  examined  them 
frequently  up  to  the  sixth  day,  when  the  surface  of  the  apple  became  of 
a  brown  colour,  and  was  covered  with  a  rapid  growth  of  Penicilium 
glaucum,  or  other  kind  of  mould,  among  which  the  structure  peculiar  to 
favus  could  no  longer  be  traced.  These  observations,  however,  showed 
that  the  sporules  of  the  Achorion  undergo  development  in  the  same 
manner  as  those  in  other  cryptogamic  plants.  That  is,  the  membrane 
Avhich  surrounds  them  throws  out  one  or  more  prolongations,  which 
are  converted  into  tubes;  and  these,  in  turn,  present,  generally  towards 
their  extremities,  a  number  of  sporules,  which  at  length  arc  pushed  out, 


ef- 


Fis.   467. 


Fi£r.   468. 


Fig.   409. 


or  are  disintegrated,  and  so  become  free.  Figs.  467  and  468  represent 
the  changes  observed  in  the  sporules  germinating  on  the  surface  of  the 
apple;  and  Fig.  469  shows  the  thalli,  mycelia,  and  sporules,  seen  in  the 
crusts,  produced  by  inoculation,  on  Remak's  arm. 

Tlie  method  of  reproduction  and  formation  of  sporules  mav  be  observed 
with  great  facility  in  any  well-developed  favus  crust,  especiallv  under 
powers  varying  from  500  to  800  diameters  linear.  Thalli,  with  variable- 
sized  cells,  may  be  observed  branching  at  the  extremities,  with  sporules 

*  I  have  never  seen  anv  anastomosis. 


Fig.  467.  Sporules  developing  on  the  surface  of  an  apple,  after  three  days. 

Fig.  468.  The  same,  after  four  days. 

Fig.  469.  The  same,  more  fully  developed  on  the  human  arm,  after  inoculation. 
a,  Thalli,  with  pale  walls;  h,  containing  sporules  (mvcelia);  c,  mycelium  separated 
from  the  thaUus ;  d,  sporules  separated  from  the  mycelium — (after  Remak).  300  diam. 


808 


DISEASES   OF   THE   INTEGUMENTARY   SYSTEM. 


forming  Avithin  them.  These  are  coTijoined  with  separated  mycelia,  con- 
taining well-developed  sporules,  many  of  which  are  also  free,  as  in  the 
fiffure  below. 


It  follows,  therefore,  that  all  the  circumstances  connected  with  the 
development  and  mode  of  reproduction  of  the  Achorion  Scboenleini  have 
been  fully  ascertained. 

The  seat  of  fuvus  has  been  much  dif^puted  by  authors.  By  some  it 
has  been  located  in  the  piliferous  bulbs  or  follicles  (Duncan,  Baude- 
locque,  Rayer),  by  others  in  the  sebaceous  glands  (Sauvages,  L'nderwood, 
Murray,  Mahon,  and  lately  by  Cazenave),  and  a  third  party  in  the  reti- 
cular tissue  of  the  skin  (  Bateman,  Gallot,  Thomson).  According  to 
Gruby  the  plants  grow  in  the  cells  of  the  epidermis,  the  true  skin  is  com- 
pressed, not  destroyed,  and  the  bulbs  and  roots  of  the  hairs  and  sebace- 
ous follicles  are  only  secondarily  aft'ected. 

I  have  made  observations  to  determine  the  correctness  of  this  state- 
ment, and  have  found  that  the  whole  inferior  surface  of  the  capsule  is 
formed  of  epidermic  scales,  thickly  matted  together.  These  are  lined 
by  finely  molecular  matter  from  which  the  plants  appear  to  spring,  and 
which  unites  the  branches  and  sporules  together  in  a  mass.  Superiorly, 
however,  the  epideimic  scales  are  not  so  dense  ;  and  I  have  always  found 
them  more  or  less  broken  up,  and  not  continuous.  This  observation  is 
valuable,  as  indicating  the  probable  mode  in  which  these  plants,  or  the 
sporules  producing  them,  are  deposited  on  the  scalp.  It  will  be  seen 
that  the  appearance  of  the  peculiar  porrigo  capsule  was  invariably  pre- 
ceded by  a  desquamation  of  the  cuticle,  that  is,  a  separation  or  splitting 
up  of  the  numerous  external  epidermic  scales  which  constitute  its  outer- 
most layer.  Hence  it  is  more  probable  that  the  sporules  or  matters  from 
which  the  vegetations  are  developed,  insinuate  themselves  between  the 


*  Fig.  470.  Thalli,  mycelia,  and  sporidia,  of  the  Achorion  Schcenkini,  showing  the 
mode  of  reproduction.  800  diam. 


DERMATOPHYTA.  809 

crevices,  and  under  the  portion  of  epidermis  tlnis  partially  separated, 
than  that  thev  spring  up  oriyinallv  below,  or  in  the  thickness  of  the 
cuticle. 

The  chemical  constitution  of  the  matter  originally  exuded  is  supposed 
by  M.  Cazenave  to  be  allied  to  fat,  but  it  appears  to  me  to  be  more  pro- 
bablv  albuminous,  and  allied  to  the  molecular  character  of  all  broken 
down  or  disintegrated  organic  material  in  which  fungi  grow.  We  have 
seen  that,  prev'ious  to  the  return  of  favus  crusts,  the  head  is  always 
covered  with  broken-up  epidermis,  more  or  less  disintegrated.  Experi- 
ments have  shown  that  the  plants  will  not  grow  on  the  healthy  skin, 
and  that  inoculation  succeeds  only  in  places  where  pustules  have  pre- 
viously been  formed.  It  is  also  exceedingly  probable  that,  when  favus 
is  communicated  from  one  person  to  another,  the  part  affected  (generally 
the  scalp)  has  been  the  seat  of  some  other  eruption  (Case  CLXXIX.), 
or  is  not  particularly  clean. 

Mr.  I^richsen  considers,  "That  the  matter  of  favus  is  a  modification  of 
tubercle — that  it  is  a  tnbercular  disease  of  the  skin.  By  tubercular  I  do 
not  mean  a  disease  like  lupus,  characterised  by  small  firm  tumours,  but 
a  disease,  the  nature  of  which  consists  in  the  deposition  of  that  heterolo- 
gous formation  called  tubercle."  This  view  of  the  nature  of  favus  I  have 
long  held ;  and  it  was  distinctly  stated  by  me,  when  treating  of  the 
pathology  of  scrofula,  in  a  work  published  in  1S41.*  The  favus  crust, 
however,' is  not  constituted  wholly  of  tubercular  matter.  The  peculiar 
exudation  only  constitutes  the  soil  from  which  the  mycodermatous  vege- 
tations spring,  as  I  shall  now  endeavour  to  show. 

Grubv  describes  the  mycodermata  of  favus  as  springing  from  an  amor- 
phous mass,  of  which  the  periphery  of  the  capsule  is  composed.  This 
mass  undoubtedly  exists,  and,  according  to  my  observations,  is  composed 
of  a  finelv  molecular  matter,  identical  in  structure  with  certain  forms  of 
tubercle,  or  recently  coagulated  exudation.  The  cheesy  matter,  for 
instance,  so  frequently  found  on  the  secreting  surface  of  serous  mem- 
branes, and  in  tubercidar  cavities  and  other  structuix-s  in  chronic  cases 
of  tuberculosis,  or  general  tendency  to  tubercidar  deposition,  presents 
this  character.  Every  pathologist  who  has  minutely  examined  tubercle 
recognises  a  granular  form  in  which  there  is  no  trace  of  nucleus  or  cell, 
and  which,  therefore,  we  are  warranted  in  considering  as  unorganised. 
I  have  mvself  repeatedly  examined  this  tubercular  matter,  and  been  una- 
ble to  detect  any  difference  between  it  and  the  mass  in  which  the  vege- 
tations of  favus  appear  to  grow.  Chemical  analysis  of  this  form  of  tuber- 
cle demonstrates  it  to  be  composed  principally  of  albumen,  with  a  minute 
proportion  of  earth v  salts;  sometimes  there  is  combined  with  it  a  small 
quantity  of  fibrin  or  gelatine.  If  this  general  result  be  compared  with 
the  analysis,  by  Thenard,  of  favus  matter,  the  identity  between  it  and 
tubercle  must  appear  highly  probable,  lie  found  in  100  parts — coagu- 
lated albumen,  70;  gelatine,  17  ;  phosphate  of  lime,  5  ;  water  and  loss, 
8  parts.  Thus  the  "evidence  furnished  by  morphology  and  chemistry 
agrees  in  determining  the  molecular  matter  found  in  the  crusts  of  favus 
and  in  tubercle  to  be  analogous. 

*  Treatise  on  the  Oleum  Jecoris  Aselli,  p.  9-4. 


810  DISEASES   OF   THE    INTEGUMENTAEY    SYSTEM. 

Remak  found  that,  althongli  the  sporules  underwent  developmental 
changes  on  the  cut  surface  of  an  apple,  as  well  as  in  animal  tluids  to 
which  sugar  had  been  added,  no  such  changes  took  place  in  spring  or 
distilled  water,  in  the  serum  of  blood,  solution  of  albumen,  pus,  muscle, 
substance  of  brain,  cut  pieces  of  skin,  or  animal  fat.  In  these  cases  the 
animal  tissues,  as  well  as  the  portions  of  favus  crust,  became  gi'adually 
disintegrated,  and  infusorial  formations  commenced.  Hence  the  Acho- 
rion  grows  under  the  same  circumstances  only  as  all  other  moulds. 
Putrefaction  of  animal  or  vegetable  substances  is  unfavourable  to  its  pro- 
duction ;  but  that  peculiar  acid  change  which  occurs  in  milk  or  paste, 
exposed  to  the  air  for  some  days,  and  in  which  growths  of  mould  and 
confervge  are  fjxvoured,  is  also  beneficial  to  the  development  of  favus. 
Hence  why  inoculation  in  healthy  tissues  fails,  and  why  certain  exuda- 
tions in  peculiar  states  of  the  constitution,  or  disintegrated  matters  which 
have  undergone  particular  chemical  changes,  probably  from  acid  secre- 
tions of  the  skin,  are  necessary  to  the  production  of  Uie  disease. 

I  believe,  therefoi'c,  that  the  pathology  of  favus  is  best  understood  by 
considL'ring  it  essentially  to  be  a  form  of  abnormal  nutrition,  with  exu- 
dation of  a  matter  analogous  to,  if  not  identical  with,  that  of  tubercle, 
which  constitutes  a  soil  for  the  germination  of  cryptogamic  plants,  the 
presence  of  which  is  pathognomonic  of  the  disease.  Hence  is  explained 
the  frecpieiicy  of  its  occurrence  in  scrofulous  persons,  and  among  cachec- 
tic or  ill-fed  children:  the  impossibility  of  inoculating  the  disease  in 
healthy  tissues,  or  the  necessity  for  there  being  scaly,  pustular,  or  vesi- 
cular eruptions  on  the  integuments,  previous  to  contagion.  But  as  ex- 
periments have  proved  the  possibility  of  inoculation  in  healthy  persons, 
it  follows  that  the  material  in  which  the  vegetations  grow,  may  at  the 
co'.umencement,  in  a  molecular  exudation,  be  formed  primarily  or 
secondarily.  That  is,  there  may  be  want  of  vital  power  from  the  first, 
as  occurs  in  scrofulous  cases,  or  there  may  have  been  production  of  cell 
forms,  such  as  those  of  pus  or  epidermis,  which,  when  disintegrated  and 
reduced  to  a  like  molecular  and  granular  material  secondarily,  constitute 
the  necessary  ground  from  whicii  the  parasite  derives  its  nourishment, 


and  in  whicli  it  grows. 


Treatment, 


Almost  every  species  of  treatment  has  been  had  recourse  to,  in  order 
to  remove  this  disagreeable  and  intractable  disease  ;  and  there  can  be 
no  doubt,  that  cases  have  recovered  under  the  use  of  all  and  each  of  the 
methods  recommended.  In  some  instances,  favus  wears  itself  out,  or 
rather,  as  the  development  of  the  frame  proceeds,  and  the  constitutional 
strength  improves,  the  conditions  necessary  for  its  production  and  main- 
tenance are  removed,  and  it  consequently  disappeai's.  In  every  case, 
however,  it  nrust  be  our  object  to  get  rid  of  the  disease  permanently 
as  soon  as  possible,  and  this  is  only  to  be  done  by  removing  the  patho- 
logical conditions  on  which  it  depends. 

The  notion  that  it  originates  in  the  bulbs  of  the  hair  caused  an 
attempt  to  remove  the  disease  by  eradicating  the  structures  with  which 
it  was  supposed  to  be  connected.     Hence  the  barbarous  and  cruel  treat- 


DERMATOPIIYTA.  811 

ment  by  means  of  the  Calotte.  This  consisted  in  spreading  a  very  ad- 
hesive plaster  inside  a  cap,  which  closely  fitted  the  shaven  scalp.  The 
hair  was  then  allowed  to  grow  and  insinuate  itself  amongst  the  sub- 
stance of  the  plaster — wlien  the  whole  was  forcibly  torn  off.  In  this 
wav,  portions  of  the  scalp  were  sometimes  separated — at  others,  pieces 
of  the  plaster  remained  firmly  attached,  and  gave  great  trouble.  A 
modification  of  this  plan  consisted  in  covering  the  head  with  the  plaster 
in  strips,  which  were  removed  separately  from  before  backwards,  and 
from  behind  forwards,  so  as  to  tear  out  the  hairs.  Even  this  plan 
failed.  The  practice  I  snw  adopted  in  Berlin,  in  1841,  consisted  in 
plucking  out  the  hairs  individually  with  a  pair  of  pincers ;  but  this 
tedious  and  painful  method,  also,  was  found  to  be  of  little  service. 

In  Paris,  the  above  kinds  of  practice  have  generally  been  pat  aside  for 
the  milder  empiric  treatment  of  the  freres  Mahon.  Between  the  years 
1807  and  1813,  439  girls  and  469  boys,  aftected  with  favus,  were  cured 
by  them  at  the  Bureau  Central  des  Ilopitaux,  and  the  mean  duration 
of  the  treatment  was  56  applications.  These  applications  are  generally 
made  every  other  day,  so  that  the  average  length  of  treatment  by  this 
much  boas'ted  and  successful  method  is  three  months  and  a-half. 

I  have  endeavoured  to  show,  however,  that  in  many  cases  it  is  a  con- 
stitutional disease,  and  dependent  upon  the  causes  which  induce  scrofu- 
lous diseases  in  general.  The  treatment,  therefore,  in  such  ought  to  be 
constitutional,  and  directed  to  removing  the  tendency  to  tubercular  exu- 
dation, on  which  the  malady  depends,  Xo  doubt,  liowever,  a  local 
treatment  in  this,  as  in  all  other  disorders  which  are  at  the  same  time 
general  and  local,  is  of  the  utmost  service. 

I  consider,  then,  that  the  chief  indications  of  treatment  are — 1st,  To 
remove  the  constitutional  derangement ;  and,  2dly,  To  employ  such 
topical  applications  as  tend  to  prevent  the  development  of  vegetable  life. 
This  line  of  practice  may  be  thought  similar  to  that  recommended  long 
ago  by  Lorry,  who  advises,  1st,  A  modification  of  the  fluids  and  solids  of 
the  economy  by  a  general  treatment ;  2<,lly,  A  vigorous  attack  upon  the 
local  disease  by  topical  applications,  capable  of  removing  the  crusts, 
causing  the  skin  to  suppurate  deeply  and  substituting  a  solid  cicatrix  for 
the  morbid  ulceration  of  the  hairy  scalp.  For  the  most  part,  however, 
the  general  treatment  of  physicians  has  been  confined  to  diluent  drinks, 
blood-letting,  purging,  and  remedies  which  depress  the  vital  powers, 
whereas  it  must  "be "evident,  that  ifthe  views  of  its  pathology  I  have 
brought  forward  be  correct,  and  it  is  in  its  nature  allied  to  tubercular 
aft'ections,  a  treatment  exactly  opposite  ought  to  be  pursued.  The  de- 
velopment of  vegetable  life  may  also  be  prevented  by  the  application  of 
much  milder  remedies  than  the  escharotics,  or  irritating  ointments 
usually  employed. 

We  have  previously  seen  that  tuberculosis  is  caused  and  kept  up  by 
some  fault  in  the  digestive  process ;  that  the  blood  is  secondarily 
aftected,  and  its  albuminous  constituents  proportionally  increased  ;  that 
the  albumen  at  length  becomes  eftased  into  the  different  structures  of 
the  economy,  causing  the  various  forms  of  tubercular  disease  ;  and  lastly, 
as  the  albumen  in  the  blood  becomes  excessive,  and  its  eft'usion  into  the 
textures  increases,  the  fatty  constituents  of  the  frame  diminish.  It  has 
been  shown,  by  numerous  facts,  that  under  such  circumstances  the  inter- 


812  DISEASES   OF   THE  "I^'TEGUME^'TARY   SYSTEM. 

nal  and  external  exliibition  of  cod-liver  oil  has  been  attended  witli  the 
most  marked  advantage,  and  often  been  made  tbe  means  of  cure  when 
all  other  remedies  have  failed.  Tlie  action  of  the  oil  appears  to  be  the 
same  in  favus  as  in  other  forms  of  scrofulous  disease,  and  its  use  should 
be  combined  with  appropriate  diet  and  exercise,  and  with  reference  to 
the  same  indications  and  contra-indications. 

The  local  treatment  I  have  employed  for  several  years,  is  directed,  in 
conformity  with  the  patholoo-ical  views  previously  detailed,  to  the  exclu- 
sion of  atmospheric  air,  so  as  to  prevent  vegetable  growth.  For  this 
purpose,  I  direct,  in  the  first  instance,  that  the  affected  scalp  should  be 
poulticed  for  several  days,  until  the  favus  crusts  are  thoroughly  softened, 
and  fall  off.  Then  the  head  is  to  be  carefully  shaved,  after  which  it  will 
be  found  to  present  a  shining  clear  surface.  Lastly,  cod-liver  oil  should 
be  applied  with  a  soft  brush,  or  dossil  of  lint,  over  the  affected  surface 
morning  and  night,  and  the  head  covered  with  an  oil-silk  cap  to  prevent 
evaporation,  and  further  exclude  the  atmospheric  air.  Everv  now  and 
then,  as  the  oil  accumulates  and  becomes  inspissated,  it  should  be 
removed  by  gently  washing  it  with  soft  soap  and  water.  It  is  very  pos- 
sible common  lard,  or  any  other  oil,  would  do  as  well  as  cod-liver  oil. 
In  one  case  I  found  a  sulphurous  acid  lotion  succeed. 

I  have  found  the  average  duration  of  this  treatment  to  be  six  weeks, 
which  contrasts  very  favourably  with  the  results  of  MM.  Mahon's  prac- 
tice at  the  Hopital  St.  Louis.  Some  cases  seem  to  be  incurable,  and 
these  are  most  frequent  among  adults ;  but  even  in  them,  so  lonsj  as  the 
scalp  is  kept  moist  with  oil,  and  the  air  is  excluded,  the  eruption  will 
not  return  (Case  CLXXVIL).  In  young  subjects,  in  whom  general  as 
well  as  local  treatment  is  admissible,  and  in  whom  a  scrofulous  disposi- 
tion is  manifest,  the  prognosis  is  more  favourable,  and  the  disease  mav 
be  permanently  eradicated  (Cases  CLXXVIII.  to  CLXXX.).  AVhenever 
favus  is  recent  and  of  limited  extcTit,  it  may  at  once  be  destroyed  bv 
cauterization  with  nitrate  of  silver  (Case  CLXXXL). 

Lebert  is  of  opinion  that  poultices  and  oily  applications  soften  the 
favi,  and  distribute  the  sporules  over  the  skin.  He,  therefore,  insists  on 
removing  the  crusts  drv,  by  means  of  a  small  spatula,  sewing  needles,  or 
other  instruments.  He  savs  that  nothing  is  more  easy  than  to  detach 
them  entire;  for,  although  pushed  into  the  skin,  they  are  not  held  there 
by  any  adhesion.  But  I  think  it  will  be  found  that,  however  dexterous 
a  pei-son  may  be  in  removing  the  crusts,  that  the  majoritv  are  held 
firmly  to  the  scalp,  by  means  of  the  hair  which  perforates  them,  and  that 
tearing  these  out  is  very  painful.  Besides,  the  crusts  are  easily  broken, 
and  the  time  and  trouble  required,  even  when  they  are  thinly  scattered, 
renders  this  plan  impracticable  in  hospitals.  When  densely  matted 
together,  it,  of  course,  cannot  be  done.  I  believe,  then,  that  repeated 
poulticing  is  l:)y  far  the  best  and  most  efficient  method  of  freeing  the  skin 
from  the  eruption,  whilst  it  has  the  extra  advantage  of  doing  so  without 
irritation,  and  thereby  diminishing  the  tendency  to  the  formation  of  im- 
petiginous pustules. 


SECTION    X. 


DISEASES   OF  THE  BLOOD. 

The  diseases  of  the  blood  have  strongl}-  engaged  the  attention  of 
modern  pathologists,  who,  putting  aside  the  vague  speculations  which 
the  ancients  heki  regarding  this  important  fluid,  have  sought  to  inves- 
tigate the  subject  by  the  aid  of  facts  derived  from  chemical,  micro- 
scopical, and  clinicai  researches.  The  general  results  of  these  have 
been  sketched,  pp.  102  to  105.  The  alterations  of  the  blood  give  rise 
to  many  of  the  most  important  disorders  which  aifect  the  body,  besides 
being  necessarily  associated  more  or  less  with  every  morbid  change 
connected  with  "alterations  of  nutrition.  It  is  the  principal  idiopathic 
or  essential  forms  of  blood  disease  which  will  be  treated  of  in  this 
place. 


LEUCOCYTHEMIA. 

On  the  19th  of  March,  IS-to.  I  examined  the  body  of  a  man,  who  died 
under  the  care  of  Professor  Christison,  in  the  Royal  Infirmary,  labouring 
under  hypertrophy  of  the  spleen  and  liver,  and  whose  blood  was  crowded 
with  corpuscles  which  exactly  resembled  those  of  pus.  This  case  was 
the  first  of  the  kind  in  which  a  careful  histological  examination  of  the 
blood  was  made,  and  in  which  the  remarkable  morbid  condition  then 
discovered,  was  separated  from  ordinary  pyaemia,  and  shown  to  be 
unconnected  with  any  form  of  inflammation.  It  was  published  in  the 
Ediuburijh  Med.  and  Surg,  Journal,  October  Ist,  1845,  vol.  Ixiv.,  p.  413. 
Dr.  Craii-ie,  who  was  present  at  the  dissection,  recognised  its  similarity 
to  one  he  had  had  under  his  care  four  yeai-s  previously,  the  blood  of 
which  had  been  examined  microscopically  by  Dr.  John  Reid,  who  found 
'•  tliat  it  contained  globules  of  purulent  matter  and  lymph."  An  account 
of  it  appeared  in  the  same  number  of  the  Edinburgh  Journal  for  October 
1845.  Six  weeks  after  these  cases  had  been  published.  Professor  Vir- 
chow  of  Berlin  gave  the  history  of  another,  in  the  second  number  for 


814  DISEASES   OF   THE   BLOOD. 

November  1845,  of  Froriep's  "Xotizen"  (Xo.  TSO),  under  the  name  of 
"  Leukhemia,"  or  white  blood.  On  the  31st  of  December  1845,  a  man 
was  received  into  St.  George's  Hospital,  London,  in  whom  Dr.  Fuller 
detected,  both  before  and  after  death,  the  increased  number  of  colourless 
corpuscles  in  the  blood.  This  man,  like  the  other  individuals,  had  great 
hypertrophy  of  the  spleen.  A  notice  of  the  case  is  inserted  in  the 
"  Lancet,'' for  July  1840.  Since  then  several  similar  cases  have  been 
met  with,  in  which  this  morbid  condition  of  the  blood  has  been  deter- 
mined to  exist,  by  an  accurate  exaniinatiou  with  the  microscope  ;  and  a 
reference  to  the  I'ccords  of  medicine  has  shown  the  previous  occurrence 
of  like  cases.  Li  these  last,  the  blood,  with  two  exceptions,  was  not 
])hysically  proved  to  contain  an  unusual  number  of  colourless  corpuscles, 
althongh  now  on  looking  back  upon  the  facts  which  are  mentioned  in 
regard  to  them,  we  can  have  little  doubt  that  such  was  the  case.  The 
exceptional  cases  occurred  to  M.  Barth  in  1839,  and  Dr.  Cragie  in  1841. 
In  the  first,  M.  Donne  found  one-half  the  corpuscles  in  the  blood  to  be 
"  mucous  globules,"  and  in  the  second.  Dr.  John  Keid  found  that  the 
blood  "contained  globules  of  purulent  matter  and  lymph.'"'' 

The  term  "Leukhemia,"  or  white  blood,  given  to  this  disease  by 
Yirchow,  is  faulty,  because,  in  the  first  place,  as  was  correctly  stated 
by  Dr.  Parkes,  the  blood  is  not  white,  but  presents  its  usual  red  tinge 
when  drawn  from  the  aim.  The  colourless  clots  occasionally  observed 
after  death  will  certainly  not  warrant  the  application  of  this  term  to  the 
blood  generally,  as  they  are  frequently  present  without  the  moibid 
condition  under  consideration.  Besides  the  same  name  (white  blood) 
has  b(!en  given  with  more  propriety  to  the  fatty  blood,  examined  bv 
Drs.  Traill,  Christison,  and  others,  which  presents  a  milkv,  opalescent 
appearance.  x\t  the  meeting  of  the  Academy  of  Medicine  in  Paris, 
on  January  29th,  1856,  the  members  were  naturally  enough  led  into 
great  confusion  in  consequence  of  not  keeping  this  distinction  in  view. 
What  ought  to  be  expressed  is,  that  the  blood  abounds  in  colourless 
corpuscles,  and  this  is  done  by  the  term  Leucocythemia — from  Xsvxoc:, 
white  ;  xurog-,  cell ;  and  aljxrx,  blood — literally,  white  cell  blood,  which 
expresses  the  simple  fact,  or  pathological  state,  and  involves  no  theory. 
Thixmghout  England  and  France  this  name  has  been  universally 
adopted. 


Case  CLXXXIIT.f — Leucocythemia  discovered  after  death — Ilypertroj^hy  of  the  Spleen, 
Liver,  and  Lymphatic  Glands — Abseiice  of  PI ilebitis  and  of  Purulent  Collections  in 
any  p)art  of  tlie  Body. 

History. — John  Monteitli,  aged  28,  a  slater— admitted  into  the  clinical  ward  of 

*  Gazette  Hebdomadaire,  March  21,  1856,  and  Edin.  Med.  and  Surg.  Journal, 
October,  1845. 

f  Thi.s  case  occurred  in  the  clinical  ward  of  Professor  Christison,  who  treated  it. 
The  body  after  death  was  most  carefully  inspected  by  me  as  pathologist  to  the  Royal 
Infirmary,  and  parts  were  removed  for  careful  subsequent  examination,  and  for  pre- 
servation, the  appearances  being  altogether  of  a  kind  quite  new  to  me.  Tiie  case, 
for  reasons  which  will  appear  in  the  sequel,  is  here  given  verbatim,  as  it  was  origi- 
nall}'  published  in  the  Edinburgh  Journal  for  1st  October  1845. 


LEUCOCYTHEMIA.  815 

the  Royal  Infirmary,  February  27,  18-45,  under  the  care  of  Dr  Cbristison.  He  is 
of  dark  couiplexion,  usually  healthy  and  temperate ;  states  that  twenty  months  ago 
he  was  aftected  with  great  listlessness  on  exertion,  which  has  continued  to  this  time. 
In  June  last  he  noticed  a  tumour  in  the  left  side  of  the  abdomen,  which  gradually 
increased  in  size  till  four  months  since,  when  it  became  stationary.  It  was  never 
painful  till  last  week,  after  the  application  of  three  blisters  to  it ;  since  then,  several 
other  small  tumours  have  appeared  in  his  neck,  axillse,  and  groins,  at  first  attended 
with  a  sharp  pain,  which  has  now,  however,  disappeared  from  all  of  them.  Before 
he  noticed  the  tumour,  he  had  frequently  vomiting  in  the  morning.  The  bowels 
are  usually  constipated,  appetite  good,  is  not  subject  to  indigestion,  has  had  no 
vomiting  since  he  noticed  the  tumour ;  he  has  used  chiefly  purgative  medicines, 
especially  croton  oil;  employed  friction  with  a  liniment,  and  had  the  tumour 
blistered. 

Stmptom,s  ox  Admission'. — On  admission,  tliere  is  a  large  tumour,  extending 
from  the  ribs  to  the  groiu,  and  from  the  spinal  column  to  the  umbilicus,  lying  on  the 
left  side.  It  is  painful  on  pressure  near  its  upper  part  only.  Percussion  is  dull  over 
the  tumour ;  pulse  90 ;  states  that  for  three  months  past  he  has  not  lost  in  strength. 
There  is  slight  oedema  of  the  legs.  To  have  two  pills  of  iodide  of  iron  morning  and 
evening. 

Progress  of  the  Case. — March  \st. — Urine  of  ye.sterday  somewhat  turbid  when 
just  passed,  natural  in  colour,  acid  to  litmus;  sp.  gr.  1013.  Sediment  presents  cubic 
crystals  under  the  microscope,  disappears  almost  entirely  on  the  addition  of  aqua 
potass«,  but  is  unaSected  by  nitric  acid.  The  filtered  urine  is  not  affected  by  aqua 
potassa;,  and  yields  only  a  slight  white  haze  when  boiled.  2Iarch  Wi. — (Edema  of 
legs  increased  They  have  been  bandaged  with  flannel  rollers.  IJ.  Pota-ssce  Carbo- 
natis,  3  i ;  Spiritus  .£therix  Kitrici,  3  iv ;  Aquce  Mentha,  5  "j ;  Aquce  foniis,  %  ij- 
M.  Sumat  unciam  ier  in  die.  March  lOih. — Tormina  and  considerable  diarrhoea ; 
urine  not  increased.  Habeat  hausium  ex  Olei  Ricini  |  ss  statim ;  et  exaciis  quaiuor 
horis  Opii,  gr.  ii.  March  13^^.— Attacked  this  morning  with  lieat  of  skiu  ;  thu-st ; 
pulse,  110,  full,  very  compressible.  The  diarrhoea,  which  had  been  checked,  returned 
yesterday:  none  this  morning  after  taking  an  opium  pill.  Urine  100  ounces.  Omit- 
ianlur  medicamenta.  Sumat  statim  Pulveris  JpecaciuinltoR  et  Opii,  gr.  x,  et  repetatur 
dosis  singulis  seinihoris  ad  tertiam  vicem.  March  l-ith. — Xo  sweating  from  the  pow- 
ders; diarrhoea  still  rather  troublesome ;  pulse  100,  softer;  tongue  dry  and  brown; 
febrile  expression  of  countenance,  resembling  tliat  of  typhus.  IJ  Aq^MX  Acetatis 
Ammonice  3vi;  Solutionis  Morphia,  3i;  Aquce  fontis,  §iij;  Syrupi,  3J.  Sumat 
xinciam  quartd  qudque  hord.  Habeat  decoctum  hordei  pro  potu.  March  Ibth. — Died 
suddenly  in  the  morning. 

Sectio  Cadaverh. — March  19  [four  days  after  death). 

Externally,  the  body  presented  a  considerable  prominence  of  the  ensiform  cartilage 
and  false  ribs  on  both  sides.  The  abdomen  was  contracted ;  considerable  dulness 
on  percussion  on  left  side,  which  had  previously  been  marked  out  by  a  line  formed 
with  nitrate  of  silver.     Xo  ascites  nor  oedema  of  the  limbs. 

Blood. — Tlie  blood  throughout  the  body  was  much  changed.  In  the  right  cavi- 
ties of  the  heart,  pulmonary  artery,  venae  cavae,  vena  azygos,  external  and  internal 
iliac  veins,  and  many  of  the  smaller  veins  leading  into  them,  it  was  firmly  coagu- 
lated, and  formed  a  mould  of  their  size  and  form  internally.  In  the  cavities  of  the 
heart  and  venje  cavte,  the  blood,  when  removed,  was  seen  to  have  separated  into  a 
red  or  inferior,  and  a  yellow  or  superior,  portion.  Tlie  red  portion  was  of  a  brick- 
red  colour ;  it  did  not  present  the  dark  purple  smooth  and  glossy  appearance  of  a 


816 


DISEASES   OF   THE   BLOOD. 


healthy  coaguhim,  but  was  dull   and   somewhat  granular  on  section,    and  when 

squeezed  readily  broke  down  into 

a    grunious    pulp.      The    yellow 

portion    was   of    a   light    yellow 

colour,   opaque    and    dull,  in    no 

way  resembling  the  gelatinous  ap- 
pearance of  a  healthy  decolorised 

clof.     When  squeezed  out  of  the 

veins,  as  was  sometimes  accident- 
ally done  where  they  were  divided, 

it  resembled  tliick  creamy  pus.    In 

some  portions  of  the  veins,  the  clot 

was  wholly  formed  of  red  coagu- 

lum.  In  others  it  was  divided 
Fig.  471.  into  red  and  yellow.  In  a  few 
places  the  yellow  formed  only  a  streak  or  super- 
ficial layer  upon  the  red,  or  covered  the  latter  with 
spots  of  various  sizes.  "Whether  this  coagulum  ex- 
isted in  all  the  veins,  could  only  have  been  ascer- 
tained by  a  complete  dissection  of  the  body.  It 
was  seen,  however,  that  the  femoral  veins,  after 
passing  under  Poupart's  ligament,  were  empty  and 
perfectly  healthy,  as  far  down  as  the  Sartorius 
muscle.  The  external  and  internal  iliac  veins,  as 
well  as  the  pelvic  veins,  were  full  and  distended. 
The  azygos,  both  axillary  and  jugular  veins,  were  Fig.  472. 

full,  also  the  longitudinal,  the  lateral,  and  other  sinuses  at  the  base  of  the  cranium, 
and  veins  ramifying  on  the  surface  of  the  brain.  In  this  last  situation  some  of  the 
veins  appeared  as  if  full  of  pus,  whilst  others  were  gorged  with  a  dark  coagulum 
— (See  Fig.  473).  In  the  aorta  and  external  arteries  were  a  few  small  clots,  resem- 
bling those  found  in  the  veins.  These  vessels,  however,  were  comparatively  empty. 
The  basilar  artery  at  the  base  of  the  brain  was  distended  with  a  yellow  clot. 

Vessels. — The  arteries  and  veins  themselves  were  perfectly  healthy.  Although 
carefully  looked  for,  in  no  place  could  thickening  or  increased  vascularity  be  observed. 
Nowhere  was  the  clot  adherent  to  the  vessels,  but,  on  the  contrary,  it  readOy  slipt 
out  when  an  accidental  puncture  was  made  in  them. 

Head. — On  removing  the  dura  mater,  the  veins  which  empty  themselves  into  the 
longitudinal  sinus  were  considerably  engorged,  especially  posteriorly.  Some  were 
filled  with  the  red,  and  others  -with  the  yellow  clot  previously  described.  Others, 
again,  were  half  filled  with  red  and  half  with  yellow  coagulum,  the  passage  of  the 
one  into  the  other  being  clearly  perceived.  Both  hemispheres,  with  the  longitu- 
dinal sinus  and  faho  in  situ,  were  removed  by  a  section  across  the  brain,  as  low 
down  as  tlie  division  of  the  cranium  would  permit.  The  brain  was  then  discovered 
to  be  very  soft  uniibrmly, — a  circumstance  accounted  for  by  the  time  which  had 
elapsed  since  death.  The  part  removed  was  put  aside,  in  order  to  be  preserved 
and  hardened  in  spirit.  The  lateral  ventricles  were  found  healtliy,  contained  no 
serum,  and  the  choroid  plexus  was  perfectly  normal.     At  the  base  of  the  brain  the 

Fig.  471.  Portion  of  clot  from  the  vena  cava,  showing  the  divisions  into  red  and 
white  coagula.     Half  the  real  size. 

Fig.  472.  Posterior  surface  of  the  aorta  and  vena  cava.  An  incision  has  been  made 
in  the  latter,  to  show  that  it  is  not  thickened  or  diseased,  as  well  as  to  expose  colour- 
less coagula  even  in  the  most  depending  portions  of  the  clot.     Half  (he  'real  size. 


LEUCOCYTHEMIA.  817 

basilar  artery  was  seen  distended  with  the  yellow  coagulum,  as  were  also  a  few  of 
the  arteries,  but  to  a  very  slight  extent.  The  substance  of  the  brain  itself  was 
throughout  iiealthy.  All  the  sinuses  at  the  base  of  the  cranium  gorged  with  the  red 
coagulum. 


Fig.  4T3. 

Chest. — A  few  chronic  adhesions  united  the  pleurae  on  both  sides,  which  were 
easily  torn  through.  Both  lungs  were  slightly  engorged  posteriorly  and  inferiorly. 
The  anterior  margin  of  the  left  lung  emphysematous,  but  to  no  great  extent.  On 
section,  tlie  yellow  coagulum  of  the  blood  was  observed  to  occupy  all  the  ramifica- 
tions of  the  pulmonary  artery.  In  some  places  it  was  so  consistent  as  to  be  drawn 
out,  exhibiting  an  arborescent  form ;  in  others,  it  was  more  soft,  and  exuded  from 
the  cut  surface  like  thick  pus.  Heart  somewhat  enlarged;  weighed,  when  freed 
from  coagulum,  eleven  and  a  half  ounces.  Its  texture  was  healthy;  the  valves 
normal.  The  right  auricle  much  distended,  and  gorged  with  a  firm  coagulum,  the 
upper  third  of  which  was  found  composed  of  the  yellow,  and  the  two  inferior  thirds 
of  the  red  clot  formerly  described.  The  right  ventricle  and  pulmonary  artery  were 
similarly  distended ;  portions  of  the  clot  closely  embraced  the  columnai  carneae,  but 
were  in  no  place  adherent.     The  coronary  arteries  and  veins  were  normal. 

Abdomen. — On  the  inferior  surface  of  the  diaphragm  there  existed  a  firm,  almost 
cartilaginous,  deposit,  about  a  line  in  thickness,  of  a  white  colour,  oval  form,  two 
inches  long  by  one  and  a  half  broad,  with  irregular  margins,  which  were  composed 
of  several  rounded  tubercular  bodies,  the  size  of  a  small  pea,  and  of  a  fibrous  struc- 
ture. The  liver  enormously  enlarged  from  simple  hypertrophy.  Its  structure 
throughout  healthy.     Gall-bladder  enlarged,  and  distended  with  a  clear  pale  yellow 


Fig.  473.  Appearance  of  the  upper  surface  of  the  hemispheres  after  removing  the 
dura  mater,  showing  the  remarkably  white  appearance  of  the  coagula  in  the  veins 
and  longitudinal  sinus.     Ilalf  the  real  size. 

52 


818  DISEASES   OF   THE   BLOOD. 

bile.  The  whole  weighed  ten  pounds  twelve  ounces.  The  spleen  also  enormously 
enlarged  from  simple  hypertrophy.  It  was  of  a  spindle  shape,  largest  in  the  centre, 
tapering  towards  the  extremities.  It  weighed  seven  pounds  twelve  ounces.  It 
measured  in  length  fourteen  inches;  in  breadth,  at  its  widest  part,  seven  inches; 
and  in  thickness,  four  and  a  half  inches.  Towards  its  anterior  surface  was  a  yellow 
firm  exudation,  about  an  inch  deep,  and  three  inches  long.  The  peritoneum,  also 
covering  a  portion  of  its  anterior  surface,  was  thickened,  opaque,  and  dense  over  a 
space  about  the  size  of  the  hand.  Both  kidneys  healthy.  The  stomach  and  intes- 
tines healthy  throughout.  About  four  inches  from  the  anus  the  superior  hemor- 
rhoidal veins  were  distended  on  both  sides  external  to  the  rectum.  They  formed 
two  chains  of  tumours  about  three  inches  long,  consisting,  on  the  one  side,  of  three 
swellings  as  large  as  a  walnut ;  on  the  other,  of  one  swelling  somewhat  larger.  They 
were  filled  with  a  red  coagulum,  broken  down  into  a  grumous  mass.  The  lymphatic 
glands  were  everywhere  much  enlarged.  In  the  groin  they  formed  a  large  cluster, 
some  being  nearly  the  size  of  a  small  hen's-egg,  and  several  being  that  of  a  walnut. 
The  axillary  glands  were  similarly  affected.  The  bronchial  glands  were  not  only 
enlarged,  but  of  a  dark  purple  colour,  and  in  some  places  black  from  pigmentary 
deposit.  The  mesenteric  glands  were  of  a  whitish  colour,  some  as  large  as  an 
almond  nut.  A  cluster  of  these  surrounded  and  pressed  upon  the  ductus  communis 
choledochus.  The  lumbar  glands  were  of  a  greenish-yellow  colour,  also  enlarged; 
forming  a  chain  on  each  side,  and  in  front  of  the  abdominal  aorta,  more  especially 
at  its  bifurcation  into  the  iliacs. 

No  collection  of  pus  could  be  found  in  any  of  the  tissues. 

Fig.  474. 


Fig.  476.  Tiff.  477.  Fig.  47S. 


Microscopic  Examination. — The  yellow  coagulum  of  the  blood  was  composed 
of  coagulated  fibrin  in  filaments,  intermixed  with  numerous  colourless  corpuscles, 

Fig.  474.  Colourless  corpuscles,  mingled  with  a  few  coloured  ones,  from  the 
white  clot  of  the  blood  in  Case  CLXXXIII. 

Fig  475.  The  same  bodies,  mingled  with  a  larger  number  of  yellow  blood  cor- 
puscles in  the  red  clot. 

Fig.  476.  Change  produced  on  the  colourless  corpuscles  on  the  addition  of  acetic 
acid,  the  yellow  corpuscles  being  dissolved. 

Fig.  477.  Cells  in  the  fluid  squeezed  from  the  lymphatic  glands,  after  the  addition 
of  acetic  acid. 

Fig.  478.  Bloodvessels  giving  off  a  capillary  from  the  pia  mater;  the  latter  is 
seen  filled  with  colourless  corpuscles;  the  former  partly  with  colourless,  mingled 
with  coloured  corpuscles.  250  diam. 


LEUCOCYTHEMIA.  819 

which  could  be  readily  squeezed  out  from  it  when  pressed  between  glasses.  Where 
the  yellow  coagulum  was  unusually  soft,  the  corpuscles  were  more  numerous,  and 
the  librin  was  broken  down  into  a  diffluent  mass,  partly  molecular  and  granular, 
partly  composed  of  the  debris  of  the  filaments  broken  into  pieces  of  various  lengths. 
The  corpuscles  varied  in  size  from  the  80th  to  the  120th  of  a  mill,  in  diameter; 
thev  were  round,  their  cell-wall  granular,  and  presented  all  the  appearance  of  pus 
corpuscles.  (Fig.  474  )  Water  caused  them  to  swell  and  lose  their  grarmlar  appear- 
ance, and  acetic  acid  dissolved  the  cell-wall  and  caused  a  distinct  nucleus  to  appear. 
Tliis  nucleus  was  compo.sed  sometimes  of  one  large  granule  about  the  200th  of  a 
millimetre  in  diameter,  at  others  of  two  or  three  smaller  granules,  as  is  seen  in  cor- 
puscles of  laudable  purulent  matter.  (Fig.  476.)  The  red  portion  of  the  coagulum 
contained  a  smaller  number  of  these  colourless  corpuscles,  mixed  with  a  multitude 
of  normal  yellow  corpuscles.  (Fig.  475.)  The  colourless  corpuscles  now  described 
were  found  in  the  blood  throughout  the  system.  They  were  seen  in  the  veins  and 
arteries  ramifying  on  the  brain,  in  the  coronary  veins,  hemorrhoidal  tumours,  and 
wherever  the  blood  was  examined.  On  stripping  off  a  portion  of  the  pia  mater,  and 
examining  the  capillary  vessels  of  that  membrane,  all  that  were  not  too  minute  to 
contain  them  were  found  crowded  with  the  same  corpuscles.  (Fig.  478.)  This  fact 
was  confirmed  by  Dr.  Allen  Thomson,  to  whom  I  sent  a  portion  of  the  brain  for 
that  purpose. 

The  cartilaginous  deposit  on  the  inferior  surface  of  the  diaphragm  was  composed 
of  dense  fibrous  tissue,  in  which  numerous  granules  and  molecules  were  observed. 
The  exudation  in  the  spleen  was  composed  of  amorphous  fibrin  mixed  with  nume- 
rous molecules,  granular  and  imperfect  cells.  These  Avere  intermingled  with  bundles 
of  filamentous  tissue.  The  enlarged  lumbar  glands,  on  being  pressed,  exuded  a  fluid 
that  was  crowded  with  corpuscles:  some  resembhng  the  colourless  corpu.scles 
already  alluded  to;  others  oval  and  round,  containing  a  distinct  nucleus.     (Fig.  477.) 

The  ultimate  textures  of  the  muscles,  brain,  nerves,  etc.,  were  carefully  examined, 
and  found  normal. 

Commentary. — I  have  reprinted  this  case  verbatim  fi-oni  the  original 
paper  published  by  me  in  the  Edinburgh  Medical  and  Surgical  Journal 
for  October  1st,  1845,  in  order  to  show  that  it  contains  a  careful  and 
minute  description  of  the  facts  which  I  discovered  on  examining  the 
body,  March  19th.  Figs,  471  to  473  are  copied  from  some  of  the 
preparations  still  in  my  possession,  taken  from  the  body.  A  cast  of  the 
spleen  is  in  the  University  Museum.  Numerous  drawings  were  also 
made  from  microscopic  demonstrations ;  some  of  which  are  represented 
Figs.  474  to  478. 

In  the  remarks  originally  appended  I  observed  : — "  The  points  con- 
nected with  this  case  that  require  discussion  are,  1st,  The  connection 
between  the  symptoms  and  morbid  appearances;  2d,  Were  the  cor- 
puscles contained  in  the  blood  really  those  of  pus?  and  3d,  If  so,  how 
were  they  produced  ?  The  discussion  of  these  theoretical  points,  it 
appears  to  me,  has  nothing  whatever  to  do  with  the  correctness  or 
incorrectness  of  the  facts  above  detailed,  which,  it  will  be  observed, 
are  studiously  separated  from  everything  of  a  hypothetical  character. 
But  in  connection  with  the  first  point  I  observed,  "  It  is  important  to 
remember  that  there  was  no  phlebitis,  abscess,  or  purulent  collection 
to  which  the  appearances  within  the  vessels  could  be  ascribed.  In  all 
cases  of  phlebitis  there  are  changes  in  the  vessels  themselves,  and  the 
clot  is  more   or  less  adherent  to  the  vascular  walls.      Nothing  of  the 


820  DISEASES   OF   THE   BLOOD. 

kind  could  be  detected,  although  particular  attention  was  paid  to  this 
point.  How  far  the  hypertrophy  of  the  liver  and  spleen  may  be 
connected  with  the  coao-ulation  of  the  blood,  and  the  formation  of  pus, 
it  is  difficult  to  say.  Whether  the  hypertrophy  of  these  organs  exer- 
cises a  peculiar  influence  on  the  blood,  or  whether  the  change  in  that 
fluid  be  caused  in  connection  with  chronic  diseases  in  general,  as  has 
been  lately  pointed  out  by  M.  Bouchut,  further  observations  alone  can 
determine." 

Concerning  the  second  point,  I  said,  "  The  only  bodies  with  which 
they  can  be  confounded  are  the  colourless  corpuscles  of  the  blood  itself, 
the  corpuscles  described  by  Gulliver  as  existing  in  softened  fibrin  and 
those  found  in  lymph.  With  regard  to  the  colourless  corpuscles  of 
the  blood,  we  know  of  no  instance  where  they  existed  in  the  amount 
or  even  presented  the  appearance  described."  I  then,  after  considering 
the  structure  of  softened  fibrin,  came  to  the  conclusion  tljat  the  physical 
characters  of  the  corpuscles  found  in  the  case  of  Menteith,  would  leave 
little  doubt  that  they  were  identical  with  those  of  pus. 

In  reference  to  the  third  question,  I  pointed  out  that  the  corpuscles 
must  originate  in  the  blood  system  itself,  in  the  same  manner  as  they 
had  been  shown  by  M.  Bouchut  to  occur  in  various  forms  of  cachexia 
and  chronic  diseases.  I  distinctly  separated  it  from  what  was  then 
understood  by  pysemia,  or  purulent  absorption,  saying,  "  Pus  has  long 
been  considered  as  one,  if  not  the  most  characteristic  proof  of  preceding 
acute  inflammation.  But  in  the  case  before  us,  what  part  was  recently 
inflamed  ?  There  was  none.  Piorry  and  others  have  spoken  of  an 
inflammation  of  the  blood,  a  true  hematitis ;  and  certainly  if  we  can  ima- 
gine such  a  lesion,  the  present  nmst  be  an  instance  of  it.  But  it  would 
require  no  laboured  argument  to  show,  that  such  a  view  is  entirely 
opposed  to  all  we  know" of  the  phenomena  of  inflammation.  Without 
entering  into  this  discussion,  however,  I  shall  assume  it  to  have  been 
satisfactorih^  demonstrated  that  we  can  form  no  idea  of  this  process 
without  the  occurrence  of  exudation  from  the  blood-vessels,  and  that, 
consequently,  the  expression,  inflammation  of  the  blood,  is  an  error  in 
terms.  A  "moment's  reflection  will  make  it  evident  that  all  our  ideas 
of,  and  facts  connected  with,  inflammation  are  associated  with  some  local 
chano-e  in  the  economy.  The  constitutional  disturbances  connected 
with  it  are  invariably  ascribed  to  phlegmasia  or  fever,  which  pathologists 
hitherto  have  always  separated  from  inflammation.  Unless,  therefore, 
it  could  be  shown  that  inflammation  and  fever  were  like  processes,  we 
must  conclude  that  the  alteration  of  the  blood  in  this  case  was  inde- 
pendent of  inflammation  properly  so  called." 

These  observations  appended  to  the  facts  of  the  case  must  at  least  be 
allowed  to  be  sufficiently  suggestive,  so  that  when,  six  weeks  afterwards. 
Professor  Yirchow  published  a  similar  case,  and  said  they  tcere  the 
colourless  corpuscles  of  the  blood,  he  merely  adopted  another  opinion 
reo-arding  them  from  what  I  had  done.  But,  I  submit,  this  does  not 
entitle  bun  to  claim  for  himself  the  discovery  of  this  morbid  condition,* 
or  to  represent,  notwithstanding  my  distinct  separation  of  the  lesion 
from  all  known  pre-existing  conditions  of  the  blood,  that  in  my  opinion 
it  was  an  ordinary  case  of  pyaemia.  He  was  fortunate  enough,  however, 
*  See  note  on  the  discovery  of  Leucocythemia  at  the  end  of  this  article. 


LEUCOCYTHEMIA.  821 

to  meet  witli  two  other  cases,  before  I  was  enabled  to  resume  the  inquiry 
by  meeting  with  the  following  one  : — 

Case  CLXXXlY.*—Leucocijthemia  detected  during  Life— Hypertrophy  of  the  Spleen 

— Ascites. 

History.— Barney  Tiulay,  a;t  17,  farm-servant — admitted  into  the  clinical  ward 
of  the  Royal  Infirmary,  January  25,  1850.  "With  the  exception  of  an  attack  of  scarlet 
fever,  which  he  experienced  about  three  years  ago,  he  enjoyed  perfect  health  until 
twelve  months  since,  when  he  first  noticed  a  tumour  in  the  abdomen,  accompanied 
by  some  pain.  The  tumour  since  this  period  has  gradually  increased  in  size,  and 
latterly  lie  has  been  unable  to  walk  fast  on  account  of  dyspnoea.  For  the  last  two 
or  three  years  he  has  been  employed  in  farm  service,  and  during  three  months  last 
summer  he  resided  in  the  fenny  district  of  Lincolnshire,  but  never  had  intermittent 
fever. 

Symptoms  ox  Adjiissiox. — Ou  admission,  his  complexion  is  pale,  the  conjunc- 
tivEe  are  unusually  blanclied,  and  his  whole  appearance  is  very  cachectic.  On  examin- 
ing the  abdomen,  a  hard  tumour  can  be  felt  occupying  the  whole  left  side.  Supe- 
riorly, it  can  be  felt  emerging  from  the  folse  ribs  about  two  inches  to  the  left  of  the 
ensiform  cartilage.  It  then  passes  downwards  an  inch  and  a  half  to  the  right  of  the 
umbilicus,  and  curves  round  inferiorly  to  a  point  about  an  inch  and  a  half  above  the 
symphysis  pubis,  from  which  it  may  be  traced  directly  backwards  to  within  three 
inches  of  the  spinous  processes  of  the  lumbar  vertebrse.  Its  anterior  margin  presents 
a  semicircular  convexity,  which  is  smooth,  with  a  distinct  notch  in  its  upper  third, 
and  is  apparently  about  half  an  inch  tliick,  as  with  the  fingers  a  fold  of  integument 
may  be  pressed  somewhat  below  it.  The  tumour  is  completely  dull  on  percussion 
throughout,  and  is  in  several  parts  painful  ou  pressure.  It  measures  about  ten  inches 
in  the  long  diameter,  and  thirteen  and  a  half  transversely.  The  rest  of  the  abdomen 
has  the  usual  tympanitic  percussion,  and  there  is  no  fluctuation.  Liver,  on  percus- 
sion, found  to  be  of  tlie  natural  size.  Tongue  clean ;  appetite  good.  There  is  profuse 
diarrhoea,  the  bowels  being  open  eight  or  ten  times  a  day ;  this  symptom  has  existed 
for  the  last  three  or  four  weeks.  Pulse  80,  weak.  Complains  of  giddiness  on 
assuming  the  erect  posture.  Heart  sounds  natural.  He  has  occasional  epistaxis 
and  hemorrhage  from  tlie  gums.  Eespiratory  and  urinary  systems  healthy.  Tlie 
appearance  of  the  blood  drawn 
from  the  extremity  of  the  fingei, 
when  magnified  250  diametti^ 
linear,  is  represented  Fig.  47'> 
Tlie  coloured  corpuscles  for  the 
most  part  have  collected  togetlier 
in  rolls,  the  numerous  colour  Ics 
corpuscles  filling  up  the  inter- 
vening space.  Acetic  acid  dis- 
solved the  coloured  bodies,  and 
rendered  the  cell  wall  of  the 
colourless  ones  very  transparent  Fi?.  4T9.  Fig.  450. 

brino-ino-  into  view  the  nucleus,  consisting  of  a  single  round  or  oval  body  in  some, 

but  in  the  majority  presenting  two,  three,  or  even  four  granules,  each  having  a 

*  Reported  by  Mr.  Hugh  M.  Balfour,  Clinical  Clerk. 


Fig.  479.  Appearance  of  a  drop  of  blood  in  this  case. 

Fig.  480.  The  same  after  the  addition  of  acetic  acid.  250  diani. 


822  DISEASES   OF   THE   BLOOD. 

depression  in  their  centre.     Here  and  there  the  nucleus  was  crescentic,  or  iu  the 
form  of  a  horse-shoe.     (Fig.  480.) 

Progress  of  the  Case. — January  21th.— Rq  lias  had  eight  leeches  applied  to 
the  epigastrium,  and  has  taken  the  lead  and  opium  pills — one  three  times  a  day. 
The  diarrhoea  is  much  diminished,  and  there  is  less  pain.  IJ  Ferri  Citraiis,  3i; 
Tind.  Card.  Comp.  5  i ;  Infus.  Calmnhce,  §  vii.  M.  Fiat  mistura ;  sumat  5  i  ter  in 
die.  5  Sulph.  Quinte,  gr.  iij ;  Pulv.  Catechu  extr.  gr.  iv ;  01.  Carui  m.  i  M. 
Fiani  pil.  ij.  Mittantur  tales  xij,  et  Sig.  sumat  ij,  mane  et  vespere.  Jan.  ?iOth. — Diar- 
rhoea now  entirely  ceased.  ^.  Pulv.  Qninm  Sulph.  gr.  iij ;  Ferri  Carb.  Sacch.  gr. 
vij.  M.  I^ant  pil.  iy,  Mittantur  tales,  \i;  sumat  unam,  ter  in  die.  Intermiitantur 
alia.  Yesterday  three  ounces  of  blood  were  taken  from  the  arm,  which  Dr.  W. 
Robertson  was  so  good  as  to  analyse.     The  results  are  as  follows : 

Sp.  Grav.  ofthe  Blood 1041-5 

Sp.  Grav.  ofthe  Serum 10265 

Composition   of  1000  parts — 

Fibrin 6 

Serous  Solids *?2 

Globules 67  5 

Total  Solids 145-5 

Water 854-5 


The  analysis  was  conducted  on  nearly  the  same  plan  as  that  recommended  by  Dr. 
Christison,  and  subsequently  adopted  by  Andral  and  Gavarret:  but  it  is  believed 
that  the  fibrin  is  more  exactly  estimated  than  by  the  process  of  the  latter  authori- 
ties. The  sp.  grav.  of  the  blood  and  serum  was  very  accurately  taken,  and  the  errors 
of  manipulation  cannot  exceed  5  per  1000  in  each  constituent.  The  blood  allowed 
to  remain  iu  a  vessel  for  twenty-four  hours  presented  a  large  and  firm  clot.  Examined 
microscopically,  it  exhibited  the  same  appearance  as  in  Fig.  479,  the  rolls  of  coloured 
bodies  not  being  so  large.  On  adding  acetic  acid,  the  same  kind  of  nuclei  were 
observed ;  but  they  were  now  tinted  of  a  deep  yellow  colour,  having  apparently 
imbibed  colouring  matter  dissolved  in  the  serum.  Some  of  the  crescentic  nuclei  had 
become  nearly  straight.  (Fig.  481.)  February  2d. — Urine  is  observed  to  be  loaded 
with  lithates,  and  diarrhoea  has  returned.  Sumat  pil  plumbi  opiat.  unam  ter  in  die, 
et  Syrupi  lodidi  Ferri  guttas  quindecem  ter  in  die  ex  aqud.  lUlnatur  Tind.  lodinii 
parti  dolenti.  Intermittantur  alia.  March  2Uh. — During 
fZ^  the  last  few  weeks  the  hemorrhage  from  the  nose  and 

^??!5\    ^^    K     j  gums  has  continued  to  recur,  and  the  ascites  has  not 

vy^    K§)       r ^v^        abated.     He  was  ordered  an  astringent  lotion  for  his 
'^^'  1^"^^  ^^        gums.     Since  the  11th,  Spongio-pihne,  with  Tr.  of  Digi- 


\iBj  f^  'kS/  I  %  j    ff^    talis,  has  been  applied  to  the  abdomen,  which  apparently, 

G^  ■<^'''i^  sW^}   in  consequence,  is  less  tense,  while  the  pain  has  undoubt- 

}j  p  ^-^^     |;  ^  \  edly  diminished.     April  8ih. — Diarrhoea  again  violent. 

[\  f  %  ;     "^-^  Stools  very  fluid.     He  suffers  also  from  cough,  and  there 

is  harshness  of  the  respirator}'  murmurs,  and  prolouged 
^'S-  481-  expiration  to  be  heard  at  the  apices  of  both  lungs.     No 

dulness  on  percussion.  Sumat  pil.  pilumhi  opiat.  unam  ter  in  die.  April  I3th. — 
Pain  in  abdomen,  and  diarrhoea  nearly  gone.  Sweats  profusely  at  night.  IJ 
Quince.  Sulph.  gr.  xij;  Acidi  Sul2oh.  dil.  3j ;   Syrupi  Aurant.  3  j;  Aquae  font.  §  v.     M. 

Fig.  481.  The  same  after  the  blood  has  stood  for  twenty-four  hours.     250  diam. 


LEUCOCYTHEMIA.  '  823 

Ft.  mistura ;  sumat  %  ss  ter  in  die.     Repeiantur  pil.  plumbi  opiat.     April  1M. — The 
diarrhoea  has  ceased  for  the  last  eight  days,  but  to-day  has  returned  with  considera- 
ble pain.      Inter miUatur  mist.    QiiincR   Sulph. ;  Applicetur  emplastrum   Opii  4x4 
ahdomini ;  Sumat  pil.  plumb,  ojjiat.  ij  ter  in  die ;   Utatur  enem.  amyli  cum  Sol.  Morph. 
sta.tim,  et  supposiforio  opii  quotidie  hord  somai.     May  oth. — Has  complained  a  good 
deal  lately  of  nausea  and  vomiting,  for  which  he  has  been  ordered  a  draught  every 
evening,  with  naphtlia.     He  has  also  taken  the  squill  and  digitalis  pill  three  times  a 
day,  and  the  tumour  has  been  fomented  with  infusion  of  digitalis.     Girth  of  abdo- 
men at  this  period  was  thirty-seven  inches.     5    Sp.  JEth.  Nitrici,  |iss;  Aqute 
PolassoE ;  Sol  Mur.  Morph.  aa,  3  ij.     M      Sig  sumat  3  j  ex  aqua  ter  in  die.     May 
7</i._Distension  of  abdomen  from  accumulation  of  fluid  still  increases,  and  pain  con- 
tinues.    The  urine  presents  an  acid  re-action,  and  is  loaded  with  a  copious  sediment 
of  lithate  of  ammonia,  with  a  few  colourless  rhomboidal  crystals  of  lithic  acid.     5. 
Pulv.  Scillce,  3j;  Pulv.  Digitalis,  gr.  x;  Extr.  Eyoscy.  5ss;     Cons.  Rosarum  q.  s., 
utfiant  piluke,  xx;   Sig.  sur^mt  unam  ter  in  die.     May  I3th.—Smce  last  repoft  diar- 
rhoea has  been  very  profuse,  the  bowels  having  been  acted  upon  sometimes  twenty 
times  in  the  course  of  a  night.     Stools   very  loose  but  foeculent.     Spongio-piline 
with  digitalis  to  be  discontinued,  on  account  of  its  pressure  causing  uneasiness.     He 
has  taken  the  lead  and  opium  pills  four  times  a  day,  as  will  as  the  starch  injection, 
with  Sol.  Mur.  Morph.  at  night.      Ondttantur  pil.  plumbi  opiat.      5 .   Tannini,  gr.  xv ; 
Pulv  opii,  gr.  vj ;   Cons.  Rosarum  q.  s.  utfiant  pil  vj ;  sumat  unam  sextd  qudque  hord. 
^  Acidi   Nitrici   dil.  ;  Syrupi,   aa  3  ss ;  AqucB.   3  j.     M.  et  Sig.  sumat    3  j  ter  in 
die  ex  aqua.     June  1st. — Since  last  report  the  diarrhoea  has  continued,  but  is  now 
much  abated.     Fluctuation  in  abdomen  evidently  diminished.     There  has  been  occa- 
sional slight  epistaxis.     Still  sweats  at  niglit.     Girth  of  abdomen  at  broadest  part 
diminished  to  thirty-five  and  a  lialf  inches.     Intermitt.  mist.  Quince.     June  12th. — 
Has  progressed  favourably  to  this  date ;  the  tumour  and  ascites  continue  to  diminish ; 
and  tlie  diarrhoea  and  otlier  symptoms  liaving  abated,  the  abdomen  is  now  flaccid, 
and  the  skin  is  cracked,  similar  to  what  is  observed  in  a  woman  after  pregnancy. 
To-day  the  diarrhoea  has  returned  with  some  violence,  with  abdominal  pain.     Eabe- 
ant  Pil.  Tannini  ut  antea.     June  26ih. — Diarrhoea  stdl  more  diminished.     There  is  a 
good  deal  of  cough,  with  some  expectoration,  and  harsh  respiration  is  heard  under 
clavicles,  with  increased  vocal  resonance.     Has  been  taking  3  ij  of  cod-liver  oil  three 
times  a  day.     His  general  strength  is  now  greatly  improved.     He  sits  up  the  greater 
part  of  the  day,  and  even  walks  about  on  the  green.     His  amendment  is  so  great 
that  he  is  very  anxious  to  return  to  his  parents,  who  reside  in  HulL     August  1th. — 
Since  last  report  the  diarrhoea  has  returned  at  intervals,  and  still  continues  to  be 
troublesome.     On  the  whole,  however,  his  health  has  improved ;  his  appetite  and 
strength  have  increased,  and  all  ascites  nearly  disappeared.     The  cough  and  expec- 
toration have  ceased.     The  tumour  measures  transversely  thirteen  and  a  half  inches, 
and  longitudinally  fifteen  inches.     From  tlie  lower  border  of  ribs  to  inferior  margin 
of  tumour,  ten  inches.     The  circumference  of  the  abdomen  at  the  widest  part  (a 
little  above  the  umbilicus)  is  thirty-four  inches.     He  was  now  dismissed,  having  for 
some  time  expressed  great  impatience  to  return  to  his  friends  in  Hull,  and  the  fur- 
ther progress  of  the  case  has  been  kindly  communicated  to  me  by  Dr.  Sandwith  of 
that  town.     For  some  time  he  was  in  the  Infirmary  there,  when  the  same  symp- 
tome  were  observed,  more  or  less  severe,  tliat  had  been  previously  noticed.     Then 
he  lived  at  his  parents'  hovel,  and  finafly  he  went  into  the  Union  Work-house,  where 
he  died  at  midnight,  July  22,  1851.     During  all  this  time  the  abdominal  swelling 
from  the  tumour  continued,  but  he  had  no  ascites;  the  diarrhoea  was  more  or  less 
urgent;  the  emaciation  extreme,  and  the  weakness  gradually  progressive  up  to  the 
moment  of  dissolution. 


824:  DISEASES   OF  THE   BLOOD. 

Sectio  Cadaveris. — Twelve  hours  after  death. 

This  was  performed  by  Mr.  West,  surgeon  to  the  Union  TTork-house.  The 
following  report  of  the  appearance  observed  was  communicated  to  me  by  Dr. 
Sandwith : — 

Extreme  attenuation  of  the  entire  bodj-. 

Thorax. — The  heart  was  small,  very  small,  with  a  few  patchy  points  on  its  sur- 
face. Its  cavities  contained  a  whitish  imperfectly-formed  lymph.  The  lungs  had 
so  perfectly  healthy  an  appearance  that  we  did  not  think  it  necessary  to  cut  into 
them.  There  was  no  more  effusion  into  either  the  pleural  or  peritoneal  cavities  than 
is  quite  natural.  There  was,  however,  an  effusion,  a  little  in  excess,  into  the  bag  of 
the  pericardium. 

Abdojiex. — Nothing  unusual  in  the  appearance  of  structure  of  the  liver,  save 
that  the  larger  hepatic  vessels  were  filled  with  small  patches  of  coagulated  black 
blood,  side  by  side  with  immense  flakes  of  a  dirty  white  matter,  like  imperfectly 
formed  lymph.  The  gall-bladder  was  tilled  with  a  glairy  amber-coloured  fluid,  not 
much  like  bile.  The  liver  weighed  three  pounds  twelve  ounces.  On  cutting  into 
the  organ,  there  oozed  out  from  the  smaller  vessels  a  very  thin  watery  blood.  The 
spleen  weighed  three  pounds  fourteen  ounces.  Its  surface  was  of  a  sky-blue  colour, 
and  dappled  with  numerous  specks  like  cicatrices,  most  of  them  very  small,  but 
there  were  two  much  larger  ones  near  the  summit.  It  adhered  here  and  there  by 
bands  of  lymph  to  the  peritoneal  huing  of  the  abdomen,  and  also  to  the  peritoneal 
covering  of  the  intestines.  On  the  under  surface  of  the  organ  there  was  a  very  small 
globular  lobule,  enveloped  in  organised  lymph.  A  cord,  run  lengthwise  along  both 
surfaces  of  the  spleen,  measured  twenty-four  and  a  half  inches.  A  cord,  similarly 
applied  across  the  organ,  measured  eighteen  inches.  Tlie  stracture  of  the  spleen  was 
very  firm, — indeed  very  much  like  that  of  liver.  The  omentum  was  utterly  wasted. 
The  mesenteric  glands  were  most  of  them  somewhat  enlarged,  pale,  and  with  hard 
gritty  matter  in  some  of  them.  There  were  several  enlarged  glands  at  the  caput 
coeli  in  a  state  of  congestion.  Pale  enlarged  glands  were  also  seen  all  along  the 
sigmoid  flexure  of  the  colon.  The  kidneys  were  unusuallj'  shrunken  and  small,  and 
weighed  together  six  ounces.  There  was  but  little  difference  in  the  relative  weight 
of  each.     Their  structure  was  firm. 

Microscopic  Examixatio.v. — Xext  day  I  received  from  Dr.  Sandwith  a  portion 
of  the  spleen,  about  four  inches  long,  three  inches  deep,  and  one  inch  thick ;  with 
a  nodule,  the  size  of  a  large  bullet,  at  the  hylus  of  the  organ.  In  structure,  it  was 
found  to  be  simply  hypertrophied,  the  fusiform  cells  of  the  trabeculse  presenting  their 
normal  character  and  arrangement,  and  the  cells  of  the  pulp  unusually  abundant. 
I  also  received  portions  of  the  clot  taken  from  the  heart,  vena  cava  ascendens,  and 
vena  portfe.  They  presented  exactly  the  same  appearance  as  the  clot  in  Case 
CLXXSIIL,  divided  into  a  dead-white  purulent-looking  layer,  and  a  tolerably  strong 
healthy-looking  red  one.  The  former,  on  microscopic  examination,  was  almost 
wholly  composed  of  colourless  corpuscles,  aggregated  together  by  molecular  fibres  of 
fibrin;  and  the  latter,  though  principally  composed  of  coloured  corpuscles,  also 
contained  many  colourless  ones.  Two  of  the  enlarged  mesenteric  glands  which  were 
sent,  on  section  yielded  a  copious  juice,  that  contained  the  same  cells  as  are  repre- 
sented Fig.  477. 

Commentary. — This  boy  was  in  the  Infirmary  upwards  of  six  months, 
and  tlie  symptoms  and  entire  progress  of  the  case  were  watched  with 
the  greatest  care.  Unlike  the  former  case,  the  spleen  was  the  only  organ 
enlarged,  the  liver  presenting  its  normal  dulness  on  percussion.  The 
abdomen,  however,  was  also  the  seat  of  ascitic  distension.     The  smallest 


LEUCOCYTHEMIA.  825 

drop  of  blood  taken  from  the  boy's  finger  exhibited,  during  the  whole 
of  his  residence  in  the  Infirmary,  the  excess  of  colourless  corpuscks,  and 
the  number  of  these  underwent  no  perceptible  increase  or  diminution, 
notwithstanding  the  varieties  of  treatment  to  which  he  Avas  subjected. 
Owing  to  the  "theories  which  have  been  from  time  to  time  advanced 
regarding  the  functions  of  the  two  kinds  of  corpuscles  found  in  the  blood, 
and  of  th^e  nature  of  its  colouring  matter,  iron  was  the  drug  which  seemed 
indicated.  This  boy  had  also^lived  in  the  fenny  districts  of  Lincoln- 
shire ;  and,  although  he  denied  ever  having  been  affected  with  intermit- 
tent fever,  it  seemed  very  probable  that  the  enlargement  of  the  spleen 
was  owing  to  this  cause.  I  commenced  the  treatment,  therefore,  with 
the  exhibition  of  iron  and  quinine.  Other  symptoms,  however,  became 
so  urgent  as  to  demand  special  attention,  and  the  suspension  of  these 
remedies.  I  allude  to  the  diarrhoea  and  dyspnoea,  the  former  of  which 
constituted  the  leading  symptom  of  the  disorder  during  the  entire  period 
he  remained  in  the  house.  All  kinds  of  astringents  were  given,  with 
occasional  temporary,  but  never  with  permanent  advantage.  At  one 
period  he  was  so  exliausted  that  for  some  Aveeks  I  daily  expected  his 
death.  He,  however,  again  gained  strength  ;  and  his  bodily  powers, 
except  towards  the  termination  of  his  residence  in  the  house,  were 
subject  to  considerable  variations,  evidently  dependent  on  the  amount  ot 
diarrhiea. 

In  April,  pulmonary  symptoms  were  added  to  his  other  complaints  ; 
and  from  the  character 'these  presented,  as  well  as  from  the  physical 
signs,  a  strong  suspicion  was  formed  that  he  laboured  under  phthisis 
pulmonalis.  IJnder  a  tonic  treatment,  with  cod-liver  oil,  assisted  by  the 
advance  of  summer,  these  symptoms  diminished,  and  his  general  strength 
was  so  improved  that,  as  is  stated  in  the  report,  he  insisted  on  going 
home.  At  the  time  of  his  discliarge  he  was  remarkably  ill,  greatly  ema- 
ciated, and  cachectic-looking,  with  an  enormous  abdomen, —  so  that  it 
was  only  by  comparison  with  what  he  had  been,  that  he  could  be  said 
to  enjoy  tolerable  strength.  It  seems,  however,  that  he  reached  Hull, 
by  the  steam-vessel,  in  safety,  and  lived  nearly  a  twelvemonth  longer, 
so  that  altogether  he  was  under  medical  observation  nearly  eighteen 
months,  the  morbid  condition  of  the  blood  existing  during  the  whole  of 
that  time.  After  death  the  appearance  and  structure  of  the  coagulated 
blood  exactly  resembled  that  presented  in  the  former  case,  and  there  was 
the  same  hypertrophy  of  the  spleen,  and  similar  enlargement  of  the 
lymphatic  glands,  but  not  to  so  great  an  extent.  The  liver,  however, 
\vas  normal,  and  the  lungs  externally  healthy,  but  not  cut  into. 

Dr.  Kobertson  was  kind  enough  to  analyse  the  blood  for  me  in  this 
case,  and  from  the  results  he  obtained,  it  appears  that  the  fibrin  was 
increased  to  about  double  its  amount  in  healthy  blood.  The  albumen 
and  salts  existed  in  their  normal  proportion.  The  globules  were  dimi- 
nished to  about  one-half  their  proper  amount,  which  deficiency  was 
counterbalanced  by  an  increase  in  the  amount  of  water.  This  combina- 
tion of  increase  in  the  amount  of  fibrin  and  diminution  in  the  amount  of 
corpuscles,  indicates  a  condition  of  the  blood  which,  so  far  as  I  am  aware, 
is  not  peculiar  to  any  other  morbid  condition  of  the  economy. 


826  DISEASES   OF   THE   BLOOD, 


Case  CLXXXV.* — Commencing  Leucocythemia  determined  during  Life — Enlarged 
Spleen  and  Liver — Ascites. 

History. — Thomas  TTelsh,  a  sailor,  set.  20 — admitted  into  the  clinical  ward  of 
the  Royal  Inflmiary,  September  22d,  1851.  In  June  18-47,  he  tirst  expei'ieiiced  a 
gnawing  pain  in  the  left  side,  and  a  hard  swelling  was  distinctly  felt  in  the  splenic 
region.  Shortly  afterwards  he  was  attacked  with  jaundice,  and  he  became  sensible 
of  a  swelling  also  on  the  right  side  of  the  abdomen.  He  says,  that  owing  to  medi- 
cal treatment,  this  latter  swelling  disappeared,  and  he  regained  his  health.  Since 
then  he  has  occasionally  had  attacks  of  jaundice,  and  the  abdomen  has  slowly 
enlarged,  notwithstanding  the  internal  use  of  large  quantities  of  mercury  and 
iodine. 

Symptoms  on  Admissiox. — On  admission,  his  bodj'  generally  is  emaciated ;  the 
abdomen  is  considerably  enlarged,  measuring  thirty-two  inches  round  the  most  pro- 
minent part,  which  is  two  inches  above  the  umbilicus;  no  fluid  can  be  detected. 
The  hepatic  dulness  measures  vertically  at  its  deepest  part  six  inches,  and  its  lower 
margin  can  be  distinctly  felt  below  the  ribs,  the  left  lobe  sweeping  backwards  and 
upwards,  and  apparently  coming  in  contact  with  the  spleen.  The  splenic  dulness 
measures  vertically  eight  and  a  quarter  inches ;  the  anterior  margin  can  be  dis- 
tinctly felt,  with  a  notch  in  its  centre,  terminating  on  a  level  with  the  upper  edge  of 
the  iliac  bone.  Bowels  are  generally  loose ;  respiration  is  embarrassed  and  thoracic ; 
no  dulness  on  percussion  over  the  cliest ;  no  cough,  but  occasional  sibilation  heard 
on  au.scultatiou ;  impulse  of  heart  feeble,  otherwise  normal;  pulse  78,  small  and 
weak.  He  has  not  increased  in  stature  since  he  was  sixteen,  and  has  the  external 
aspect  of  a  boy  of  that  age  ;  generative  organs  not  developed ;  urine  healthy ;  skin 
of  a  dingy  yellowish  colour.  On  microscopic  examination  of  the  blood,  it  was 
ascertained  that  the  colourless  and  coloured  corpuscles  presented  their  normal  rela- 
tive number. 

It  is  unnecessary  to  follow  the  progress  of  this  case  minutely.  It  will  sufiBce  to 
say,  that  the  bowels  every  now  and  then  became  xevy  loose ;  he  occasionally  had 
epistaxis,  and  frequently  more  or  less  tenderness  over  various  parts  of  the  swollen 
abdomen.  In  October,  he  experienced  a  severe  attack  of  acute  laryngitis,  from 
which  he  recovered  in  fifteen  daj-s.  During  the  latter  part  of  December  ascites 
came  on,  the  excretion  of  urine  diminished  in  amount,  and  it  was  intensely  loaded 
with  lithates.  The  blood  had  been  examined  from  time  to  time,  and  on  the  third  of 
January  a  decided  increase  of  the  colouiless  corpuscles  was  observed.  A  diuretic 
treatment,  by  increasing  the  amount  of  urine,  caused  the  ascites  to  diminish.  But 
the  number  of  colourless  corpuscles  graduallv  increased,  so  that,  during  the  whole  of 
February,  considerable  groups  of  these  bodies  could  be  seen  between  tlie  rolls  of 
coloured  discs  in  a  demonstration  under  the  microscope.  Latterly,  his  general 
strength  became  much  diminished;  but  his  mother  insisted  on  taking  him  home 
to  Berwick,  and  he  left  the  Infirmary,  Feb.  27,  1852.  I  learnt  from  Dr.  Johnson 
that  he  died  two  days  after  reaching  Berwick.  Tiiere  was  no  post-mortem  exami- 
nation. 

As  soon  as  it  was  determined  that  the  colourless  corpuscles  of  the  blood  had 
decidedly  increased,  I  requested  Dr.  W.  Robertson  to  anah'se  the  blood,  which  he 
did  on  the  7th  of  Januarv,  with  the  following  results : — The  blood  coagulated  firmly^ 
but  little  serum  exuded  from  the  coagulum,  although  it  stood  undisturbed  for  forty- 
eight  hours.     Surface  of  coagulum  flat,  and  thinly  coated  with  fibrin. 

*  Reported  by  Mr.  T^'m.  M.  Calder,  Clinical  Clerk. 


LEUCOCYTHEMIA.  827 

Density  of  blood 10435 

„      of  serum 1027- 

Composition  of  1000  parts. 

Fibrin 3-2 

o  ,• -,      (  OrMnic,       70*4  ) 

Serous  sobds.   |  ^^l,^^^^^^   ^^.^  J- SO-7 

Globules 82-3 


Total  solids   lGti-2 

"Water   8338 


1000 

Commentary. — Up  to  the  occurrence  of  the  present  case,  no  exan^ple 
of  leucocythemiH  had  been  met  with  in  whicli  the  disease  was  seen  to 
commence  and  progress.  It  will  be  observed  that  the  spleen  and  liver 
had  attained  a  very  large  size  before  the  blood  became  affected.  Nothing, 
indeed,  can  be  more  various  than  the  mere  bulk  of  one  or  more  of -the 
blood  glands,  and  the  leueocythemic  condition  of  the  blood.  In  several 
cases  the  spleen  has  been  greatly  hyperti'ophied,  without  any  change  in 
the  blood  whatever.  The  true  explanation  of  these  apparent  discre- 
pancies has  yet  to  be  discovered.  The  increase  of  colourless  cells  must 
commence  at  some  particular  time,  but  the  exact  period  of  commence- 
ment has  been  observed  subsequently  only  in  one  other  case  by 
Yirchow. 

The  three  previous  cases,  too-ether  with  six  others  proviouslv  recorded 
in  this  work  (Cases  LXV.,  LX'X.,  LXX^'L,  LXXXV.,  CXII.,  and  CLII.), 
are  sufficient  for  the  study  of  this  important  lesion  of  the  blooil.  In  my 
work  on  Leucocythemia,  published  in  1852,  I  have  given  thiitv-seven 
cases  more  or  less  illustrative  of  the  symptoms  and  pathologv  of  the 
disease.  Since  then  I  have  myself  met  with  a  considerable  number  of 
others,  and  many  more  have  been  published  in  the  British,  American, 
French,  and  German  periodicals.  Several  other  analyses  of  the  blood 
also  have  been  made.  But  very  little  advance  seems  to  have  occurred 
in  our  knowledge  of  the  pathology  and  treatment  of  leucocvthemia  since 
I  Avrote  in  1852,  whilst  all  the  facts  which  have  been  published  confirm 
the  conclusions  which  I  then  arrived  at.  A  systematic  account  of  the 
symptoms  and  progress  of  the  disease,  divided,  as  is  usual  among  French 
writers,  into  three  stages,  has  been  compiled  by  M.  Vida!,*  chieflv  fiom 
the  facts  contained  in  my  work.  It  has  been  carefully  done,  although 
the  basis  as  regards  number  of  cases  (only  32)  is  not  sufficiently  large. 

Pathology  and   Treatment  of  Leucocythemia. 

If  the  blood  of  living  persons  affected  with  this  disease  be  examined 
microscopically  (which  is  most  readily  accomplished  bv  extracting  a  drop 
from  the  finger  by  pricking  it  with  a  needle,  and  placing  it  between 
glasses,  under  a  power  of  250  diameters  linear),  the  coloured  and  colour- 
less corpuscles  will  be  at  first  seen  rolling  confusediv  together,  and  the 
excess   in   number  of   the   latter  at  once   perceivecl.      This,   however, 

*  Gazette  Hebdomadaire,  4  Avril,  1 856. 


828 


DISEASES   OF   THE   BLOOD. 


becomes  more  evident  after  a  short  time,  when  the  coloured  bodies  are 
aggregated  together  in  rolls,  leaving  clear  spaces  between  them,  which 
are  more  or  less  crowded  with  the  colourless  ones.  Means  are  altogether 
wanting  to  enable  us  to  determine  with  exactitude  the  relative  proportion 
of  the  two  kinds  of  corpuscles  in  diiferent  cases.  In  some  the  colour- 
less corpuscles  are  only  slightly  increased  beyond  their  usual  number. 
In  one  case  they  are  described  as  five  times  as  numerous  as  those  in 
health.  They  are  also  said  in  particular  instances  to  be  "greatly 
increased,"  "  one-third  as  numerous,"  and  "  as  numerous"  as  the  coloured 
corpuscles.  In  all  these  statements  there  is  nothing  exact.  Perhaps 
the  best  method  of  judging,  is  to  regard  the  spaces  or  meshes  left 
between  the  rolls  or  aggregations  of  vellow  blood  corpuscles.  When 
these  are  completely  filled  up,  the  colourless  bodies  do  not,  in  fact, 
amount  to  one-third  of  the  coloured  ones,  on  account  of  the  large  num- 
ber of  the  latter  which  may  exist  in  a  small  space,  in  the  form  of  rou- 
leaux.    This  will  appear  upon  counting  them  in  Fig.  479,  p.  821. 

The  size  of  the  colourless  corpuscles  in  the  various  cases  given,  differs 
considerably.  Even  when  at  first  sight  they  appear  to  be  of  tolerably 
uniform  size  in  any  one  case,  it  mav  be  observed,  when  thev  are  magni- 
fied highly  and  carefully  measured,  that  some  are  twice  the  size  of 
others,  with  all  the  intervening  sizes  between  them.  In  some  cases, 
though  comparatively  few  in  number,  they  are  described  as  being  three 
or  four  times  larger  than  the  coloured  corpuscles,  and  in  two  cases  they 
were  in  one  about  the  same  size,  or  somewhat  smaller.  Fig.  484,  and  in 

the  other  of  two  sizes,  one 
larger  and  the  other  decidedly 
smaller.  Figs.  492,  493. 

In  the  cases  in  which  the 
blood  V,  as  carefully  examined 
after  death,  the  same  varia- 
tions with  regard  to  number 
and  size  of  the  colourless  cor- 
puscles were  found  to  exist,  as 
have  just  been  referred  to  in  blood  drawn  fresh  from  the  finger.  It  was 
always  observable,  however,  that  thev  were  most  numerous  in  the  clot ; 
and  when  they  existed  in  any  number,  as  in  Case  CLXXXIII.,  they 
communicated  to  the  colourless  coagulum  a  peculiar  dull,  whitish  look, 
and  rendered  it  more  friable  under  pressure.  When  less  numerous,  por- 
tions of  the  colourless  coagulum  from  the  heart  and  large  vessels  might 
be  seen  to  present  a  dull  cream  colour,  easilv  distinguishable  from  the 
gelatinous  and  fibrous  appearance  of  a  healthy  clot,  and  such  altered 
portions  always  contained  a  large  number  of  the  colourless  bodies. 

The  blood  has  been  carefully  examined  chemically  in  several  cases, 
from  which  it  would  appear  that  there  is  generally  an  excess  of  the  fibrin 
and  diminution  of  the  corpuscles.  The  former  ranges  from  3  to  7  parts, 
and  the  latter  from  100  to  49  parts  in  a  thousand.  In  a  well-recorded 
case  by  Dr.  Wallace  of  Greenock,  the  blood  was  analysed  by  Dr.  W. 


M 


Fis.  4^. 


Fig.  482.  Colourless  corpuscles  slightly  increased  in  number. 

Fig.  483.  The  same  after  the  addition  of  acetic  acid.  250  diam. 


LEUCOCYTHEMIA.  829 

Robertson,  and  ascertained  to  contain  in  1000  parts  onlj'  1-5  of  fibrin, 
and  79'  of  corpuscles.* 

The  oro-ans  Avhicb  liave  been  found  most  uniformly  diseased  are  the 
spleen,  the  liver,  and  lymphatic  glands.  The  spleen,  in  the  g-reat  ma- 
jority of  cases,  has  been  enlarged,  varying  in  weight  from  one  to  above 
ninepounds.  The  texture  of  the  organ  varied  in  ditferent  cases — in  some 
being  of  unusual  density,  in  others  it  was  natural,  and  in  a  third  class 
was  more  or  less  pnlpy.  In  a  few  cases  it  contained  yellowish  masses, 
apparently  a  form  of  deposit,  but  in  reality  degenerated  tissue.  In  most 
cases  the  cell  and  nuclear  elements  of  the  pulp  were  increased  in  amount, 
while  the  fibrous  portion  of  the  organ  was  apparently  normal.  Mere 
enlargement  of  the  spleen,  however,  is  not  necessarily  connected  with 
leucocythemia,  as  I  have  met  with  many  cases  where  it  has  been  greatly 
hvpertVophied  without  appreciable  alteration  of  the  blood.  It  has 
appeared  to  me  that  in  such  instances  the  enlargement  is  more  owing  to 
congestion  and  fibrous  hypertrophy,  than  to  increase  in  cell  elements. 
Next  to  the  spleen,  the  liver  is  most  commonly  found  diseased  in  leuco- 
cythemia. In  the  majority  of  cases  it  is  simply  hypertrophied,  and,  in  a 
few,  cirrhosed  in  various  stages,  or  cancerous.  The  lymphatic  glands 
are,  also,  frequently  enlarged.  In  most  cases  they  are  soft,  presenting 
on  section  a  granular  whitish  appearance,  and  yielding  a  copious  turbid 
juice  on  pressure.  In  a  few  cases  they  were  indurated,  loaded  with  cal- 
careous deposits,  or  infiltrated  with  .  i  ^  J—^y^s^  ^ 
cancerous  or  tubercular  exudation.  (Tn  ,  X^'i'M?^^  •  /^^^* 
T\ie  soUtanj  and  aggregated  glands  ^  -  °^M^  f^-"  (S^i  "  v-~\  vJ' 
of  Peyer  have  also  been  found  hy-  -ry^  '  ^^^^^''^.  "'^*-  w  • 
pertrophied  in  a  few  cases.  The  r-^vlK.  C  °,j^  ^j  »  (/)*  *"  r^ 
thyroid  body  was  cancerous  in  one  '^'^Mm^  '^l^^~'  '-"^  \£^  •  ^ 
case,  and  evidently  gave  rise  to  the  '  V^^  (,  '\^^y^o°  »°r~\%  "• 
leucocvthemia  (Case  CLII.) :  and  Ax^%7o~°  -'  a  "  -^ 
in  certain  cases  ot  bronchocele,  in  ^-^ »  y^  .  .;^-> 
which  the  blood  was  examined  by  ^'S-  484.  Fig.  485. 
Drs.  Holland  and  Neale,  a  similar  condition  was  observed.  Dr.  Addison 
has  also  shown,  in  two  of  his  cases  of  disease  of  the  supra-renal  capsules, 
that  the  blood  was  leucocytheniic.  Other  lesions  which  have  been 
occasionally  found  in  cases  of  leucocythemia  are  evidently  accidental, 
and  in  no  way  connected  with  that  morbid  state  of  the  blood  which  we 
are  now  considering. 

Relation  existing  betiveen  the  Colourless  and  Coloured  Cor2mscles  of 
the  Blood. — Many  physiologists  have  maintained  that  the  coloured  cor- 
puscles are  formed  from  the  colourless  ones  ;  and  among  those  who  hold 
this  opinion,  some  have  supposed  that  the  latter  bodies  are  directly 
transformed  into  the  former  (Pagetf).  Others,  again,  contend  that, 
whilst  sucli  may  be  the  case  in  fishes,  reptiles,  and  birds,  in  mammals 
the  coloured  disc  is  merely  the  liberated  nucleus  of  the  colourless  cell 
(Wharton  JonesJ).     From  the  observations  I  have  made  on  the  blood 

*  Glasgow  Journal.     April  1 855. 
f  Kirke's  Physiology,  pp.  68,  69.  %  Lend.  PliU.  Trans.,  1846. 

Pig.  484.  Colourless  corpuscles  increased  in  number,  and  of  small  size. 

Fig.  485.  The  same  after  the  addition  of  acetic  acid.  i:50  diam. 


830  DISEASES   OF   THE   BLOOD. 

corpuscles  in  cases  of  leucocythemia,  tlie  latter  appears  to  me  to  be  the 
moi-e  correct  opinion. 

The  mode  ot"  transformation  of  the  nucleus  of  the  colourless  cell  into 
the  flattened,  biconcave,  coloured  disc,  has  not  yet  been  described  ;  but, 
from  the  appearances  I  have  observed,  it  woukl  seem  to  take  place  in 
the  following  manner  : — The  colourless  cell  may  frequently  be  seen,  on 
the  addition  of  acetic  acid,  to  have  a  single  round  nucleus.  But  more 
commonly  the  nucleus  is  divided  into  two,  each  half  having  a  distinct 
depression,  presenting  a  shadowed  spot  in  its  centre.  Occasionally, 
before  the  division  takes  place,  the  nucleus  becomes  oval,  and  sometimes 
is  elongateil,  more  or  less  bent,  and  even  of  a  horse-shoe  form.  Not 
unfrequently  the  nucleus  is  divided  into  three  or  four  granules,  each 
having  the  central  shadowed  spot.  All  the  appearances  here  figured 
have  been  frequently  observed,  and  I  have  placed  them  in  the  presumed 
order  of  development. 


,^^.  .^1 
\^l[^ 


FijT.  436. 


On  one  occasion  the  colourless  bodies  in  the  blood  were  of  two  distinct 
sizes.  The  smaller  were  evidently  free  nuclei,  such  as  could  be  observed 
-within  the  larger.  (See  Figs.  492*  and  493.)  On  examining  these  latter, 
after  the  addition  of  acetic"  acid,  all  the  appearances  represented  in  the 
accompanying  figure  were  observable,  and  these  I  have  again  placed  in 


Fis.  4s:. 


the  presumed  order  of  development.  On  examining  the  lymphatic 
glands  in  this  case,  they  were  observed  to  contain  the  first  body  figured 
(«)  in  great  numbers,  associated  with  a  few  of  the  second  one  [h). 

On  several  occasions  the  blood,  when  crowded  with  colourless  cor- 
puscles, was  removed  from  the  arm  by  venesection ;  and  it  was  observed, 
that  after  standing  twenty-four  hours  these  variously-shaped  nuclei  had 
become  of  a  straw  colour,  and  exactly  resembled  the  coloured  discs  in 
tint.  It  was  immediately  apparent  that  they  had  imbibed  the  colouring 
matter  of  the  blood,  leaving  the  cell  which  surrounded  them  perfectly 
transparent.     (See  Fig.  481,  p.  822.) 

With  a  view  of  still  further  determining  the  transitional  changes  in 
the  colourless  cells,  I  performed  the  following  experiment ; — A  rabbit 
was  killed  three  hours  after  having  eaten  a  meal.  The  thorax  was  ra- 
pidly opened,  and  a  ligature  placed  round  the  pulmonary  artery,  to  pre- 

Fig.  486.  Colourless  blood-cells  observed  in  leucocythemia,  showing  the  different 
appearances  of  the  nuclei,  placed  in  the  presumed  order  of  iheir  development. 

Fig.  487.  Pre.sumed  development  of  the  nucleus  in  colourless  blood-cells,  iu  another 
case  of  leucocj'themia.  500  diam. 


LEUCOCYTHEMIA. 


831 


vent  the  corpuscles  coining  from  the  tlioracic  duct  passing  into  the  lungs. 
The  abilomen  was  then  pressed  gently  for  a  few  moments,  to  favour  the 
flow  of  chvle,  and  then  a  ligature  placed  round  the  large  vessels,  and  the 
heart  removed  bv  cutting  above  it.  On  examining  the  blood  in  the  right 
ventricle,  it  presented  an  unusually  large  number  of  colourless  cells,  the 
nuclei  of  which,  on  the  addition  of  acetic  acid,  exhibited  all  the  tran- 
sition stages  figured  Fig.  486.  On  examining  the  blood  in  the  left  ven- 
tricle, thecolourless  cells  were  found  normal  in  amount.  This  experiment 
was  repeated  with  the  same  results. 

I  am  therefore  of  opinion,  with  Valentin,  Wharton  Jones,  and  others, 
that  the  coloured  blood  corpuscles  in  mammals  are  free  nuclei.  But  I 
do  not  consider,  with  the  latter  observer,  that  these  nuclei  in  mammals 
should  necessarilv  proceed  so  far  in  development  as  to  be  surrounded 
with  a  cell-wall, — in  other  words,  the  coloured  disc  is  not  always  a  fur- 
ther phase  in  the  evolution  of  the  colourless  cell.  "  On  the  contrary,  I 
believe  that  the  vast  majority  of  the  coloured  blood  discs  simply  reach 
the  nuclear  stage  of  growth  before  they  join  the  circulation.  Many  of 
them,  however,  do  proceed  beyond  this  point  in  development,  and  may 
be  seen  to  have  cell-walls  around  them.  Under  such  circumstances,  the 
nuclei  increase  endogenously  by  a  process  of  fissiparous  division,  in  the 
manner  formerlv  described,  circulate  in  the  blood  within  colourless  cells, 
and  on  the  solution  of  the  cell-wall,  also  become  coloured  blood  discs. 

I  have  further  examined  the  blood  of  birds,  reptiles,  and  fishes,  and 
have  been  enabled  to  observe  transitional  forms  between  the  colourless 
and  coloured  cell,  with  even  greater  facility  than  1  could  in  man.  Indeed, 
the  attention  once  directed 
to  this  point,  scarcely  a 
demonstration  of  blood  can 
be  made  in  these  animals 
without  seeing  abundant 
evidence  that  the  latter  is 
a  transformation  from  the 
former.  In  them,  however, 
the  colourless  cell,  at  first 
round,  enlarges  gradually, 
becoming  oval,  and  colour 
is  addedto  it.  The  nuclei,  also,  after  the  addition  of  acetic  acid,  may 
be  observed  in  these  animals  to  be  undergoing  fissiparous  multiplication 
within  the  cells.  Thus  all  the  appearances,  o  0  ft  I?  ** 
Fig.  48'.),  mav  readily  be  seen.     Hence  the  ^  ° 

same    mode    of  endogenous    development      ©  ©  @  ^  q 
may  take  place  in  the  blood-cells  of  all  the  /sv  a  i,  b   « 

vertebrated  tribes  of  animals,  the  difi"erence       ®  ©  I  g  sSo 
being,  that  whilst    in    birds,  reptiles,  and  Fig.  489. 

fishes,  the  corpuscles  retain  the   form   of 
nucleated  cells,  in  mammals  we  find  the  majority  of  them  to  be  free  nuclei. 


FifT.  4SS. 


Haddock. 

Turker. 

Fros. 


Figr.  488.  Cells  of  various  sizes,  colourless  and  coloured,  observed  in  the  blood  of  a 
haddock,  fro^.  and  turkey,  placed  in  the  order  of  their  supposed  development.  The 
three  first  bodies  flsured  in  each  line  are  colourless. 

Fig.  489.  The  nuclei  of  the  blood-cells  of  the  haddock,  frog,  and  turkey,  as  seen 
after  the  addition  of  acetic  acid.  450  diam. 


832  DISEASES   OF  THE   BLOOD. 

Origin  of  the  Blood  Corjyuscles. — Ilewson  was  the  first  "\v ho  distinctly 
stated  that  the  blood  corpuscles  were  derived  from  the  lymphatic  glands, 
yet  few  have  adopted  his  opinions.  Even  Crnickshank,  who  wrote  on 
the  lymphatic  system  immediately  after  him,  and  was  one  of  his  contem- 
poraries, says  of  the  lymphatic  fluid  in  which  these  corpuscles  swim, 
"that  we  do  not  know  the  use  of  this  fluid."*  The  correctness  of  Ilew- 
son's  views  is  not  even  clearly  admitted  by  his  recent  commentator,  Mr. 
Gulliver,f  and  has  been  denied  by  most  physiologists  in  this  country; 
and  although  Nasse,  Wagner,  Miiller,  and  a  few  others,  liave  contetided 
that  the  lymph  corpuscles  in  the  blood  are  the  same  as  those  found  in 
the  lymphatic  vessels,  the  mode  of  their  origin  and  their  functional 
importance  is  not  even  alluded  to. 

On  examining  the  chyle  in  the  lacteals  ramifying  below  the  serous 
coat  of  the  intestine,  it  is  found  to  consist  of  a  multitude  of  minute  fatty 
molecules,  floating  in  a  fluid  (see  Fig.  438,  p.  686).  These  diminish 
in  number  as  the  chyle  progresses  towards  the  thoracic  duct,  in  which 
it  is  found  to  contain  a  number  of  free  nuclei,  mingled  with  a  few  others 
which  are  surrounded  by  a  delicate  cell-wall.  The  free  nuclei  may  fre- 
quentlv  be  observed  in  mammals  to  present  the  same  size  and  bi-concave 
discoid  form  of  the  coloured  blood  coi'puscles.  (Fig.  438,  a.)  ^lore- 
over,  on  the  addition  of  water,  they  in  like  manner  become  globular, 
and,  after  the  fluid  has  been  allowed  to  evaporate  a  little,  assume  a 
j)uckered  or  crenated  appearance.     They  only  dift'er  in  their  want  of 

colour,  and  in   not  being   par- 
r^  '-   ■->  tially  soluble  on  the  addition  of 

acetic  acid.     (Figs.  438,  a  ;  490  , 

C    ^iid   491.)     On   cutting   into  a 

T"         '.^  ■    well-formed    lymphatic    gland, 

■^         1    °  .    •    and  examining  the  juice  which 

(^^    c    '   c5  •    niay  be  squeezed  from  it,  it  will 

'  ■       O  be  found  to  contain  numerous 

„  ^  ^gg  ^  ^  ..J  free  nuclei  and  nucleated  cells. 

These  are  evidently  the  same 
bodies  as  are  found  in  the  lymph  and  chyle,  and  those  found  in  the 
latter  closely  resemble  the  colourless  cells  of  the  blood.  The  nucleus 
of  these  corpuscles  also  may  frequently  be  observed  to  have  undergone 
the  fissiparous  division  formerly  described,  and  to  exhibit  vaiious 
stages  of  this  process,  in  chyle  taken  from  the  thoracic  duct.  The 
opinion,  therefore,  held  by  many  physiologists,  that  the  colourless  cells 
of  the  blood,  and  those  of  chyle  or  lymph,  are  the  same,  and  conse- 
quently that  in  the  highest  class  of  animals  they  are  not  formed  in 
the  blood  itself,  but  before  they  are  mixed  with  that  fluid,  seems  to 
be  well  founded. 

*  The  Anatomy  of  the  Absorbing  Vessels  of  the  Human  Body.  London,  4to,  1786. 
P.  73. 

f  Tlie  Works  of  William  Hewson,  F.R.S.,  edited  by  George  Gulliver,  F.R.S.L. 
Printed  for  the  Sydenham  Society.     Note,  p.  281. 


Fig.  490.  Fluid  chyle,  mingled  with  water,  taken  from  the  thoracic  duct  of  a  cat 
three  hours  after  it  had  been  led  on  milk. 

Fig.  491.  The  same  after  the  addition  of  acetic  acid.  250  diam. 


LEUCOCYTHEMIA.  833 

According  to  Henle,  the  molecules  of  the  chyle  unite  together  in 
order  to  form  the  nuclei,  which  are  afterwards  surrounded  by  an 
envelope.*  These,  he  thinks,  are  delayed,  and  become  more  fully 
developed  in  the  lymphatic  glands.f  Nasseij;  also  states,  that  he  has 
seen  aggregations  of  the  chyle  molecules  and  granular  bodies,  formed 
before  they  reach  the  lymphatic  glands.  Ou  the  other  hand,  it  is 
certain  that  both  nuclei  and  cells  are  most  abundant  in  the  glands 
themselves,  and  the  cases  of  leucocythemia  prove,  that  excess  of 
colourless  cells  in  the  blood  is  not  dependent  upon  an  increase  in  the 
amount  of  chyle  molecules,  but  is  coincident  with  the  enlargement  of 
the  spleen  and  other  glandular  organs.  It  is  to  these,  therefore,  we 
must  attribute  the  principal  influence  in  the  formation  of  the  colourless 
cells,  and  to  them  evidently  we  must  look  for  the  origin  of  the  blood- 
corpuscles. 

llewson  considered  the  lymphatic  glandular  system  to  consist  of  the 
spleen,  thymus,  and  lympiiatic  glands.  He  believed  that  particles 
were  produced  in  these  organs  Avhich  ultimately  became  the  blood- 
corpuscles,  and  that  the  spleen  especially  served  to  secrete  the  colour- 
ing matter  which  surrounded  them.  This  doctrine,  though  supported 
to  a  greater  or  less  extent  by  some  German  authors,  has  been  repudi- 
ated by  all  British  physiologists  up  to  this  time.  Mr.  Simon  §  declares 
it  to  be  impossible  that  the  globules  of  the  thymus  can  enter  the 
lymphatic  or  blood-vessels,  on  account  of  the  limitary  membrane  within 
which  they  are  enclosed.  But  that  they  do  find  their  way  into  those 
vessels  was  shewn  by  llewson  and  Sir  Astley  Cooper,|  who  found  them 
there  ;  and  that  the  colourless  corpuscles  of  the  spleen  and  lymphatic 
glands  enter  the  blood  in  large  numbers,  is  proved  by  what  occurs  in 
leucocythemia,  and  by  the  great  preponderance  of  these  bodies  at  all 
times  in  splenic  and  portal  blood. 

But  there  are  other  glands  which  must  be  associated  with  those  just 
mentioned  as  part  of  the  lymphatic  system,  such  as  the  thyroid  body 
and  supra-renal  capsules.  The  pituitary  and  pineal  glands  have  also 
been  referred  to  the  same  class  of  organs  by  Oesterlen.^  Without 
entering  into  lengthy  anatomical  details  of  each,  it  may  be  said  that 
all  these  organs  resemble  one  another  in  the  following  particulars  :— 

1.  They  consist  of  a  fibrous  stroma,  enclosing  spaces  lined  by  a 
structureless  membrane,  which  spaces  are  filled  with  colourless  mole- 
cules, nuclei,  and  cells,  in  all  stages  of  development. 

2.  The  corpuscles  of  all  these  glands  resemble  one  another, — the 
nuclei  corresponding  in  size  to  the  coloured  blood-discs  of  mammals, 
and  the  cells  corresponding  to  the  colourless  corpuscles  of  the  blood. 
The  very  slight  ditferences  which  do  exist  are  at  once  explained  by  vari- 
ations in  the  degree  of  development. 

3.  They  have  no  excretory  ducts,  so  that  if  the  corpuscles  formed  in 

*  Anatomie  Generate,  par  Jourdain.     Tom.  i.  p.  455. 
f  Anatomie  Generate,  par  Jourdain.     Tom.  ii.  p.  103. 
X  Wagner's  Handworterbucli.     Arts.  Cliylu.s  and  Lymplie. 
§  On  the  Tliymiis  Gland.     P.  91. 
II  Anatomy  of  the  Thymus  Gland.     Pp.  15  and  43. 

•|[  Beitrage  zur  Physiologie  des  gesunden  und  kranken  Organisraus.  Jena, 
1843. 

53 


834 


DISEASES   OF   THE   BLOOD. 


§ 


them  are  to  leave  the  organs  in  ^vhich  they  originate,  it  can  only  be  by 
the  lymfiliatios  or  veins. 

Now,  it  is  certain  that  the  blood  of  the  splenic  and  portal  veins,  even 
in  health,  is  ahvays  richer  in  coloniless  corpuscles  than  that  of  the  sys- 
temic circulation!*  It  is  also  well  known  that  in  young  animals  the 
blood  contains  a  larger  number  of  these  bodies  than  it  does  in  their 
adult  condition, — that  is,  when  all  these  glands,  including  the  thymus, 
thyroid,  and  supra-renal  capsules,  are  fully  developed  and  in  a  state  of 
activity.  In  leucocythcmia,  we  observe  that  when  those  glands  are  hyper- 
trophied  and  their  corpuscular  elements  are  multiplied,  the  colourless  cor- 
puscles of  the  blood  are  increased  in  number.  Two  very  carefully  made 
observations,  however,  apjiear  to  me  sufficient  in  themselves  to  determine 
the  connection  of  these  lymphatic  glands  with  the  cells  of  the  blood. 
Thus  in  Case  CLII.,  where  the  thyi'oid  body  was  enlarged,  its  cells  and 
their  included  nuclei  were  considerably  smaller  than  usual,  and  it  was 

ascertained  that  the  colour- 
less bodies  in  the  blood  and 
their  nuclei  were  smaller  also. 
(Figs.  439  and  440,  p.  697, 
f)    andFig.  484,  p.  829.)    In  one 

'■^  '      ©         -"       ^^^^    it   ^'^'^^    *^^^^"    t''^t    t^^^ 
.     _   •  o    ®     colourless   corpuscles  in   the 
('|g^  blood    were    of  two   distinct 

"^     q""    &  sizes,  the  smaller  correspond- 

ing with   the   nuclei   of  the 
Pj    ^gg  larger  ones,  and  the  lympha- 

tic glands  were  found  to  be 
crowded  with  corpuscles  also  of  two  distinct  sizes,  exactly  corresponding 
to  those  in  the  blood.  (Figs.  492  and  4V3.)  From  these  facts,  we  can 
have  little  doubt  that  the  colourless  corpuscles  are  formed  in  the  lym- 
phatic o-lands,  and  from  thence  find  their  way  into  the  blood. 

Bv  what  channel  they  effect  this,  whether  by  the  lymphatics,  the 
veins,  or  by  both,  it  is  very  difficult  to  determine.  The  limitary  mem- 
brane which  surrounds  the  saccular  glands  is  exceedingly  delicate ; 
indeed,  so  much  so,  that  its  existence  has  been  denied  by  some  obsei'vers. 
When  distended,  therefore,  it  may  easily  break,  and  the  contents  be 
poured  into  the  pulp,  surrounding  stroma,  or  blood-vessels.  Dr.  Sandersf 
lias  shown  that  the  Malpighian  sacs  of  the  spleen  are  traversed  by  very 
large  vessels,  and  Mr.  Gray  has  attempted  to  demonstrate  an  intimate 
relation  between  the  former  and  the  splenic  veins.J  But  it  must  be 
acknowledged,  that  notwithstanding  the  certainty  which  exists  as  to  the 
connection  between  the  closed  lymphatic  glands  and  tlie  blood-vessels, 
and  the  passage  of  corpuscles  from  one  to  the  other,  the  method  by 


Fig.  492. 


*  Tlii.s  well-known  fact  has  been  confirmed  by  the  careful  ob-servations  of  Funke. 
—Eenlts  Zeilschrift,  1851,  p.  172. 

f  Report  of  Physiological  Society  of  Edinburgh  for  January  31st,  1852.  Monthly 
Journal  lor  February  1852. 

X  On  the  Spleen,  pp.  233-4.     1854. 


Fig.  492.  Numerous  naked  nuclei  of  the  colourless  corpuscles  of  the  blood. 

Fig.  493.  The  same  after  the  addition  of  acetic  acid.  250  diam. 


LEUCOCYTHEMIA.  835 

whicli  this  is  accomplislied  has  not  yet  been  satisfactorily  shown.  I 
cannot  help  thinking,  however,  that  there  mnst  be  a  direct  venous  com- 
munication. 

Of  late  vears  physiologists  have  been  in  the  habit  of  calling  these 
glands  the  blood  glands,  although  nothing  more  definite  has  been  deter- 
mined with  reo-ard  to  them  than  that  they  are  in  some  way  subservient 
to  nutrition,  especially  during  an  early  period  of  life.  But  if  I  have 
been  successful  in  establishing  that  the  corpuscular  elements  found  in 
these  oro-ans  are  transformed  into  those  of  the  blood,  it  will  follow 
that  the  Ivmphatic  glands  secrete  the  blood  corpuscles  in  the  same 
manner  as  the  testes  secrete  the  spermatozoa,  the  mammee  the  globules 
of  the  milk,  or  the  salivary  and  g;vstric  glands  the  cells  of  the  saliva  and 
gastric  juice. 

With  regard  to  the  exact  mode  in  which  the  corpuscles  are  formed 
in  the  glands,  two  theories  exist,  both  of  which  are  dependent  upon 
numerous  facts  and  observations  closely  connected  with  the  origin  of  all 
vital  structures,  and  indeed  of  organization  itself.  One  is,  that  they  are 
thrown  off,  in  the  form  of  epithelium,  from  the  membrane  which  sur- 
rounds them  ;  the  other,  that  they  originate  in  an  organic  fluid,  by  the 
production  of  molecules,  the  successive  development  and  aggregation  of 
which  constitute  the  higher  formations.*  I  have  long  been  of  opinion 
that  the  latter  theory  is  the  more  consistent  wnth  known  facts,  and  cer- 
tainly all  that  I  have  seen  during  repeated  investigations  into  the  struc- 
ture of  the  various  lymphatic  glands,  is  in  harmony  with  it.  Nowhere 
have  1  seen  the  nuclei  and  cells  of  these  glands  attached  to,  or  appa- 
rently given  off  from,  a  membrane,  still  less  from  supposed  fixed  germs, 
but  everywhere  pervading  a  molecular  fluid  within  the  closed  sacs.  But, 
however  produced,  whether  from  molecules  or  fixed  germs,  it  is  here  they 
are  formed,  and  are  subsequently  thrown  into  the  torrent  of  the  circula- 
tion,— there,  colour  is  added  to  them,  and  they  become  blood  corpuscles. 
Multitudes  of  free  nuclei  in  this  way  join  the  blood,  and  are  at  once 
converted  into  coloured  blood  discs.f  The  cells,  which  in  health  are 
comparatively  few  in  number,  circulate  for  a  time  as  colourless  corpuscles, 
but  after  a  certain  period  their  walls  dissolve,  when  their  included  nuclei 
also  become  coloured  discs.  In  leucocythemia  the  colourless  cells  are 
increased,  whilst  the  free  nuclei  are  diminished  in  number.  The  conse- 
quence is,  that  the  former  are  developed  at  the  expense  of  the  latter, 
and  as  they  do  not  become  coloured  on  reaching  the  lungs,  the  forma- 
tion of  red  blood  is  more  or  less  checked.  In  the  three  inferior  verte- 
brate tribes,  the  entire  cell  becomes  oval,  and  assumes  colour. 

All  that  is  known  of  the  development  of  the  blood  corpuscles,  on 
the  one  hand,  and  of  the  blood  glands  on  the  other,  supports  the  theory 
now  brought  forward.    The  primitive  production  of  blood  in  the  embryo 

*  Report  of  Physiological  Society  of  Edinburgh  for  January  3 1st,  1852.  Monthly 
Journal  for  April  1852. 

f  In  making  this  statement.  I  am  aware  of  the  possibility  of  these  nuclei  being 
surrounded  by  a  cell-wall  so  fine  as  not  to  be  detected  by  the  best  iustrumenls.  But 
having  confirmed  the  observations  made  originally  with  Oberhccuser's  microscope, 
by  means  of  an  excellent  lens  by  Ross,  of  one-eighth  of  an  inch  focus,  with  the 
most  careful  attention  to  the  management  of  the  light,  it  is  my  conviction  that  the 
great  majority  of  these  bodies  possess  no  cell- walls. 


836  DISEASES   OF  THE   BLOOD. 

occiu's  in  the  interior  of  cells  in  the  vascular  layer  of  the  germinal  mem- 
brane, which  cells  are  afterwards  transformed  into  vessels.  At  tliis 
period  the  colourless  cells  are  very  abundant,  and  their  nuclei  may  be 
seen  to  undei'go  the  fissiparous  mode  of  multiplication  formerly  described ; 
the  cells  themselves  also  in  this  foetal  condition,  multiply  by  division.*  In 
the  invertebrate  tribes,  there  are  no  lymphatic  vessels  or  glands.  In 
fact  there  is  only  one  circulation,  which  has  been  shown  by  Milne 
Edwards  to  consist  of  a  series  of  tubes,  analogous  to  arteries  or  veins, 
which  communicate  by  means  of  lacunaj  that  surround  viscera.  But 
the  circulating  fluid  contains  two  distinct  kinds  of  corpuscles,  which 
Mr.  Wharton  Jones  has  shown  to  be  different  phases  of  each  other,  and 
to  correspond  with  the  colourless  and  coloured  corpuscles  of  fishes,  rep- 
tiles, and  birds.  In  fishes  a  lymphatic  system  exists  separately,  and  in 
them  we  first  observe  a  pituitary  body,  supra-renal  capsules,  and  a  spleen. 
In  reptiles  there  are  added  the  thymus  and  thyroid  glands,  and  in -both 
these  classes  of  animals  the  communications  between  the  blood-vessels 
and  lymphatics  arc  numerous  and  direct.  In  birds  we  first  observe,  in 
addition,  glands  on  the  lymphatics  of  the  neck,  but  not  on  the  lacteals, 
and  there  are  two  thoracic  duets.  In  the  mammalia,  the  liighest  develop- 
ment of  the  lymphatic  glandular  system  exists,  including  mesenteric 
and  lymphatic  glands,  a  spleen,  thymus,  thyroid,  pineal  and  pituitary 
bodies,  and  supra-renal  capsules.  Thus  we  observe  a  correspondence 
between  the  amount  of  corpuscular  elements  in  the  blood,  and  the 
extent  and  complexity  of  the  lymphatic  glandular  system.  The  cor- 
puscles are  comparatively  few  and  colourless  in  most  of  the  invertebrata, 
and  in  such  animals,  as  stated  by  Wagner,  should  be  considered  analogous 
to  those  of  lymph.  They  become  more  numerous  and  coloured,  with 
the  appearance  of  a  spleen  and  supra-renal  capsules,  in  fishes.  Both 
in  fishes  and  reptiles,  however,  the  colourless  cells  are  numerous.  In 
birds  the  coloured  cells  are  smaller,  but  still  nucleated ;  and  in  mammals 
the  coloured  bodies  are  free  nuclei,  and  are  even  much  more  abundant. 

Again,  it  has  been  supposed  that  the  coloured  cannot  be  foi'med  from 
the  colourless  bodies  of  the  chyle, — 1st,  Because  the  former  can  be  seen 
of  all  sizes  in  the  blood  itself;  2d,  Because,  on  examining  the  blood  of 
foetal  animals,  no  intermediate  stages  of  growth  can  be  seen  between 
them;  and  3d,  Because,  on  the  addition  of  acetic  acid,  while  the  coloured 
bodies  are  nearly  dissolved,  the  naked  nuclei  of  the  chyle  are  not,  and 
hence,  it  is  said,  they  are  of  different  chemical  composition. 

With  regard  to  the  first  argument,  derived  from  variations  in  the  size 
of  the  colom-ed  particles,  it  may  be  said  that,  granting  the  fact,  nuclei  may 
also  be  observed  both  free  and  within  cells,  of  all  sizes,  so  that  they  cor- 
respond perfectly  with  the  coloured  corpuscles  of  the  blood.  Besides, 
in  different  cases  of  leucocythemia,  although  the  colourless  cells  have 
been  seen  to  be  smaller,  of  the  same  size,  somewhat  larger,  and  even 
twice  as  large  as  the  coloured  bodies,  their  nuclei  may  always  be  observed 
to  correspond  exactly  with  the  different  phases  of  the  latter.  With 
regard  to  the  second  argument,  advanced  by  those  who  have  not  suc- 
ceeded in  detecting  transition  forms  in  embryonal  blood,  I  am  persuaded 
that  this  arises  from  the  circumstance,  that  attention  is  directed  to  the 

*  These  changes  are  well  figured  by  Fahmer. — De  Globulorum  Sanguinis,  &c. 
Turici,  1845. 


LEUCOCYTHEMIA.  837 

colourless  cells,  instead  of  to  their  nuclei.  For  ray  own  part,  I  have 
never  failed  to  observe  all  the  changes  previously  described,  not  only  in 
foetal,  but  even  in  adult  blood.  As  to  the  third  objection,  in  reference 
to  dissimilarity  of  chemical  composition,  it  must  be  remembered  that 
when  the  chyle  corpuscles  enter  the  circulation  by  the  left  jugular  or 
sub-clavian  vein,  they  pass  immediately  through  the  pulmonary  artery 
into  the  lungs,  come  in  contact  with  oxygen,  and  undergo  chemical 
changes,  with  which  we  are  as  yet  unacquainted.  Some  physiologists 
have  supposed  that  colour  is  added  to  them  before  they  join  the  pul- 
monary circulation,  because  yellow  corpuscles  have  been  seen  in  the 
upper  extremity  of  the  thoracic  duct.  In  all  such  observations,  how- 
ever, they  have  been  necessarily  exposed  to  the  atmosphere  ;  and  I  have 
frequently  confirmed  the  observation  of  Enimert,  viz.,  that  the  coagulum 
of  chyle,  at  first  colourless,  becomes  pinkish-red  in  contact  with  air. 
On  this  point  I  ofter  no  opinion,  believing  that  neither  chemistry  nor 
physioloijy  has  as  yet  communicated  to  us  any  exact  information  with 
regard  to  when  or  how  lueinatin  is  produced.  But  whatever  the 
clianges  may  be  which  occur  in  the  lymph  corpuscles  on  their  passage 
into  the  lungs,  to  those  organs  we  nuist  attribute  the  alteration  in  their 
chemical  constitution,  as  they  are  colourless  and  insoluble  in*  the  lymphatic 
glands  and  in  chyle,  but  coloured  and  partially  soluble  in  the  torrent  of 
the  circulation. 

Moleschott,*  having  found  the  colourless  cells  increase  in  the  blood  of 
the  frog  after  excision  of  the  liver,  supposes  that  it  is  in  the  latter  organ 
colour  is  added  to  the  blood.  In  man  we  have  seen  that  the  structural 
diseases  of  the  liver  are  frequently  associated  with  enlargement  of  the 
spleen  in  leucocythemia,  but  in  other  cases  the  liver  has  been  quite 
natural  even  in  very  severe  examples  of  the  blood  disease.  Besides,  it 
is  difficult  to  understand  how  chemically  so  important  a  function  should 
be  performed  by  this  organ. 

Ultimate  destination  of  the  blood-corpuscles. — There  may  frequently 
be  observed  in  the  spleen  of  all  animals,  groups  of  blood-corpuscles, 
surrounded  by  an  albuminous  deposit  closely  resembling 
a  cell-wall.  This  fact  has  been  dift'erently  interpreted. 
Gerlach  is  of  opinion  that  they  are  new  blood-corpuscles 
forming  within  a  mother  cellf — whilst  KollikerJ  and 
Ecker§  maintain  that  they  are  old  ones,  which,  having 
fulfilled  their  functions  in  the  circulation,  go  to  the 
spleen,  and  are  there  dissolved.  These  large  cells,  con- 
taining several  coloured  nuclei,  I  believe  to  be  cells  of 
the  lymphatic  glands,  which,  under  especial  circumstances,  assume  power 
of  increased  development,  with  endogenous  multiplication  of  nuclei. 
Thev  are  common  not  only  in  the  spleen,  but  in  the  mesenteric  and 

*  Miiller's  Archives.    Hept.  1,  1853. 

f  Handbuch  der  AUgemeine  uiid  Speciellen  Gewebelehre,  etc.,  s.  53. 

i  Mikroskopisc'he  Auatomie,  etc.     2  Band,  s.  282. 

§  Wagaer's  Haadworterbuch.     Art.  Blukgefassdriisen. 

Fig.  494.  Cells  with  single  and  multiple  nuclei ;  many  of  the  latter  in  colour  and 
form  exactly  resemble  blood  globules.     From  the  human  spleen.  250  diam. 


838  DISEASES   OF   THE   BLOOD. 

other  lymphatic  glands,  especially  -when  hypertrophied  from  neighbour- 
ing irritation,  the  result  of  inflammatory  or  canceious  exudations,  and 
especially  in  typhoid  fever.  A  similar  increased  power  of  development 
may  occasionally  be  observed  in  the  epithelial  cells  of  the  pulmonaiT  air 
vesicles  in  certain  kinds  of  pneumonia ;  in  those  covering  the  choroid 
plexus  in  hydrocephalus;  in  those  of  the  epidermis  in  epithelial  cancer; 
and  in  pus.  On  the  other  hand,  that  extravasated  blood-corpuscles  may 
assemble  together  in  groups,  and  subsequently  be  surrounded  by  an 
albuminous  deposit  closely  resembling  a  cell-wall,  is  a  fact  of  great 
pathological  importance.*  It  is  true  they  closely  resemble  the  lymph 
cells,  Avith  multiplying  nuclei,  but  may,  I  think,  be  sepaiated  from  them 
by  possessing  more  colour.  I  have  seen  them  not  only  in  the  spleen, 
but  in  other  glands,  and  especially  in  the  brain,  following  spontaneous 
and  artificial  sanguineous  extiavasations  (see  Figs.  292,  293,  p.  214). 
But  surely  it  will  not  be  maintained  that  the  normal  function  of  the 
organs  in  which  these  accidental  formations  occur,  is  to  dissolve  the 
blood-corpuscles.  l>esides,  from  the  numerous  facts  -which  have  been 
referred  to,  I  trust  it  has  been  made  ap)>arent  that  the  siileen  is  much 
more  probably  a  blood-forming  than  a  blood-destroying  gland. 

The  view  \vf\ich  seems  to  me  most  consistent  with  facts  is,  that  the 
blood-corpuscles  are  dissolved  in  the  liquor  sanguinis,  and  with  the  ofl;ete 
matter  absorbed  from  the  tissues  by  the  lymphatics,  constitute  blood 
fibrin.     (Seep.  103.) 

From  the  various  facts  which  have  been  stated,  I  think  we  may 
conclude : — 

1.  That  the  blood-corpuscles  of  vertebrate  animals  are  originally 
formed  in  the  lymphatic  glandular  system,  and  that  the  gi'cat  majority 
of  them,  on  joining  the  circulation,  become  coloured  in  a  manner  that  is 
as  yet  unexplained.  Hence  the  blood-corpuscles  may  be  considered  as 
a  secretion  from  the  lymphatic  glands,  although  in  the  higher  animals 
that  secretion  only  becomes  fully  formed  after  it  has  received  colour  by 
exposure  to  oxygen  in  the  lungs, 

2.  That,  in  mammalia,  the  lymphatic  glandular  system  is  composed  of 
the  spleen,  thymus,  thyroid,  supra-renal,  pituitary,  pineal,  and  lymjihatic 
glands. 

3.  That,  in  fishes,  reptiles,  and  birds,  the  coloured  blood-corpuscles 
are  nucleated  cells,  originating  in  these  glands;  but  that,  in  mammals, 
they  are  free  nuclei,  sometimes  dei'ived  as  such  from  the  glands ;  at 
others,  developed  Avithin  colourless  cells. 

4.  That,  in  certain  hypertrophies  of  the  lymphatic  glands  in  man, 
their  cell  elements  are  multiplied  to  an  unusual  extent,  and  under  such 
circumstances  find  their  way  into  the  blood,  and  constitute  an  increase 
in  the  number  of  its  colourless  cells.  A  corresponding  diminution  in  the 
formation  of  free  nuclei,  and  consequently  of  coloured  corpuscles,  must 
also  occur.     This  is  leucocythemia. 

Since  the  above  views  were  published  by  me  in  1851,  they  have 
been  confii'med  by  observations  of  various  kinds.     Thus  Hollandf  and 

*  See  Dr.  Sanderson  on  the  Metamorphosis  of  Coloured  Blood  Corpuscles,  etc. 
Monthly  Journal  for  September  and  December,  1851. 
•J-  Journal  of  Microscopical  Science,  vol.  i.  p.  176. 


LEUCOCYTHEMIA. 


839 


Neale*  have  shown  that  in  many  cases  of  bronchocele  the  blood  is 
leucocythemic.  In  the  only  two  cases  of  supra-renal  disease  described 
by  Addison  in  which  the  blood  was  examined,  the  colourless  cells  were 
increased  in  number.  In  a  case  of  dysentery,  with  thickening  of  the 
mucous  membrane  of  the  small  intestine,  I  found  leucocythemia.     (Case 

LXXV.)t 

Attempts  have  been  made  to  divide  leucocythemia  into  varieties. 
Thus,  Virchow  speaks  of  a  splenic  and  a  lymphatic  variety.  But  in 
this  manner  we  might  make  further  distinctions  of  a  thyroid,  a  supra- 
renal, an  intestinal,  and  a  mesenteric  variety,  according  as  disease  in 
these  organs  occasioned  the  blood  lesion.  Nay  more,  we  might  speak 
of  an  hypertrophic,  a  tubercular,  a  cancerous,  a  dysenteric,  and  an 
anajmic  form,  according  as  we  found  tlie  blood  glands  simply  increased 
in  size,  loaded  with  tubercle  or  cancer,  or  associated  with  dysentery 
or  anoemia.  These  distinctions  I  believe  to  be  of  no  advantage,  either 
in  a  scientific  or  practical  point  of  view.  The  different  blood  glands 
contain  elements  which,  when  locally  increased  in  number,  find  their 
way  into  the  blood,  to  constitute  leucocythemia.     They  form  one  system 

*  Medical  Times  and  Gazette,  vol.  viii.  p.  430. 

•j-  The  first  eleven  of  tlie  following  cases  of  Leucocythemia  have  been  under  my 
care  since  the  publication  of  m}'  work  in  1852.  To  these  Dr.  Haldane  has  kindly 
added  seven  others,  the  bodies  of  which  he  has  examined  in  the  Patliological  Theatre 
of  the  Royal  Infirmary  since  November  1853 — making  eighteen  in'  all.  I  might 
have  swelled  the  list  greatly  by  adding  numerous  cases  obligingly  communicated  to 
me  by  professional  friends :  — 


Name. 

< 
15 

Degree. 

Liver. 

Spleen. 

Abdominal 
Glands. 

Eemarks. 

1.  Tho.  Christie 

Advanced. 

Not 

examined  after 

death. 

2.tWin.  Biiillie.  43 

Advanced.    3  lb. 

10  oz. 

2  lb.  4.  oz. 

Little  enlarged. 

3.  Patrick  Flo,,.] 

13 

Well  mark'd 

Dls- 

missed  from  the 

house,   and  did  not  return. 

4.  Jn.  (latt'iiey. 

10 

Moderate.    61b. 

14  oz. 

22  oz. 

Twice  natl.  size  1 

5.  Clias.  Keimic. 

lit 

Well  m.arkM  4  lb. 

7  oz. 

2  lb.  14  oz. 

Enlarged.       | 

6.  J.  M-Arthur. 

•25 

Moderate. 

31b. 

5  oz. 

6oz. 

Highly   tubercu-  Tubercular  peri- 
lar.                         tonitis. 

7.  Eliz.  Pollocli. 

56 

Advanced. 

Not 

examined  after 

death. 

8.  Win.  Dods. 

23 

Slight. 

3  1b. 

2oz. 

5oz. 

Greatly  enlarged  Cancer  in  various 

1     organs. 

9.  T.  Crease. 

28 

Moderate. 

2  1b. 

8oz. 

6oz. 

Mucous  coat  of  Cancer  in  lung, 
ileum  thickened.' 

10.  Eliz.  Barker. 

17 

Slight. 

2  1b. 

7oz. 

Natural. 

Enlarged.        Tubercular  pen- 

tonitis. 

11.  Janet  Young. 

50 

Moderate. 

2  1b. 

Natural. 

Not  mentioned. 

Aneurism- Waxy 

Kidnevs. 

12.  John  Young. 

27 

Well  mark'd 

Natural. 

14  oz.  dense. 

Not  mentioned.  iGlanders?    Cere- 

bral       hemor- 
rhage. 

13.  G.  Harper. 

60 

Advanced. 

Do. 

8  lb.  with  deposit 

Little  enlarged. 

1-4.  Ber.  Collins. 

35 

Well  mark'd 

51b. 

10  oz. 

27  oz. 

Not  enlarged. 

Tubercle  in  lungs 
— Pneumonia. 

15.  D.  Cockfield. 

32 

Slight. 

6  1b. 

8oz. 

22  oz.  deposit. 

Little  enlarged.  iBright's  disease. 

16.  J.  M-Gregor. 

S> 

Do. 

5  1b. 

11  oz. 

16  oz. 

Much  enlarged.    Mehena. 

17.  Jer.  Brown. 

29 

Advanced. 

5  1b. 

9oz. 

3  lb.  13  oz. 

Enlarged. 

Acute  tuberculo- 

18. John  Short. 

50 

Well  mark'd 

41b. 

8  oz.  dense. 

Not  enlarged. 

sis. 
Brighfs  disease. 

X  The  blood  in  this  case,  when  subsequently  under  the  care  of  Dr.  Halliday  Douglas,  was  analysed 
by  Mr.  Kemp,  who  found — water,  8C4'67;  albumen,  71  25;  fibrin,  5  35;  corpuscles,  5S'97. 


840  DISEASES   OF  THE   BLOOD. 

of  organs,  and  any  kind  of  disease  in  them  may  strnctnrally  affect  the 
blood.  What  appears  to  me,  however,  now  a  desideratum  in  research, 
is  to  determine  why,  in  some  cases,  the  blood  should,  and  in  others 
should  not,  be  leucocythemic,  when  these  glands  are  diseased;  and  why 
smiple  anaemia,  as  was  first  shown  by  Eemak,  should  increase  {he 
number  of  colourless  cells  in  the  blood  ?  In  one  case  examined  by  me 
in  the  autumn  of  ]8o2,  and  the  characteristic  blood  in  which  I  had  the 
pleasure  of  showing  to  Dr.  Hannover  of  Copenhagen  and  to  Dr.  Sharpey 
of  London,  I  unexpectedly  ascertained  that  the  microscopic  examination 
cleared  up  a  doubtful  diagnosis.  It  was  the  case  of  a  woman  concern- 
ing whom  a  difference  of  opinion  existed  between  two  distinguished 
obstetricians,  the  one  declaring  a  tumour  in  the  left  flank  to  be  s})lenic, 
and  the  other  that  it  Avas  ovarian.  I  showed  it  to  be  splenic,  by  demon- 
strating that  the  blood  Avas  crowded  with  colourless  ceils. 

AVitli  regard  to  treatment,  nothing  that  I  have  yet  ti-ied  has  appeared 
to  be  of  the  slightest  service  in  well-marked  cases  of  leucocytliemia 
associated  with  distinct  glandular  enlargements.  Iron,  quinine,  chloride 
of  potassium,  hydiiodate  of  potash,  and  a  variety  of  medicines  given 
internally,  with  tincture  of  iodine  applied  externally,  have  been  of  no 
avail.  The  chief  indications  in  advanced  cases,  however,  will  be  found 
to  be  furnished  by  accidental  complications,  the  most  common  of  which 
are  diarrhoea  and  epistaxis,  which  require  astringents,  combined  with 
tonics,  nutrients,  and  stimulants,  to  support  the  vital  powers. 


Discovery  of  Leucocytliemia, 

Professor  Kolliker  of  Wurtzburg  (in  Month.  Jouin.  of  Med.  Science,  Oct.  1854), 
laid  before  the  English  medical  public  the  history  of  the  discovery  of  Leucocythemia 
as  it  is  understood  in  Germany^  from  the  representations  of  Professor  V  irchow.  The 
following  is  my  reply: — 

It  is  said  by  Professor  Kolhker  that  the  first  observations  on  this  subject  occur  in 
the  year  18-15,  and  take  their  origin  from  a  case  of  disease  by  Dr.  Craigie.  Now,  the 
fact  is,  tliat  Dr.  Craigie's  case  occurred  in  1841 ;  and  it  is  admitted  by  Dr.  Craigie 
himself  that  it  would  not  have  been  published  even  four  years  aiterwards  but  for  the 
occurrence  of  mine.  He  says,  "  I  kept  it  unpublished  from  the  period  at  which  it 
took  place ;  and  it  is  published  at  tliis  time,  chiefly  because  the  occurrence  of  a 
case  in  many,  if  not  in  all,  respects  similar  to  another  physician  in  the  same  hospital, 
led  me  to  anticipate  similar  results,  and  went  far  to  confirm  my  conclusions  deduced 
from  the  first  case." — Edin.  Med.  and  Surg.  Journ.,  vol.  Ixiv.  p.  402. 

Professor  Kolliker  takes  great  pains  to  show  that  Dr.  Craigie  and  m}'self  held  the 
same  opinions  as  to  these  cases,  and  that  in  mine,  which  followed  his,  "nothing 
further  was  elucidated."  On  the  other  hand,  he  says  Professor  Virchow  was  the 
first  to  point  out  that  "no  signs  of  inflammation  in  the  veins  were  anywhere  dis- 
coverable," etc.  Now,  exactly  the  contrary  of  this  is  the  fact.  Dr.  Craigie  put 
forth  two  possibilities  as  to  the  cause  of  the  blood  disorder.  \st,  He  says,  "It  is 
barely  possible  that  some  inflammatory  action  had  taken  place  in  the  tributary  or 
constituent  veins  of  the  mesenteric  trunks;  and  that  the  pimiknt  matter  and  lymph 
thus  formed  had  been  conveyed  into  their  interior  with  the  blood,  and  thence  into 
the  vena  cava,  heart,  and  vessels  of  the  brain."  2d,  He  says,  "Another  opinion 
occurred  to  me,  however,  as  more  probable,  and  which  various  circumstances  in  the 
case  induced  me  to  regard  as  the  most  correct.  Considering  that  the  spleen  had 
been  for  some  time,  that  is,  for  several  weeks,  in  a  state  of  chronic  inflammation,  and 
taking  into  account  the  large  vessels  with  which  this  organ  is  connected  to  other 
organs,  it  appeared  to  me  that  this  inflammatory  jyrocess,  which  had  been  continuing 


LEUCOCYTHEMIA.  841 

so  long  without  abating,  subsiding,  or  being  subdued,  was  at  length  beginning  to 
give  rise  to  the  fonuation  of  lymph  and  purulent  matter,  and  that  these  substances, 
as  they  were  formed,  were  immediately  taken  into  the  veins,  and  thus  circulating 
with  the  blood,  gave  rise  to  the  peculiar  assemblage  of  symptoms  which  the  patient 
presented  during  the  few  days  preceding  his  death."'  (P.  409.)  From  these  extracts 
it  must  be  clear  that  Dr.  Craigie  considered  the  blood  disease  as  secondarj-,  and 
dependent  on  the  absorption  of  pus  from  an  inflammatory  lesion  either  iu  the  mesen- 
teric veins  or  spleen. 

The  view  talcen  up  by  myself  was  wholly  different,  viz.,  that  the  blood  disease 
was  primary,  originating  in  that  Huid  itself,  altogether  independent  of  local  inflam- 
mation, and  especially  unconnected  with  inflammation  of  the  veins.  This  will 
appear  from  tiie  following  extracts  from  my  paper: — "In  the  present  state  of  our 
knowledge,  then,  as  regards  this  subject,  the  following  case  seems  to  me  particularly 
valuable,  as  it  will  sen'e  to  demonstrate  the  existence  of  true  pus  formed  universally 
within  the  vascular  .system,  independent  of  any  local  jjuruient  colledian  from  which  it 
could  he  derived."'  (Pp.  413,  414.)  And  again,  "Pus  has  long  been  considered  as 
one.  if  not  the  most  characteristic,  proof  of  preceding  acute  inflammation.  But  in 
the  case  Isefore  us,  what  part  was  recently  inflamed  f  There  was  none.  Piorri-  and 
others  have  spoken  of  an  inflammation  of  the  blood,  a  true  hematitis;  and  certainly 
if  we  can  imagine  such  a  lesion,  the  present  must  be  an  instance  of  it.  But  it  would 
require  no  laboured  argument  to  show,  that  such  a  vieiu  is  entirely  op2)osed  to  all  we 
knoic  of  the  2}henornena  of  inflammation."  (P.  421.)  From  these  passages  it  must 
be  clear  tl)at  I  tlien  separated  the  state  of  the  blood  from  pre-existing  inflammation 
in  any  of  the  tissues,  which  had  not  been  done  by  any  preceding  author.  I  espe- 
cially distinguished  it  from  pya?mia  as  it  was  then  generally  understood.  Thereby  I 
established  a  new  blood-disease — one  of  a  primary  "nature. '  I  carefully  described  all 
the  f-ACts  which  Virchow  has  only  subsequently  confirmed.  I  spent  three  entire 
days  investigating  the  histological  character  of  all  the  tissues  in  the  body,  and  in 
demonstrating  the  important  fact,  that  the  colourless  corpuscles  in  the  blood,  which 
I  minutely  described,  were  unconnected  with  inflammation.  Notwithstanding  all 
this.  Professor  Virchow  has  pertinaciously  endeavoured  to  persuade  his  countrymen 
that  I  regarded  the  case  as  one  of  ordinary  pyjemia  or  purtilent  absorption ;  and 
Professor  Kolliker,  in  his  communication,  says  of  these  laborious  researches,  that 
"  nothing  further  was  elucidated  "  beyond  what  had  previously  been  determined  by 
Craigie  and  Rei(L 

Here,  it  sliould  be  observed,  that  Dr.  Craigie  was  no  histologist,  and  had  never 
employed  the  microscope  in  the  investigation  of  disea.se.  To  argue,  then,  that  the 
discovery  of  this  condition  of  the  blood — a  discovery  altogether  dependent  on  histo- 
logical research — was  made  by  him,  seems  absurd  in  the  extreme.  But  it  may  be 
maintained  tiiat  this  part  of  the  inquiry  was  carried  out  by  Dr.  John  Reid,  because 
he  .stated  in  the  register,  kept  by  him  as  pathologist  of  the'  Infirmary,  that  the  blood 
"contained  globules  of  purulent  matter  and  lymph."  The  few  words  now  quoted 
constitute  literally  the  whole  of  Dr.  Reid's  observations  on  the  matter.  They  would 
have  been  buried  in  oblivion,  if  I  myself  had  not  found  them  in  the  register  of  dissec- 
tions, pointed  them  out  to  Dr.  Craigie.  and  indicated  their  importance.  I  have 
frequently  conversed  with  Dr.  Reid  himself  on  the  subject,  who  had  forgotten  the 
circumstance  of  having  examined  the  blood  microscopically  in  Dr.  Craigie's  case,  or 
of  having  made  a  note  of  it.  Certainly  he  paid  no  more  "attention  to  it.  or  in  any 
way  thought  it  more  important  than  a  host  of  other  notes  he  made,  which  still  exist 
in  the  pathological  register,  and  in  which  some  future  controversialist  may  doubtless 
find  many  similar  discoveries,  as  yet  unknown.  At  all  events,  it  is  certain  that 
neither  Dr.  Craigie  nor  Dr.  Reid  ever  imagined  to  themselves  that  the  "  globules  of 
purulent  matter  and  lymph  "  seen  by  the  latter,  originated  independent  of  purulent 
absorption,  or  ever  dreamed  of  claiming  for  themselves  the  discovery  of  leucocythemia. 
Who  then  did  make  it  ?  Certainly  not  Virchow,  who  with  Kolliker,  in  "order  to 
depreciate  the  value  of  my  observations,  claims  it  for  these  gentlemen.  And  if  none 
of  the  tiiree  made  it,  tlie  inference  undoubtedly  is,  that  the  discovery  belongs  to  me. 

What,  then,  it  may  be  asked,  does  Professor  Kolliker  claim  for  his  colleague  ?  It 
cannot  be  the  discovery  of  the  facts,  or  of  the  existence  in  large  numbers,  of  colour- 
less corpuscles  in  the  blood,  independent  of  inflammation.  All  the  histological  facts 
—the  white  appearance  of  the  blood  (white  blood),  its  independence  of  inflammation, 
and  its  separation  from  all  previously  known  pathological  conditions — were  minutely 
described  by  me  in  the  pajjer  of  the  first  of  October  1845,  and  their  accuracv  has  been 


84:2  DISEASES   OF   THE   BLOOD. 

everywhere  confirmed  (See  Case  CLXXXIII.)  Surely  tliis  description  of /acte  never 
before  published,  and  of  their  connection  with  a  new  blood-disease,  consliiuies  the 
discovery.  On  the  other  hand  A'irchow's  short  and  comparatively  imperfect  histo- 
logical description  of  a  case  of  white  blood  (the  white  appearance  of  the  biuod  being 
the  chief  point  he  dwelt  upon)  was  printed  in  the  second  number  for  the  following 
Xovember,  although  from  the  admission  of  Professor  Kolliker,  as  to  the  practice  which 
prevails  in  (jerman}-,  the  actual  period  of  its  publication  may  have  been  much  later. 
Hence  all  that  can  be  claimed  for  Virchow  amounts  to  this,  that  lie  puts  fortii  an 
opinion  regarding  these  facts  difierent  from  muie.  but  the  possibilit\'  of  wliich  I 
clearly  indicated.  For  having  described  the  peculiarities  of  the  blood — the  white 
coagulum,  its  structural  characters,  the  colourless  corpuscles,  the  relation  to  the  red 
ones,  and  tiie  absence  of  the  inflanuuatory  appearances  in  every  tissue,  not  except- 
ing the  veins — tiie  questions  remained,  What  are  these  coipusclts?  How  are  they 
produced  ?  In  reply,  I  remarked,  that  "  with  regard  to  the  colourless  corpuscles  of 
the  blood  ice  know  of  no  irieianct  where  they  existed  m  tlie  amount,  or  ever  presented 
the  appearance  described."  From  this  passage  Professor  Kolliker  draws  the  inference 
that  I  denied  that  these  bodies  were  the  colourless  corpuscles  of  the  blood.  But  I 
need  scarcely  point  out  that  the  passage  does  not  fairh'  bear  that  construction.  On 
the  other  hand,  it  clearly  shows  that  the  possibility  of  their  being  these  colourless 
corpuscles  was  fully  entertamed.  At  that  time  the  whole  subject  was  hislologieally 
new;  and  having  shown  that  the  cells  observed  closeh'  resembled  those  of  pus  in 
their  structural  and  chemical  characters,  I  said  so,  and  concluded  they  were  pus 
corpuscles.  But  having  also  demonstrated  that  they  could  not  have  been  derived 
from  any  inflamed  tis-sue,  it  only  remained  to  be  concluded  that  these  bodies  were 
formed  in  the  blood  system  itself^  constituting  a  primary  suppuration  of  the  blood. 
Here.  I  contend,  was  the  real  discovery,  which  was  at  that  time  quite  new,  and 
remains  up  to  this  hour,  in  mj'  belief,  a  correct  generalization. 

"Whilst  Profes.sor  Kolliker  .seems  to  attach  no  importance  whatever  to  my  careful 
histological  examination  of  the  blood  and  of  the  tissues,  and  wliolly  disregards  the 
fact  I  was  at  so  nmch  pains  to  establisli,  that  the  colourless  corpu-des  I  described 
were  not  dependent  on  intlanunation,  he  thinks  it  of  the  greatest  importance  that 
Tirchow  should  have  stated  that  these  corpuscles  were  not  tho.se  of  pus.  To  me  it 
has  always  seemed  of  little  importance  by  what  name  these  bodies  weie  designated, 
so  long  as  the  facts  regarding  them  were  described  with  exactitude  It  cannot  be 
denied  that  I  first  discovered  and  described  them,  and  pointed  out  their  origin  in  the 
blood  itself  TThat  histological  difterence  tliere  can  be  between  pus  cells  independent 
of  inflammation,  originating  spontaneously  in  the  blood,  and  the  colourless  corpuscles 
of  that  fluid,  I  am  at  a  loss  to  imagine.  Yet  this  is  the  only  distinction  which  Yir- 
chow  made.  But  what  are  pus  corpuscles  but  cells  presenting  certain  pliysical 
characters  originating  in  an  exuded  blood-plasma?  and  what  are  the  colourless 
corpuscles  of  the  blood  but  similar  cells  originating  in  a  plasma  contained  in  the  blood 
glands?  I  have  yet  to  learn  that  there  is  any  true  histological  difi'erence  between 
them ;  I  believe  still  that  the  only  distinction  is,  that  the  same  corpuscles  originate 
in  blood-plasma,  sometimes  outside,  and  sometimes  within  the  blood-system.  If  so, 
the  controversy  raised  by  Tirchow,  and  maintained  by  Kolliker,  is  wholly  one  of 
words.  Here  I  may  mention,  that,  acting  on  the  persuasion  that  tiie  two  kinds  of 
corpuscles,  hitherto  separated,  are  reall\-  identical,  I  opposed  the  generalization  of 
Mr.  Henry  Lee,  which  set  forth  that  pus  brought  in  contact  with  living  blood  caased 
its  coagulation.  In  conjunction  with  the  late  Professor  Barlow  of  tlie  Veterinary 
College.  I  injected  considerable  quantities  of  pus  into  the  veins  of  an  a.ss,  in  order  to 
determine  this  point.  I  thus  increased  the  colourless  cells  in  the  blood  of  the  animal 
"without  producing  any  coagulation  or  inflammation  whatever. — {Monthly  Journal, 
January  and  March  1853,  pp.  80  and  272,  273).  Moreover,  it  may  be  questioned, 
and  indeed  it  has  been  questioned  in  a  communication  which  I  received  from  Pro- 
fessor Gluge  of  Brussels,  and  in  an  article  by  Dr.  Radcliffe  {Half-  Yearly  Abstract  of 
Medical  Sciences,  vol  xvi.  p.  295).  whether  this  distinction  can  have  any  real  foun- 
dation. Rokitansky  still  maintains  that  the  colourless  corpuscles  of  the  blood  in 
leucocytliemia  aretrulj'  those  of  pus,  and  Tidal,  after  a  series  of  observations  directed 
to  this  very  point,  has  come  to  the  conclusion  that  the  colourless  corpuscles  of  the 
blood,  those  of  pus  and  those  of  mucus,  are  the  same  {Gazdte  Ethdimiadaire.  Avril 
llth,  1856).  If  so,  the  pretended  discovery  of  Tirchow  sinks  into  nothing,  as  it  is 
not  founded  on  fact,  but  simply  on  opinion. 

As  to  the  subsequent  progress  of  this  inquiry,  I  have  only  to  express  my  astonish- 


LEUCOCYTHEMIA.  843 

ment  at  the  statement  made  hy  Professor  Ivolliker,  that  in  1851,  in  the  Monthly 
Journal.  Awii.  that  in  1852,  in  my  separate  work,  I  made  no  allusion  to  my  former 
views,  and  did  not  take  tlie  sliglitest  notice  of  the  labours  of  Virchow.  It  is  most 
untrue.  My  views  regarding  this  disease  have  always  been  the  same,  but  never  such 
as  Yirchow  and  Kolliker  have  represented  them  ;  and  so  far  from  denying  the  labours 
of  the  former  pathologist,  I  have  fully  set  them  forth,  and  quoted  all  his  facts  and 
observations.  I  always  have  and  still  continue  to  estimate  highly  the  value  of  the 
facts  he  has  contributed  in  connection  with  this  important  subject.  But  what  he  has 
accomplished  does  not  entitle  him  to  the  original  discovery  of  leucocytliemia,  or  to 
the  merit  of  giving  it  a  place  in  pathology. 

Careful  investigation  into  this  subject  will,  I  am  satisfied,  convince  the  candid 
inquirer  that  the  discovery  of  leucocytliemia  and  the  subsequent  progress  of  ideas 
regarding  its  nature  may  be  divided  into  three  epochs  or  stages  as  follows:  — 

1.  Professor    Bennett. — Discovery  of  a  new  morbid  condition  of  the  blood, 

October  1,   1845.  consisting  of  multitudes  of  colourless  corpuscles,  re- 

sembling those  of  pus,  associated  with  hypertrophy  of 
the  spleen  and  liver,  and  presenting  after  death  pecu- 
liar white  coagula.  Shown  to  be  unconnected  with 
inflammation  in  any  of  the  tissues,  and  especially  un- 
connected with  phlebitis.  Attributed  to  tlie  develop- 
ment of  the  corpuscles  in  the  blood  itself 

2.  Professor    Virchow. — Confirmation  of  the  preceding  facts,  but  the  corpuscles 
Series  of  papers  from  the     said  to  be  an  increase  in  the  colourless  cells  of  the 
2d  or  3ii  week  of  November     blood.     New  cases,  and  especially  one  of  great  value, 
1845  to  1847.  '  in  which  a  similar  condition  ot  the  blood  was  associ- 
ated with  enlargement  of  the  lymphatic  glands  with- 
out hypertrophy  of  the  spleen      Origin  of  the  colour- 
less cells  attributed  to  the  Ij^mph  glands ;  proposed 
name  of  leukhemia  or  white  blood. 

3. — Professor  Benxett. — Systematic  view  of  the  whole  subject.     Additional 
Series  of  Papers,  1851.        facts  and  cases,  with  chemical  analysis  of  the  blood. 
and  separate  ivork,  Doctrine  that  the  lymphatic  and  other  ductless  glands 

1852.  Rl.  8vo,  Edinr.  secrete  the  blood  ;  proposed  name  of  leucocytliemia 
or  white-cell  blood,  and  the  relation  of  this  disease  to 
other  pathological  conditions,  and  to  practical  medi- 
cine, pointed  out. 

From  this  view  of  the  case,  it  will  be  seen  that  although  I  claim  the  discovery  of 
leucocytliemia,  and  have  given  it  the  correct  scientific  name  it  bears,  I  am  far  fi'om 
undervaluing  or  wishing  to  hide  Professor  Virchow's  contributions  to  its  pathology 
— whereas  he,  in  order  to  make  it  appear  that  the  origin  as  well  as  development  of 
the  whole  subject  is  due  to  himself  has  not  hesitated  to  give,  and  circulate  in  Ger- 
man}-, the  most  erroneous  and  partial  accounts  of  my  facts  and  views. 

Since  the  above  statement  was  published.  Professor  Virchow  has  continued  not 
only  to  repeat  his  former  errors,  but  to  assert  that  his.  case,  published  at  lea.st  six 
weeks  after  mine,  was,  in  fact,  the  first  one.  Thus  in  his  "Gezammelte  Abhand- 
lungen,"  dated  1856,  he  says,  p.  155 — "About  the  same  time  that  my  case  was 
published,  two  other  cases  were  made  known  in  Edinburgh,"  etc.  He  then  goes 
on  to  detail  them,  observing,  ''Case  1,  observed  hij  me;  Case  2,  by  David  Craigie; 
Case  3,  by  John  Hughes  Bennett."  Thus  distinctly  claiming  for  himself  priority  in 
observation.  In  the  same  manner,  Vogel,  in  giving  a  report  in  Canstatt's  Jalir- 
biicher  of  the  progress  of  Medical  Science  in  1852,  part  3,  on  special  and  local 
pathology,  puts  1st,  Virchow's  paper  from  the  Archives,  vol  v. ;  2ndly,  my  papers 
in  the  Monthly  Journal ;  and  3rdly,  my  separate  work.  Yet  what  are  the  dates  of 
these  puljlications?  My  papers  appeared  in  1851,  with  the  first  chemical  analyses 
of  the  blood  made  by  Br.  W.  Robertson.  My  separate  work  is  dated  March  1*852, 
and  Virchow's  paper,  with  the  chemical  analyses  by  Professor  Scherer,  is  dated 
August  1852  ! 

The  French  writers  on  this  subject  have  declared  the  term  leukhemia  to  be  fiiulty, 
and  adopted  that  of  leucocytliemia.  Leudet,*  Vidal.f  and  Sclinepf|  have  followed 
the  representations  of  Virchow,  and,  in  a  professed  historical  sketch,  have  stated  that 

*  Gazette  Hebdoraadaire,  27  .Tuillet,  1855.  f  Idem,  15  Fevrier,  1856. 

I  Gazette  Medicale  de  Paris,  5  Avril,  1856. 


8-i4  DISEASES   OF   THE   BLOOD. 

his  and  my  cases  appeared  about  the  same  time.  As  if  six  weeks  were  not  more 
tlian  a  sufficient  period  for  the  Edin.  Med.  and  Surg.  Journal  to  reach  Berlin,  and  to 
be  placed  on  the  library  table  of  the  Royal  Library  there,  where  it  mic^ht  have  been 
seen  by  such  readers  of  English  medical  literature,  as  Virchow  undoubtedly  i.-^,  long 
before  the  latter  published  his  note,  in  the  2nd  number  for  Xoyember  of  Froriep's 
Notizen.  Schnepf  (who  is  evidently  unacquainted  with  my  writings,  and  has  only 
seen  the  short  resume  I  presented  to  the  Biological  Society  of  Paris  in  1851,  at 
the  request  of  my  friend  M.  Lebert)  represents  Virchow's  ca.se  as  occurring  in  March, 
and  mine  in  October  18J:5.  That  is,  he  gives  to  Yirchow's  case  the  date  at  whicli 
mine  was  investigated  in  Edinburgh,  hve  months  before  the  latter  occurred !  The 
real  dates  are  as  Ibllows :  — 

Observed.  Published. 

1st  Case Prof.  Bennett March  19th,  1845 October  1st,  1845. 

2d  Case   . .  .Prof.  Virchow August  1st,  1845. . .  .Xovem.  2d  week,  1845. 

3d  Case Dr.  Fuller Decem.  31st,  1845 July,  1846. 

Dr.  Craigie's  case  must  obviously  be  placed  amongst  those  that  occurred  long  before 
the  discoverj^  of  leucocy themia  was  made,  although  on  looking  back  upon  it  one  can 
have  no  doubt  that  it  was  an  example  of  the  disease  similar  to  a  verj'  excellent  one 
published  by  Duplay,  in  the  Archives  Gen.  de  Mrdecine,  2d  series,  vol.  xxxvi  p.  223, 
1834;  or  tiie  one  which  occurred  to  M.  Barth  in  1836,  but  was  only  published  in 
1856  by  Vidal,  when  the  subject  was  fully  known. 

In  a  recent  work,  '•  Die  Cellular  Pathologic"  1858,  Professor  Virchow  for  the  first 
time  admits  (p.  170)  that  mj-  lirst  case  occurred,  not  about  the  same  time,  but  "  some 
months  "  bef()re  his.  He  continues,  however,  to  assert  that  my  conclusion  as  to  the 
cells  being  formed  in  and  not  outside  the  blood,  and  therefore  being  a  suppuration  of 
that  fluid,  was  not  original,  but  was  based  on  the  views  of  Piorrj-  as  to  hcmatitis, 
although,  in  the  words  previously  quoted.  I  expressly  repudiated  that  doctrine.  But 
Vh-chow  himself  now  says  (p.  140  op.  cit.)  that  pus  corpuscles  and  the  colourless 
cells  of  the  blood  cannot  be  distinguished  from  one  another.  "  If  found  outside  the 
blood,  we  can  with  certainty  conclude  that  tliey  are  pus ;  if  this  is  not  tlie  case,  they 
belong  to  the  elements  of  the  blood."  Further,  as  a  jjroof  of  the  impropriety  of  the 
word  leukhemia,  he  now  speaks  of  this  morbid  state  under  the  name  of  leucocytosis ! 
Hence  after  twelve  years'  misrepresentation  of  mj  discovery  and  views,  he  thus 
(indirectly)  acknowledges  my  priority  in  observation,  as  well  as  the  correctness  of 
all  the  facts  and  opinions  I  originally  put  forth. 


CHLOROSIS  AND  AN.EMIA. 

Case  CLXXXVL* — Chlorosis  and  Ancemia — Cured. 

History. — Lilias  Eoss,  set.  19,  servant  in  a  hotel — admitted  October  13th,  1856. 
She  states  that  menstruation  commenced  in  her  sixteenth  year,  and  continued  to 
recur  regularly  till  about  a  year  ago.  It  then  ceased,  and  she  experienced  debility, 
palpitation  with  pain  under  the  left  breast,  defective  appetite,  and  discomfort  after 
meals.  On  leaving  ofl'  work  for  six  weeks,  her  health  was  restored,  and  the  cata- 
menia  returned.  She  again  went  into  service,  and  in  four  months  the  symptoms 
came  back.  She  dates  the  present  indisposition  from  the  last  menstrual  period,  four 
weeks  ago. 

Symptoms  ox  Admission. — She  seems  in  every  respect  well  formed,  not  ema- 
ciated, but  the  skin  is  blanched,  and  of  a  slight  greenish  waxy  tint.  Over  the  chest 
and  mammfe  are  a  few  patches  of  pityriasis  versicolor,  of  a  faint  yellowish  tint.  She 
complains  of  occasional  palpitation.  On  examination,  the  heart's  impulse  is  in  its 
normal  position,  and  is  at  present  of  natural  force.  There  is  a  soft  but  distinct  blow- 
ing murmur  with  the  first  sound,  loud  at  the  base  of  the  organ,  and  audible  in  the 

*  Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


CHLOROSIS   AXD   AX.EMIA.  845 

course  of  the  aorta  and  large  arteries.  Over  the  carotids  above  the  clavicle,  a  loud 
double  blowing  is  audible,  which,  on  pressure  with  the  stethoscope,  becomes  a  con- 
tinuous humming-top  sound.  Pulse  100,  soft.  Tongue  pale  and  flabby,  appetite 
defective,  food  causes  a  painful  sense  of  weight  with  distension  in  the  stomach,  no 
vomiting  or  flatulence,  occasional  sense  of  constriction  in  the  throat,  bowels  costive, 
having  for  some  weeks  been  opened  only  by  laxatives.  She  has  frequent  giddiness, 
rarely  headache,  often  darkness  before  the  eyes,  no  spinal  irritation,  but  great  weak- 
ness over  the  loins,  and  such  a  sense  of  fatigue,  with  heaviness  in  the  limbs,  that 
she  has  great  difiSculty  in  walking.  The  catamenia  have  not  appeared  at  the  usual 
period  on  this  last  occasion.  They  have  never  been  profuse  or  accompanied  by  pain. 
Urine  healthy.  Respiratory  system  normal  B  Pil.  Bhcei  Camp.  xij.  Two  to  be 
taken  every  third  night.  5  Feiri  Citralis,  3j;  Syrupi  Aurantii,  et  Tr.  Aurantii, 
aa  3  j ;  Tafm.  Calumh.   §  iv.     M.      One  table-spoonful  to  be  taken  three  times  a-day. 

Progress  of  the  Case. —  October  25th. — Is  improved  in  strength,  and  can  -walk 
about  the  ward.  The  heart's  palpitations  are  easily  excited.  Sometimes  the  mur- 
mur over  the  carotids  in  the  neck  is  of  a  hoarse  double  character,  at  others  con- 
tinuous and  very  loud.  To  encourage  a  return  of  the  catamenia, /owr  leeches  mclered 
to  be  applied  to  the  vulva,  followed  by  a  warm  hip-bath.  November  lOih. — Is  gaining 
strength  slowly  on  the  whole,  but  experiences  alternations  in  this  respect — palpi- 
tations and  pain  under  lefl  mamma  being  sometimes  severe,  at  others  absent.  The 
soft  blowing  murmur  at  base  of  heart  has  disappeared,  but  the  humming-top  sound 
over  cervical  vessels  continues.  November  2oth. — Blowing  murmur  at  base  of  heart 
occasionally  returns  only  alter  exertion.  Sounds  in  neck  less  intense.  No  cata- 
menia, although  pediluvia,  mustard  poultices  to  the  feet,  and  other  means  have  been 
employed  at  the  supposed  menstrual  period.  December  lOth. — Has  continued  to 
take  the  chalybeate  mixture  all  this  time,  and  is  now  strong  and  vigorous.  A  faint 
sound  only  is  audible  over  the  vessels  in  the  neck,  after  exertion.  Appearance 
healthv.  appetite  good,  bowels  regular,  no  headache,  nor  nervous  pain.  With  the 
exception  of  amenorrhcea,  may  be  said  to  be  quite  welL  Advised  to  go  to  the 
country  for  a  httle.     Dismissed. 

Comnientanj. — This  was  a  well-marked  case  of  anaemia  and  cblorosis, 
cured  by  iron,  tonics,  and  rest.  Such  cases,  in  yonng  women,  are 
exceedingly  common  in  the  female  wards  of  the  Infirmary,  especially 
amono-  the  class  of  servants.  Great  discussion  has  occurred  as  to  the 
cause  of  the  murmurs  in  the  heart  and  large  blood-vessels,  some 
maintaining  their  seat  to  be  the  arteries,  others  the  veins.  The  argit- 
meuts  of  Dr.  Ogier  AVard,  who  first  maintained  the  seat  of  the  anaemic 
murmur  to  be  in  the  jugular  vein,  are  generally  considered  to  be  well 
founded.  They  are — Ist,  The  continuous  murmur  is  often  co-existent 
with  distinct  carotid  impulse,  which  alternates  with  repose ;  2d,  It  may 
be  interrupted  bv  pressing  the  vein  above  the  stethoscope  ;  .3d,  The  two 
murmurs  mav  be  occasionally  heard  by  employing  a  small-ended  stetho- 
scope, and  shifting  it  slightly  to  the  right  or  left ;  4th,  It  is  increased 
by  anv  cause  which  accelerates  the  flow  of  blood  through  the  jugular 
vein,  as  during  the  act  of  inspiration,  and  when  in  the  upright  posture — 
it  is  diminished  when  there  is  an  impediment  to  the  venous  circulation, 
as  during  expiration,  the  recumbent  posture,  and  when  the  veins  are 
swollen  or  turgid.  Andral  endeavoured  to  show  that  the  constancy 
of  the  murmur  is  proportionate  to  the  diminution  of  corpuscles,  and 
that  it  became  continuous  if  the  blood  globules  fell  below  80  parts 
in   1000.      But  Dr.  Davies  has  pointed  out  that  the  murmur  is  not 


846  DISEASES   OF   THE   BLOOD. 

peculiar  to  anoemic  persons,  but  often  exists  in  individuals  of  robust 
liealtli.  He  attributes  it  to  friction  on  the  inner  surface  of  tlie  veins, 
which  is  more  or  less  audible  according  to  the  readiness  with  which 
tlieir  parietes  talce  up  vibrations,  and  the  facility  Avith  which  the  latter 
are  conducted  to  the  outer  surface  of  the  body.  Hence  their  frequency 
in  children  and  young  persons,  and  in  the  quick  ventricular  contraction 
■with  thin  blood,  of  the  chlorotic  girl,  and,  on  the  other  hand,  their 
absence  during  the  slower  circulation,  and  thickened  condition  of  the 
tissues  in  adult  and  aged  persons.  At  the  same  time  there  can  be  little 
doubt  that  the  interrupted  blowing  at  the  base  of  the  heart,  over  the 
aorta  and  carotids,  which  .is  synchronous  with  the  impulse,  is  often 
arterial  and  not  venous.  Indeed,  the  sepai-ation  of  anamic  arterial  and 
venous  murnuirs  is  frequently  a  matter  of  excessive  difficulty.  Some- 
times also,  as  has  been  well  pointed  out  by  Stokes,  they  are  associated 
with  organic  disease,  which  adds  to  the  complexity,  and  occasions  still 
greater  difficulty  in  forming  a  correct  diagnosis. 

The  coloured  corpuscles  of  the  blood  may  be  increased" or  diminished 
in  quantity,  constituting  Polycijthiemia  and  Olifiocythcemia  (\^ogel). 
These  changes  may  be  absolute  or  relative.  In  the  former  case,  the 
corpuscles  are  uniformly  increased  or  diminished  throughout  the  body 
generally;  in  the  latter,  this  depends  upon  the  amount  of  water  which, 
by  being  less  or  more,  alters  the  proportion  of  the  corpuscles  to  the 
other  constituents  of  the  blood.  Becquerel  drew  a  distinction  between 
aniemia  and  chlorosis,  which,  on  the  whole,  is  well  founded.  Thus, 
anaemia  is  caused  by  a  variety  of  circumstances  which  impoverish  the 
blood,  such  as  long-continued  hemorrhage,  exhaustive  discharges,  starva- 
tion, chronic  diseases,  certain  poisons,  etc.;  chlorosis  is  induced  by 
obscui'e  causes  connected  with  the  nervous  system,  generally  originating 
in  disturbed  uterine  functions.  In  antemia,  the  alteration  of  the  blood 
is  constant  and  pathognomonic ;  in  chlorosis,  it  is  only  one  of  the  pheno- 
mena, and  not  always  present.  In  both  diseases  the  physical  signs 
may  be  alike,  but  in  auajmia  the  functional  sound  is  more  often  in  the 
arteries,  in  chlorosis  in  the  veins.  In  anaemia  there  is  constant  relation 
between  intensity  of  symptoms  and  poverty  of  the  blood.  This  is  not 
the  case  in  chlorosis.  The  duration  and  progress  of  ansemia  is  de- 
pendent on  the  causes  Avhich  produce  it,  but  chlorosis  is  very  variable, 
and  no  such  evident  connection  is  visible.  The  treatment  of  anajmia 
has  two  indications — 1st,  To  suppress  the  exhausting  causes  which 
occasion  it ;  and,  2dly,  By  means  of  wine,  proper  nutrients,  and  regu- 
lated exercise,  to  improve  the  quality  of  the  blood.  In  chlorosis,  iron 
is  the  chief  remedy,  which  should  be  conjoined  with  efforts  to  regulate 
the  menstrual  function. 


ICHOK^MIA  OR   PYEMIA.  8-17 


ICHOR^MIA  OR  (so-called)  PY.EMIA. 

Case  CLXXXVII.* — AcvAe  Articular  Rheumatism — Multiple  Abscesses  in  the  Joints^ 
in  the  JIurScles,  within  the  Cranium,  etc. 

History. — James  Lockie,  set.  17,  a  rope-spinner — admitted  December  1,  1854. 
Ten  days  ago,  when  spinning  ropes  iu  the  open  air,  he  was  exposed  to  more  than 
usual  cold  and  wet.  Next  day  rigors  and  other  febrile  symptoms  appeared,  followed 
by  pain,  redness  and  swelling  of  the  riglit  elbow  joints.  During  the  four  following 
days  the  right  wrist  and  ankle  joints  were  also  affected,  together  with  both  knee 
joints.  Four  days  before  admission  the  heart's  action  became  very  violent,  and 
leeches  were  applied  to  the  precordial  region.  The  pain  and  swelling  of  the  joints 
have  continued  since. 

Symptoms  ox  Admissiox. — On  admission  he  complained  of  great  pain  in  the  right 
wrist,  ankle,  and  left  shoulder  joints,  which  were  swollen,  immovable,  doughy  to 
the  feel,  tender  to  the  touch,  with  the  integuments  over  them  erythematous. 
From  the  left  shoulder  joint,  the  swelling  extended  into  the  axilla  and  down  the 
inside  of  the  arm.  Pulse  130,  full  and  strong;  heart's  impulse  violent,  but  no 
blowing  murmur.  The  tongue  coated  with  brown  in  the  centre  and  white  at  the 
edges ;  no  appetite ;  great  thirst ;  skin  hot  and  dry ;  urine  turbid  from  excess  of 
lithates ;  bowels  open ;  no  headache,  and  the  other  functions  normal.  Fiat  vene- 
seciio  ad  §  xiv.  IJ  Fotassce  Xitratis  1  ss.  Aqua  §  vj  solve.  §  ss  to  6e  taken  in 
half  a  tumblerful  of  water  every  four  hours — warm  saturnine  lotions  to  the  inflamed 
joints. 

Progress  of  the  Case  — December  2d. — Little  change,  pulse  120,  more  soft,  blood 
not  buffed,  but  it  was  drawn  from  a  small  orifice.  Dec.  4th. — Pain  in  all  the  joints 
greatly  diminished ;  the  swelling,  however,  continues.  A  blister  has  formed  over  the 
external  malleolus  of  right  ankle — complains  of  soreness  in  the  heels.  Pulse  100,  of 
good  strength.  Xo  blowing  murmur  with  the  heart's  sounds.  Took  3  j  of  castor 
oil  last  night  (the  bowels  having  been  constipated),  which  has  acted  copiously. 
Tongue  dry,  and  covered  with  a  brown  fur.  Febrile  symptoms  continue,  with  pro- 
fuse diaplioresis.  On  the  6th  December  the  blister  over  the  malleolus  of  right  ankle 
burst,  and  gave  issue  to  a  quantity  of  pus.  Distinct  fluctuation  existed  over  the  right 
wrist  and  dorsum  of  the  hand,  which  was  opened  by  an  incision,  and  also  gave  exit 
to  a  considerable  quantity  of  pus.  To  omit  the  nitrate  of  potash.  On  the  8?/i,  com- 
plained of  pain  in  the  back  of  the  neck,  and  a  bed  sore  was  seen  to  be  forming  over 
the  sacrum.  To  be  jAaced  on  the  water  bed.  From  this  time  the  pulse,  which  ranged 
from  110  to  140,  lost  its  fulness,  and  became  much  more  weak;  the  skin  assumed  a 
dirty  yellowish  or  tawny  hue,  the  typhoid  febrile  symptoms  continued,  with  dry 
tongue  and  sordes,  and  numerous  abscesses  formed  in  the  joints  and  various  parts  of 
the  body,  several  of  which,  as  soon  as  they  became  soft,  were  opened.  A  very  large 
abscess  formed  over  the  occiput,  which  was  opened  on  the  18ih,  and  another  over  the 
manubrium  of  the  sternum,  extending  up  the  left  side  of  the  neck,  which  was  opened 
on  the  24th.  The  skin  over  the  heels,  trochanter  of  the  right  hip,  and  the  sacrum, 
sloughed,  notwithstanding  every  care  taken  to  prevent  it.  On  the  26ih,  the  whole 
of  the  right  lower  extremity  was  swollen,  oedematous,  and  while,  resembhng  in 
aspect  phlegmasia  dolens ;  there  was  laborious  breathing,  and  great  prostration.  Low 
muttering  delirium,  and  involuntary  evacuations  supervened,  and  he  sank  on  the 
morning  of  the  21th.     The  treatment  had  latterly  been  directed  by  generous  diet  and 

*  Reported  by  Mr.  A.  "W.  Moore,  Clinical  Clerk. 


848  DISEASES   OF   THE    BLOOD. 

stimuli,  to  support  his  streugth,  relieve  pressure  on  depending  parts,  and  to  dressing 
his  sores. 

Sectio  Cadaveris. — Sevenfy-tioo  hours  after  death. 

Body  greatly  emaciated ;  a  fistulous  opening,  the  size  of  a  shilling,  existed  imme- 
diately in  front  of  the  left  sterno-clavicular  articulation.  Other  sores,  varying  in  size 
from  half  an  inch  to  three  inches  in  diameter,  and  laying  bare  the  bones,  existed  over 
the  right  elbow,  ankle,  both  hip  joints,  I'ight  knee,  and  sacrum. 

Head. — The  integument  covering  the  occiput  was  separated  from  the  skull, 
infiltrated  with  putrid  pus,  a  great  quantity  of  which  had  been  evacuated  by  openings 
previously  made.  On  removing  the  calvarium,  an  abscess,  containing  thick  j'ellow 
pus,  existed  between  the  bone  and  dura  mater,  about  the  centre  of  the  occipital  bone- 
The  bone  externally  was  somewhat  carious,  but  internally  it  was  healthy.  No 
communication  could  be  traced  between  the  external  and  internal  abscesses.  Brain 
healthy. 

Chest. — On  removing  the  heart  and  aorta,  a  fluctuating  oval  swelling,  about  f 
inch  in  its  long  diameter,  was  situated  outside  the  aorta,  about  an  inch  from  the 
aortic  valves,  which  was  distended  with  yellow  purulent  matter.  The  posterior  por- 
tions of  both  inferior  lobes  of  the  lungs  were  condensed.  On  section  they  {^resented 
a  reddish  purple  colour,  the  air  vesicles  filled  with  a  soft  sanguineous  exudation  and 
readih'  sinking  in  water.     Heaii  healthy. 

Abdomen. — Kidney's  slightly  enlarged — one  section  presenting  a  whitish  mottled 
appearance,  without  great  atrophy  of  the  secreting,  or  encroachment  on  the  tubular 
substance.     Other  abdominal  organs  healthy. 

Joints. — The  left  sterno-clavicular  articulation  was  carious  and  disarticulated, 
with  matter  burrowing  to  considerable  depths  in  the  surrounding  soft  textures.  The 
right  shoulder,  left  elbow,  right  wrist,  both  hip  joints,  both  knees,  and  both  ankle 
joints,  were  filled  with  dirty  purulent  looking  matter,  which,  in  several  instances, 
more  especially  in  the  left  elbow  and  hip  joints,  had  infiltrated  itself  more  than  half 
way  down  the  fore  arm  and  thigh.  The  various  articular  cartilages  presented  all 
stages  of  abrasion,  softening,  and  ulceration,  whilst  the  osseous  textures  below  exhi- 
bited a  carious  and  blackened  necrosed  condition.  The  base  of  the  ulcer  over  the 
sacrum  consisted  of  necrosed  bone,  and  over  the  right  elbow,  riglit  hip,  and  knee 
joints,  bone  was  exposed  and  necrosed. 

The  Veins  were  carefully  examined,  especially  in  the  right  inguinal  region,  and 
with  the  sinuses  at  the  base  of  the  brain,  were  everywhere  found  healthy,  and  free 
from  coagula ;  indeed,  the  blood  was  everywhere  unusually  fluid — even  in  the  heart 
presenting  small,  dark,  and  soft  coagula. 

Microscopic  Examination. — The  pus  consisted  of  molecular  and  granular  matter 
with  debris  of  disintegrated  jjus  cells,  with  the  exception  of  the  abscess  within  the 
cranium,  the  pus  of  which  was  normal.  The  cartilage  covering  the  joints  was  in 
some  places  healthy,  but  in  others  its  cells  were  enlarged,  filled  with  secondary  cells, 
and  not  unfrequently  with  fatty  granules.  Around  the  articulations  of  the  joints 
were  laminte  of  chronic  exudation,  consisting  of  dense  amorphous  matter,  principally 
composed  of  minute  molecules.  The  blood  was  carefully  examined,  and  everywhere 
found  normal. 

Commentary. — This  was  a  case  of  what  is  frequently  called  pj'jiemia, 
a  disease  wliicli  is  not  uncommon  as  the  result  of  mechanical  injuries,  or 
suppurative  diseases.  I  believe  it  to  be  very  rare,  however,  as  a  conse- 
quence of  attacks  of  acute  rheumatism,  such  as  the  symptoms  and  the 
history  of  this  case  prove  it  to  have  been.     The  lad  was  healthy  and  in 


ICHOR^MIA  OR   PYEMIA.  84:9 

pursuit  of  Ins  ordiuary  occupation  when,  after  exposure  to  cold  and  wet,  lie 
was  seized  with  the  usual  symptoms  of  rheumatic  fever,  including  violent 
action  of  the  heart,  and  on  this  supervened  suppuration  in  almost  all  the 
joints,  with  numerous  abscesses,  accompanied  by  a  low  typhoid  fever, 
under  the  effects  of  which  he  sank.  Dr.  Watson  has  recorded  two  cases 
singularly  like  it,  but  in  them  the  constitutional  disease  was  preceded  by 
oton-lufia  and  abscess  in  the  ear,*  to  which  he  theoretically  ascribes  the 
origin  of  the  disease.  In  the  present  case  there  was  no  primary  abscess, 
no  evidence  of  a  pre-existing  collection  of  pus  before  the  attack  of  rheu- 
matism, and  I  think  there  can  be  little  doubt  that  the  constitutional 
state  of  the  blood,  whatever  it  may  have  been,  was  dependent  on  the 
abscesses  which  residted  from  the  acute  inflammation  of  the  joints. 

This  morbid  condition,  so  much  dreaded  by  surgeons  and  obstetricians, 
in  which  typhoid  fever  comes  on  after  severe  accidents  or  parturition, 
accompanied  with  purulent  infiltration,  or  multiple  abscesses,  in  one  or 
more  organs,  has  received  different  explanations.  The  various  obser- 
vations and  experiments  performed  with  a  view  of  elucidating  this  sub- 
ject in  modern  times  have  led  to  the  four  following  theories: — 1.  That 
this  condition  is  owing  to  an  admixture  of  the  blood  with  pus  (pyohemia 
of  Piorry),  and  that  tlie  pus  corpuscles  being  larger  than  the  coloured 
ones  of  blood,  are  arrested  in  the  minute  capillaries,  and  give  rise  to 
secondary  abscesses.  2.  That  it  is  owing  to  the  presence  of  some  irri- 
tating body,  which  not  being  able  to  escape  from  the  economy,  produces 
capillary  phlebitis.  3.  That  it  is  dependent  on  a  property  possessed  by 
pus  of  coagulating  the  blood.  4.  That  it  is  caused  by  the  presence  of  a 
peculiar  poison  which  contaminates  the  system.  All  these  views  have 
been  maintained  with  much  ingenuity,  and  they  are  all  supported  by 
experimental  and  clinical  researches.  A  knowledge  of  the  circumstances 
previously  detailed  concerning  leucocythemia  will  enable  us  to  criticise 
these  doctrines  from  a  new  point  of  view. 

1.  With  regard  to  the  first  theory,  it  must,  I  think,  be  granted  by  all 
those  who  have  examined  the  blood  in  leucocythemia,  or  will  study  the 
fio-ures  I  have  given  illustrative  of  that  disease,  that  no  difference  what- 
ever can  be  detected  between  the  colourless  cells  of  the  blood  and  those 
of  pus.  Their  general  appearance,  size,  structure,  and  behaviour,  on  the 
addition  of  re-agents,  are  identical, — indeed  so  much  so,  that  in  the  first 
case  I  observed  in  1845,  I  could  not  resist  the  conclusion  that  the  blood 
was  crowded  with  pus  cells.  It  follows,  that  all  explanations  of  puru- 
lent infection  founded  upon  the  mechanical  impaction  of  these  bodies  in 
the  minute  capillaries  must  be  erroneous.  Some  of  these  colourless 
corpuscles  have  been  observed  much  larger  than  ordinary  pus  corpuscles. 
In  one  instance,  many  of  them  were  twice  as  large ;  and  although  this 
may  in  some  measure  be  owing  to  endosmosis  of  serum,  there  can  be  lit- 
tle doubt  that  they  must  have  exceeded  the  usual  size  of  pus  cells.  In 
Case  CLXXXIIL,  also,  it  was  observed  that  several  of  the  colourless 
cells  were  larger  than  the  average,  and  yet  the  circulation  went  on,  and 
every  drop  of  the  patient's  blood  contained  hundreds  of  these  bodies. 
The  first  theory,  then,  is  no  longer  tenable. 

*  Practice  of  Physic,  vol.  i.  p  381,  4th  edition. 
54 


850  DISEASES   OF   THE   BLOOD. 

Xeitlier  does  tliere  seem  to  be  anything  peculiar  in  the  nature  of  good 
and  laudable  pus,  which  necessarily  leads  it  to  poison  the  blood  ;  for  it 
is  a  matter  of  common  observation,  that  large  abscesses  are  absorbed  and 
eliminated  without  occasioning  so-called  purulent  infection.  In  all  such 
cases,  the  pus  corpuscles  must,  in  the  first  instance,  be  disintegrated  and 
reduced  to  a  fluid  condition  ;  still  the  matter  or  substance  of  which  they 
were  composed  passes  into  the  blood.  Hence,  while  leucocythemia 
proves  that  corpuscles,  identical  in  form,  size,  structure,  and  chemical 
composition  with  those  of  pus,  uiav  float  in  the  blood  and  circulate 
innocuously,  the  well-known  fact  of  the  absorption  of  abscesses  demon- 
strates, that  pus,  when  healthy,  does  not  possess  any  poisonous  proper- 
ties. If,  then,  the  fever  and  other  marked  symptoms  are  owing  to  the 
absorption  of  pus,  it  must  be  of  pus  possessing  properties  wholly  differ- 
ent from  those  of  what  is  called  good  or  laudable  pus. 

2.  The  second  explanation  was  advanced  bv  Cruveilhier,  who,  on 
injecting  mercury,  ink,  and  other  substances  into  the  blood  of  a  living  ani- 
mal, found  that  abscesses  were  formed  wherever  these  accumulated. 
From  hence  it  follows,  that  the  impaction  of  certain  substances  in  the 
tissues  may  induce  local  inflammations,  and  lead  to  abscesses;  but  that 
such  is  not  the  necessary  result  of  admixture  of  pus  with  the  blood,  is 
proved  not  only  by  the  previous  observations,  but  by  numerous  experi- 
ments of  Lebert*  and  Sedillot,t  in  which  the  animals  recovered. 

3.  The  third  doctrine  was  advanced  by  Mr.  Henry  Lee,J  and  resulted 
from  observing  that  when  pus  was  mingled  with  reccntlv-drawn  blood, 
it  coagulated  more  rapidly  and  more  firmly  than  under  ordinary  circum- 
stances. This  observation  he  connected  with  the  well-known  fact,  that 
phlebitis  was  often  associated  with  coagula  causing  obstruction  of  the 
veins.  Now  it  is  worthy  of  remark,  that  in  decided  cases  of  leuco- 
cythemia the  blood  is  more  highly  coagulable  than  when  drawn  from  the 
arm,  and  after  death  it  often  pi-esents  firm  coagula,  filling  the  vessels,  as 
in  Case  CLXXXIII.  Figs.  471  to  473  illustrate  these  colourless  coa- 
gula, as  observed  in  difi"erent  parts  of  the  body.  The  same  occurred  in 
Case  CLXXXIY. ;  and  yet,  during  the  life  of  the  patient,  the  blood, 
loaded  with  the  colourless  corpuscles,  rolled  through  the  vessels  without 
impediment  or  the  formation  of  coagula.  It  does  not  follow,  then,  that 
because  dead  pus  is  mingled  with  recently-drawn  blood  about  to  coagu- 
late, that  therefore  it  should  induce  coagulation  of  living  blood  in  the 
vessels  of  an  animal.  Indeed,  numerous  experiments  by  Lebert  and 
Sedillot  show  that  such  does  not  take  place;  for  although  in  some  cases 
death  followed,  in  others  the  animals  lived,  and  the  pus  corpuscles  were 
dissolved.§  Hence,  although  the  fact  to  a  certain  extent  must  be  admit- 
ted, that  when  pus  is  mingled  with  blood  the  coagulum  foi'med  is  more 
firm,  it  by  no  means  follows  that  it  produces  coagulation  of  living  blood, 
and  is  the  cause  of  phlebitis  or  purulent  infection. 

*  Physiologie  Path  ologi  que,  torn.  i.  p.  313. 
f  De  rinfection  Purulente.  p.  73,  et  seq. 

\  Ou  the  Origin  of  Inflammation  of  the  Veins.     London,  1850. 
§  In  1852,  to  determine  this  point  more  definitely.  I  performed,  -with  the  late  Professor  Barlow 
of  the  Veterinary  College,  the  followins  experiments: — 

Experiment  1. — The  saphena  vein  of  an  ass  was  exposed,  and  a  tnbe  introduced  confined  by  a 
ligature.  Fresh  and  healthy  pus  was  then  slowly  injected  upwards  towards  the  heart,  from  a 
syringe  holding  an  ounce.    A  slight  obstruction  was  now  perceived,  and  the  vein  above  the  liga- 


ICHOR^MIA   OR   PYJEMIA.  851 

4.  The  fourth  theory  seems  to  have  been  maintained  by  A.  Boycr* 
and  l>onnet,f  who  believed  good  pus  to  be  innocuous,  and  the  bad  effects 
occasionally  produced  to  depend -on  its  becoming  putrid,  or  being  other- 
wise altei'ed.  This  view  was  also  more  or  less  suppoi-ted  by  DarcettJ 
and  r3erard,§  who,  in  order  to  explain  the  undoubted  effects  of  putrid 
substances  when  injected  into  the  veins,  separated  pyohemia  from  puru- 
lent infection.  But  as  pus  corpuscles  do  not  alone  cause  the  symptoms, 
it  is  certainly  more  probable  that,  in  all  cases,  thei'c  must  be  a  toxic  prin- 
ciple associated  with  pus  when  it  proves  mortal.  Dr.  Millington||  has 
shown,  in  repeating  Mr.  Lee's  experiments,  that  putrid  fluids  prevent 
coagulation  of  the  blood,  and  that  the  coagulum  caused  by  the  addition 
of  pus  is  more  j^erfect  the  fresher  the  purulent  matter  is.  This  fact  is 
opposed  to  the  idea,  that  multiple  abscesses  are  induced  by  the  coagula- 
tion, but  corresponds  with  what  is  observed  after  death  in  cases  of  puru- 
lent infection.  When,  therefore,  we  consider  the  typhoid  nature  of  the 
symptoms  so  similar  to  that  of  certain  animal  poisons ;  the  multiple 
abscesses  so  analogous  to  what  occurs  in  glanders,  plague,  sypliilis, 
variola,  etc. ;  and  the  undoubted  fact,  that  the  blood  may  be  loaded 
with  corpuscles  in  every  respect  identical  with  pus  cells,  without  causing 

tare  could  be  seen  to  be  somewhat  swollen.  This  swelling,  on  beintr  felt,  was  very  soft;  and  on 
pressing  the  vein  from  below  upwards,  the  mixed  blood  uud  pus  was  readily  pushed  before  the 
finger,  when  all  obstruction  to  the  passage  of  i>us  from  the  syringe  was  removed.  The  syringe 
was  ajain  filk-il.  and  another  ounce  of  pus  injected,  without  occasiuninir  any  further  local  etfects. 
The  aniuial  was  then  allowed  to  get  up,  and  exhiliited  no  change  in  its  iini-ni;il  condition  whatever. 
E.rpi>rhnent  2. — The  same  ass  was  the  subject  of  this  experiment  a  fortniglit  later,  bavins:  been 
perfectly  well  in  the  intervah  Six  inches  of  the  jugular  vein  in  the  neck  were  carefully  dissected 
and  exposed  ;  and  a  minute  aperture  was  then  made  in  the  npper  end  of  the  exposed  vein,  and  the 
bent  tube  of  the  syringe  introduced  without  a  ligature.  The  coats  of  the  vein  were  so  transparent 
that  the  tiowing  blood  couhl  be  seen  through  them.  An  ounce  of  fresh  and  perfectly  healthy  pus 
^vas  then  slowly  injected  doionicards  towards  the  heart,  and,  owing  to  the  transparency  of  the 
vein,  the  yellow  opaque  fluid  was  seen  to  join  the  blood,  to  continue  a  few  moments  running  side 
by  side  with  tlje  crimson  current,  until  at  length  the  vein  became  full  of  pus.  On  removing  the 
syringe  to  obtain  a  fresh  supply,  the  blood  from  above  could  be  seen  to  join  the  pus,  to  continue 
side  by  side  with  that  fluid,  presenting  a  streaked  red  and  white  appearance,  without  any  coagula- 
tion, until  all  the  pus  was  carried  forwards  and  downwards  towanls  the  heart,  and  the  vein  was 
again  full  of  blood.  Another  syringeful  of  pus  was  then  injected,  which  could  once  more  be  seen 
first  to  flow  with  the  blood,  then,  as  its  quantity  increased,  to  take  the  place  of  the  blood,  and  then, 
on  the  syringe  being  exhausted,  to  receive  blood  from  above;  the  two  mixini:  toiretber,  and  con- 
tinuing their  course  witlmut  coau'ulating,  until  once  more  the  vein  contained  ncjthintr  but  blood. 
The  wound  was  now  closed,  and  the  animal  allowed  to  rise,  which  he  did  without  apparent  sufter- 
ing.  He  presented  no  unusual  symptoms  whatever  during  the  next  four  days,  when  he  was  killed, 
and  the  parts  carefuUv  dissected.  The  vein  was  pervious,  presented  no  thickening,  nor  cording  or 
abscesses,  and  the  external  wound  was  nearly  healed. 

This  experiment  appeared  to  be  so  decisive,  and  so  clearly  opposed  to  the  idea  that  the  contact  or 
mixture  of  pus  and  blood  necessarily  induced  coagulation  in  a  livini:  animal,  that  it  was  thought 
unnecessary  to  repeat  it.  With  regard  to  the  slight  coagulability  ajipareiitly  occasioned  in  the  tirst 
experiment,  it  was  attributed  to  injecting  contrary  to  gravity,  whereby  the  mixed  pus  and  blood 
were  allowed  to  fall  backwards  and  remain  stationary,  while  the  liirature  prevented  any  flow  of 
blood  from  being  continued,  No  such  phenomenon  was  observed  in  the  second  experiment,  where 
no  ligature  was  employed,  and  where  the  etfect  of  gravity  was  avoided  by  injecting  downwards. 
In  a  communication,  however,  received  from  Dr.  Henry  Lee,  I  was  informed  that  no  ligature  was 
employed  by  him. 

The  second  experiment  was  in  its  nature  the  same  as  the  seventh  and  eishth  experiments  of  Dr. 
Henry  Lee,  and  yet  none  of  the  appearances  observed  by  that  gentleman  resulted.  There  was  no 
fulness  or  cording  of  the  vein,  no  acceleration  of  respiration  or  constitutional  symptoms;  and  after 
death  no  coagulation  of  the  blood,  no  obliteration  of  the  vein,  nor  local  inflammation.  What  are 
the  circumstances  which  occasioned  this  difference,  I  am  not  jirepared  to  say ;  but  the  positive 
fact  of  having  introduceil  the  pus  on  two  separate  occasions,  as  recorded  in  Experiment  2,  of  hav- 
ing seen  the  pus  mix  with  the  blood  and  the  blood  with  the  pus,  through  the  transparent  vein, 
withi>ut  producing  coagulation,  is  sufficient  to  negative  the  general  pi-iipo>iti(]n.  tliat  whenever  pus 
is  mingled  with  blood  in  a  living  animal,  co.agulatiou  of  the  latter  fluid  is  the  invariable  result. 

*  Gazette  Med  de  Paris,  p,  19:5.     1834. 

f  Ibid.  p.  593.     1837.     Both  cited  by  Sedillot,  Op.  cit.  p.  5.5. 

X  These  Inaao;urale.     Paris,  18-12. 

t?  Dictiorniaire  de  Med,,  torn.  26.     1842. 

I  Monthly  Journal.     November  1851.     P.  486. 


852  DISEASES  OF   THE   BLOOD. 

these  symptoms,  the  irresistible  conclusion  is,  that  these  effects  are  not 
owing  to  pus  in  the  blood,  but  to  an  animal  poison. 

This  view  has  been  opposed  on  the  ground  that  fresh  pus,  to  all 
appearance  healthy  and  without  odour,  has  yet  caused  the  death  of  ani- 
mals. But  what  sensible  property  distinguishes  the  pus  of  the  vaccine 
from  the  small-pox  pustule,  and  either  of  these  from  healthy  pus?  And 
yet  how  different  their  effects  when  introduced  into  the  blood  !  The 
subject  of  animal  poisons  is  certainly  obscure ;  but  it  is  more  in  accord- 
ance with  our  actual  knowledge  to  attribute  purulent  infection  to  such 
a  cause,  than  to  consider  it  as  the  consequence  of  the  mere  mixture  of 
pus  with  the  blood,  or  a  so-called  pyohemia. 

This  doctrine,  which  was  first  clearly  put  forth  in  my  work  on  "  Leu- 
cocythemia"  in  1852,  seems  now  to  be  generally  adopted,  and  the  con- 
dition of  the  blood  has  been  called  septicaemia  (Vogel),  and  ichorhfemia 
(Virchow).  The  so-called  pus-corpuscles,  which  some  observers  have 
thought  they  saw  in  the  blood,  are  identical  with  the  colourless  cells  of 
that  fluid,  and  if  in  excess,  constitute  white  cell  blood.  Virchow  himself, 
who  has  claimed  so  much  for  simply  denying  that  leucocythemia  can  be 
pyaemia,  is  obliged  to  admit,  when  writing  on  the  latter  subject,*  that 
the  diagnosis  between  pus  and  the  colourless  cells  of  the  blood  is  very 
difficult,  and  frequently  impossible.  In  truth  these  bodies  are  the  same, 
and  in  the  majority  of  cases,  what  has  been  called  pyaemia  is  not  depend- 
ent on  pus  cells  mingling  with  the  blood,  bnt  on  a  matter  derived  from 
some  kinds  of  pus,  which  poisons  the  blood,  and  occasions  the  secondary 
phenomena. 


GLUCOH^MIA. 

Case  CLXXXVUI.^— Diabetes  MeUitus. 

History. — Allan  M'Clemont,  fet.  32,  labourer — admitted  Ttli  June,  1852.  About 
three  weeks  ago,  on  recovering  from  a  general  rheumatic  attack,  he  found  himself 
much  reduced  in  strength,  and  somewhat  emaciated.  He  experienced  great  thirst, 
and  passed  a  large  quantity  of  urine.     These  symptoms  have  rapidly  increased. 

Symptoms  on  Admission. — On  admission,  tongue  moist  and  clean,  appetite 
increased,  thhst  excessive,  bowels  rather  costive,  skin  dry,  urine  very  pale,  and 
shghtly  turbid.  On  heating  a  portion  of  the  urine  with  an  equal  portion  of  Aq. 
Potassse,  a  deep  brown  colour  is  produced.  He  has  passed  during  the  last  24  hours, 
380  oz.,  spec.  grav.  1030,  having  drunk  460  oz.  of  water  in  that  time.  Other  func- 
tions performed  normally.  His  weight  was  11  stone  8  lbs.  Ordered  pills  of  Aloes 
and  Ipecacuan,  and  a  mixture  of  Irf.  Quassice  and  Tr.  Aurantii. 

Progress  op  the  Case. — On  the  lOth  June,  he  was  ordered  the  following  diet: 
3  cakes  made  of  bran,  butter,  and  milk,  weighing  half  a  pound ;  3  eggs;  4  oz.  steak 
for  breakfast,  12  for  dinner,  4  for  supper;  1  cabbage;  3  bottles  of  soda  water;  8  oz. 
of  lime  water;  3  oz.  of  wine.  To  have  a  warm  bath  every  third  night.  On  15th 
June  the  amount  of  urine  passed  was  diminished  to  120  oz.  in  the  day,  of  density 
1036,  and  he  drank  during  that  time  150  oz.  His  weight  was  11  stone.  On  the 
22d,  he  was  ordered  4  oz.  of  steak  additional,  and  another  bran  cake.     From  this 

*  Gesammelte  Abhandlungen.     P.  653. 

f  Keported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


GLUCOHJEMIA.  853 

time  the  amount  of  urine  fluctuated  from  IGO  to  190  oz.  daily;  but  on  the  bth  July, 
it  was  reduced  to  150  oz.,  spec.  grav.  1034,  and  his  drink  was  167  oz.  He  tlien 
weio-hed  11  stone  2  lbs. ;  but  being  wearied  of  the  treatment,  he  insisted  on  going- 
out  on  the  6th. 

Case   CLXXXIK..*— Diabetes    Melliius — PJdhisis    Pulmonalis— Vomica    on    Right 

Side — Death. 

History. — Robert  Fallow,  a  tailor,  xt.  24 — admitted  into  the  clinical  ward,  July 
8th,  1851.  Last  December,  while  in  America,  was  attacked  with  bilious  fever, 
which  continued  ten  weeks.  Shortly  afterwards,  he  observed  that  the  quantity  of 
urine  he  passed  was  greatly  increased,  and  that  his  thirst  was  excessive.  Cough 
appeared  sis  weeks  ago,  followed  by  purulent  expectoration ;  and  the  skin,  which 
had  previously  been  remarkably  dry,  was  now  covered  with  copious  sweat  during 
the  night. 

Symptoms  on  AD^[ISSIOX. — Percussion  elicits  no  decided  difference  of  sound  on 
either  side  of  the  chest,  but  there  is  a  much  greater  degree  of  resistance  under  the 
right  clavicle  than  under  the  left.  On  auscultation,  cavernous  respiration  is  very 
distinct  under  the  right  clavicle,  but  the  sounds  are  dry.  The  vocal  resonance,  also, 
is  greatly  Increased  in  the  same  situation,  and  has  somewhat  of  a  metallic  character. 
Under  the  left  clavicle,  inspiration  is  harsh,  and  expiration  prolonged.  On  the  left 
side,  posteriorly  and  inferiorly,  the  inspiration  is  everywhere  harsh,  -nath  occasional 
cooing  rales  and  prolongation  of  the  expiration.  The  expectoration  is  copious, 
muco-purulent,  and  of  brownish  tint,  without  distinct  traces  of  blood.  Cough  severe. 
Tongue  furred  and  dry,  coated  near  the  base.  Appetite  good.  Thirst  insatiable. 
Sour-sweet  taste  in  the  mouth.  Pulse  108.  small  and  weak.  Has  voided  70  oz.  of 
urine  during  the  last  twelve  hours.  The  addition  of  liq.  potassse,  followed  by  heat, 
throws  down  a  reddish  brown  sediment.     Skin  soft  and  moist. 

Progress  of  the  Case.— On  the  11  ^7i  of  July,  gurgling  was  heard  under  the 
right  clavicle.  On  the  20^^,  there  was  complete  loss  of  appetite,  and  repugnance  to 
food.  The  urine  varied  since  last  report,  from  170  to  230  oz.  voided  in  the  24 
hours.  Profuse  sweating  at  night.  Mucous  rales  heard  over  the  whole  anterior 
surface  of  chest  on  the  right  side.  Vocal  resonance  still  metallic  under  right 
clavicle,  with  cracked-pot  sound  on  percussion.  August  A.th. — The  amount  of  urine 
passed  now  varies  from  100  to  150  oz.  during  the  24  hours.  'S\'eakness  and 
emaciation  have  greatly  increased ;  sweating  and  loss  of  appetite  continue.  Died 
at  7  p.iM. 

As  to  treatment,  he  was  ordered  a- diet,  consisting  at  first  of  eggs,  boiled  meat,  and 
stale  bread  and  milk;  pills  of  opium  and  hyoscyamus  at  night,  and  cod-liver  oil 
internall^v.  An  expectorant  mixture,  afterwards  combined  with  antispasmodics,  was 
ordered  to  relieve  the  cough. 

Permission  to  examine  the  body  could  not  be  obtained. 

Commentary. — riitliisis  pulmonalis  is  a  very  common  complication 
of  diabetes  in  persons  under  30 — a  circumstance  which  appears  to  nie 
to  support  the  pathological  views  formerly  given,  as  to  the  great  import- 
ance which  should  be  attached  to  derangement  of  the  nutritive  func- 
tions, as  a  cause  of  the  tubercular  disease.  An  animal  and  oleaginous 
diet  is  indicated  in  both  disorders;  which,  however,  when  present  in 
the  same  individual,  may  easily  be  supposed  to  constitute  a  hopeless 
form  of  malady. 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


854  DISEASES   OF  THE   BLOOD. 

The  excretion  of  sugar  in  large  quantities  by  the  kidnej^  has  for  a 
lengthened  period  excited  the  attention  of  pathologists,  and  given  rise 
to  abundant  speculation.  It  hfiving  been  shown  bv  Mr.  Macgregor  of 
Glasgow,  that  sugar  was  foi'med  in  the  stomach  from  the  digestion  of 
food,  while  that  principle  was  subsequently  detfcted  in  the  blood  by  the 
same  observer,  as  -svell  as  by  Ambrosiani,  Maitland,  and  Percy — the  vicAv 
of  RoUo  was,  on  the  whole,  considered  the  coiTect  one,  and  the  treat- 
ment he  proposed  has  been,  in  its  main  features,  followed  by  subsequent 
})ractitioners.  This  theory  supposed  that  the  sugar  formed  in  the 
stomach  and  alimentary  canal,  from  the  starchy  and  saccharine  principles 
of  the  food,  instead  of  being  rapidly  conveited  into  other  compounds,  as 
Prout  supposeil,  was  absorbed  into  the  blood,  and  excreted  bv  the  kid- 
neys. The  treatment  based  upon  this  theory  was,  therefore,  directed  to 
keeping  up  nutrition  from  substances  which  were  thought  incapable  of 
being  converted  into  sugar;  and  it  is  worthy  of  remark,  that  such  treat- 
ment does  often  greatly  diminish  the  excretion  of  sugar,  without,  how- 
ever, suppressing  it,  and  also  ameliorates  the  other  symptoms.  Dr.  Gray 
of  Glasgow  was  induced  to  give  rennet  in  teaspoonfnl  doses  after  each 
meal,  and  published  three  cases,  in  two  of  which  it  occasioned  an  appa- 
rent cure.  (Monthly  Journal,  January,  1853.)  He  argued,  that  if  out 
of  the  body  rennet  converts  a  solution  of  sugar  into  lactic  acid,  it  may 
have  a  similar  etfect  upon  a  solution  of  sugar  within  the  body  ;  and 
bearing  in  mind  that  lactic  acid  is  found  in  the  juice  of  tlesh,  and,  accord- 
ing to  Liebig,  is  a  supporter  of  the  respiratory  process,  he  considered 
that  if  sugar,  formed  in  the  body  of  a  diabetic  patient,  could  be  con- 
verted by  the  rennet  into  lactic  acid,  it  would  be  burned  in  the  lungs; 
and  that  if  a  larger  quantity  was  formed  than  could  be  consumed  in  this 
wav,  that  portion  would  be  excreted  by  the  kidneys.  In  consequence  of 
this  ingenious  theory,  and  the  facts  in  its  support  adduced  bv  Dr.  Gray, 
rennet  was  tried  in  several  cases  admitted  into  the  Eoyal  Infirmary  of 
Edinburgh,  but  without  success. 

The  researches  of  M.  Bernard  have  given  rise  to  other  views  as  to  the 
origin  of  diabetes.  He  admits  that  sugar  may  be  formed  in  the  process 
of  digestion,  and  that  a  certain  amount  of  it  may,  as  a  result  of  absorp- 
tion from  the  alimentary  canal,  find  its  way  into  the  blood.  But  he  has 
demonstrated  that,  in  dogs  fed  entii-ely  on  animal  food,  sugar  may  exist 
in  the  liver  and  in  the  blood  of  the  hepatic  vein,  while  it  is  absent  in  the 
portal  vein.  Moreover,  he  has  shown  that  sugar  is  a  normal  secretion 
of  the  liver  of  all  animals,  from  man  down  so  low  in  the  scale  of  beings 
as  the  mollusca ;  and  that,  moreover,  it  is  secreted  by  the  liver  of  the 
foetus.  He  has  proved,  experimentally,  that  this  secreting  function  is 
increased,  and  diabetes  produced,  by  irritating  the  eighth  pair  of  nerves 
at  their  origin  in  the  fourth  ventricle ;  while,  on  the  other  hand,  section 
of  these  nerves  destroys  its  formation.  I  have  seen  M.  Bernard  perform 
these  experiments,  and  have  repeated  them  myself  in  this  city,  and  have 
no  doubt  as  to  the  accuracy  of  these  results.  That  sugar  does  not  exist 
normally  in  urine  and  in  blood  drawn  from  the  arm,  is  explained  by  its 
rapid  decomposition  in  a  state  of  health,  and  its  excretion  by  the  lungs. 
But  when  it  is  so  increased  in  quantity  that  the  lungs  cannot  excrete  the 
whole  of  it,  the  remainder  passes  off  by  the  kidneys,  and  hence  diabetes. 
M.  Bernard  has  also  ascertained,  that  although  section  of  the  pneumo- 


GLUCOH^MIA.  855 

gastric  nerves  destroys  the  formation  of  sugar  in  the  liver,  it  is  restored 
by  artificially  irritating  their  central  cut  extremities ;  and  that  diabetes 
is  produced  exactly  in  the  same  manner  as  by  irritating  their  origins  in 
the  brain.  He  was  therefore  led  to  conclude,  that  the  nervous  action 
necessary  for  the  secretion  of  sugar  does  not  originate  in  the  brain,  to  be 
transmitted  directly  along  the  pneumogastrics,  but  indirectlv  and  bv 
reflex  action  ;  the  vagi  being  incident  nerves,  the  medulla  oblongata  the 
centre,  and  the  spinal  cor  I,  communicating  with  the  solar  ganglion,  the 
excident  channel.  Following  oat  this  theory,  he  found  that  whenever 
the  respiratory  function  is  violently  stimulated,  sugar  appears  in  the 
urine;  and  that,  whenever  aetlier  or  chloroform  is  given,  a  temporarv 
diabetes  is  occasioned.  He  further  supposes,  that  in  the  same  way  that 
the  lungs  thus  act  by  reflex  nervous  influence  on  the  liver,  so  increased 
action  of  the  liver  acts  upon  the  kidney ;  consequentlv,  that  the  sugar 
produced  in  excess  by  one  organ  is  excreted  by  the  other.  Hence  mav 
probably  be  explained  the  occasional  temporary  presence  of  suorar  in  the 
urine,  independent  of  the  disease  known  as  diabetes. 

Continuing  his  researches,  M.  Bernard  has  arrived  at  the  conclusion, 
that  the  liver  does  not  secrete  sugar  directlv,  but  rather  a  substance 
which  presents  all  the  physical  and  chemical  properties  of  hydrated 
starch,  and  which  is  transformed  into  sugar  by  the  aid  of  a  ferment. 
This  substance  he  has  at  length  succeeded  in  separating  from  the  liver. 
The  ferment  he  presumes  to  exist  in  the  blood,  so  that  the  starchv 
substance  formed  by  the  vital  action  of  the  liver  undergoes  a  chemical 
transformation  into  sugar  when  it  comes  into  contact  with  the  blood. 
The  sugar,  thus  formed  in  the  blood,  on  arriving  at  the  lungs,  is  in  its 
turn  decomposed  by  the  oxygen  of  the  air,  and  disappeais.  Hence 
the  liver  and  the  lungs  are  so  far  opposed  to  one  another  in  function, 
that  the  one  produces  the  substance  out  of  which  sugar  is  formed,  whilst 
the  other  decomposes  the  sugar  which  in  health  exists  in  that  part  of 
the  circulation  only  that  lies  between  the  liver  and  lungs.  It  follows 
that  the  occurrence  of  sugar  in  the  circulation  generally,  and  its  pre- 
sence in  the  urine,  is  probably  dependent  not  so  much  upon  excess  of 
hepatic,  as  upon  diminution  of  pulmonary  action.  It  is  certain  that  the 
great  majority  of  diabetic  patients  die  phtiiisical. 

These  more  recent  views  of  Bernard  point  to  the  importance  ot  the 
observations  made  by  Yirchow,  Busk,  Carter,  and  others,  as  to  the 
existence  and  even  wide  diflusion  of  starch  corpuscles  throughout  the 
animal  economy  (Carter),  and  should  stimulate  organic  chemists  to 
ascertain  whether  some  chemical  change  in  the  lung  mav  not  be  the 
true  cause  of  diabetes. 

In  the  meantime,  the  researches  of  M.  Bernard  explain  whv  Rollo's 
treatment  diminishes  the  excretion  of  sugar,  by  cutting  off  all  that 
enters  the  blood  through  the  alimentary  canal.  According  to  Trauhe, 
the  intensity  of  the  secretion  of  sugar  varies  at  different  times  of  the 
day,  and  under  different  circumstarices.  Thus  it  is  greatlv  increased 
after  meals,  and  is  least  during  the  night.  At  the  commencement  of 
the  disease,  it  is  principally  derived  from  the  food;  in  the  latter  stage, 
it  is  largely  formed  by  the  organism.  Hence  why  treatment  directed 
to  the  stomach  does  not  cure,  because  it  fails  to  affect  the  hepatic 
organ.     Bernard's  observations  appear  to  me  also  capable  of  throwing 


856  DISEASES   OF  THE   BLOOD. 

light  on  the  o-ood  effects  of  opium — effects  -which  are  universally  recog- 
nised— from  its  power  of  diminishing  nervous  irritability.  No  other 
practical  results,  however,  are  as  yet  derivable  from  them,  nnless  the 
well-known  symptom  of  dryness  of  the  skin  be  connected  with  the 
cause  of  the  disorder,  in  which  case  diaphoretics,  though  they  have 
often  been  used  with  great  benefit,  would  be  more  strongly  indicated. 
Perhaps,  also,  exercise  and  a  cold  atmosphere,  which  increase  the 
oxygenating  power  of  the  lungs,  might  be  of  some  avail.  Further 
researches  are  required  on  these  points,  and  it  is  to  be  hoped  that 
practitioners,  no  longer  exclusively  directing  their  attention  to  the 
digestive  organs,  may,  by  new  efforts,  ultimately  be  enabled  to  control 
this  singular  disorder. 

The  diet  ordered  in  Case  CCVII.  is  one  which  admits  of  very  slight 
formation  of  sugar  in  the  alimentary  canal,  and,  together  w'ith  opiates 
and  the  occasional  use  of  the  warm  bath,  constitutes  the  best  treatment 
which  has  hitherto  been  adopted.  Its  good  effects  were  well  mani- 
fested, although  it  proves,  in  conjunction  with  the  confinement  of  an 
hospital,  ver}'  irksome  to  the  patient. 


CONTINUED  FEVER. 

A  state  of  fever  may  be  said  to  exist  when  we  find  the  pulse  accele- 
rated, the  skin  hot,  the  tongue  furred,  unusual  thirst,  and  headache. 
These  symptoms  are  commonly  preceded  by  a  period  of  indisposition 
varying  in  extent  and  severity,  the  febrile  attack  being  marked  by  a 
rigor  or  sensation  of  cold.  This  rigor,  though  not  invariably  well 
characterised,  is  the  symptom  from  which,  when  present,  we  date  the 
commencement  of  the  fever. 

Although  fever  may  in  one  sense  always  be  said  to  exist  when  the 
above  group  of  symptoms  is  present,  such  fever  may  be  idiopathic  and 
essential,  or  symptomatic  of  some  local  lesion.  It  is  to  the  former 
condition  that  the  term  fever  is  universally  applied.  Some  pathologists, 
indeed,  have  endeavoured  to  show  that  there  is  no  such  thing  as  idio- 
pathic or  essential  fever,  although  they  have  differed  among  themselves 
as  to  the  lesion  of  which  it  is  symptomatic.  Intermittent  fever  has 
been  supposed  to  be  symptomatic  of  diseased  spleen,  and  remittent  fever 
of  intestinal  derangement.  With  regard  to  continued  fever,  some  have 
spoken  of  cerebral,  others  of  intestinal  or  abdominal  typhus.  Another 
class  have  supposed,  from  the  occasional  appearance  of  an  eruption 
on  the  skin,  that  it  is  allied  to  the  exanthemata.  If,  however,  you 
carefully  watch  the  Ediubui'gh  continued  fever,  you  will  easily  satisfy 
yourselves  that  it  frequently  occurs  independent  of  any  of  these  lesions. 
Did  we  indeed  adopt  these  views,  we  might,  as  Dr.  Christison  has 
pointed  out,  with  more  plausibility,  maintain  the  existence  of  a  pulmo- 
nary typhus,  as  we  observe  the  lungs  to  be  much  more  commonly 
affected  in  this  city  than  any  other  organ  in  the  body  during  fever. 
I  agree,  therefore,  with  those  who  consider  continued  fever  as  an 
essential  disease,  dependent  on  some  unknown  constitution  of  the  blood, 
and  occasionally  accompanied  or  followed  by  various  local  lesions  of  the 


CONTINUED   FEVER. 


857 


cranial,  thoracic,  or  abdominal  viscera,  and  with  various  eruptions  on 
the  skin. 

Although  this  may  be  considered  as  the  correct  general  view  of  con- 
tinued fever,  it  cannot  be  denied  that  it  assumes  various  forms,  which 
have  been  described  in  different  ways  by  authors  in  this  and  foreign 
countries.  Considerable  confusion  has  consequently  arisen,  as  to 
whether  fevers  observed  in  different  places,  and  at  various  times,  were 
identical  or  dissimilar  in  their  nature ;  and  whether  the  varieties  they 
presented  were  only  attributable  to  the  concomitant  lesions  which 
might  be  present.  Any  one  who  studies  fever  first  in  this  citv,  and 
afterwards  in  Paris,  will  soon  convince  himself  that  there  are  at  least 
two  predominant  kinds  of  fever ; — the  one  called  by  us  typhus,  the  other 
called  by  the  French  typhoid, — that  is,  resembling  typhus.  Ao'ain, 
those  who  have  studied  fever  in  Edinburgh  tor  the  last  fourteen  vears 
consecutively,  are  aware  that  every  now  and  then  a  form  of  the  disease 
is  prevalent,  which  runs  a  short  course,  but  has  a  tendency  to  relapse 
at  pretty  regular  periods.  Lastly,  there  is  in  fever,  as  in  most  other 
diseases,  a  kind  which  is  very  slight,  and  soon  ceases — a  so-called 
febricula.* 

Every  practical  physician  is  acquainted  with  these  forms  of  fever ; 
but  whether  they  constitute  varieties  of  the  disease,  which  can  be  at 
all  times  separated,  which  have  a  distinct  and  invariable  course,  the  one 
not  being  protective  of  the  other,  and  so  on,  are  points  that  are  by  no 
means  determined. 

Dr.  Jenner,  in  a  very  elaborate  series  of  papers  inserted  in  the 
"Monthly  Journal"  during  1849-50,  has  endeavoured  to  show  that 
febricula,  relapsing  fever,  typhoid  and  typhus  fevers,  are  four  distinct 
diseases.  He  considers  them,  to  use  his  own  language,  "as  distinct 
from  each  other  as  are  measles,  scarlet  fever,  and  sinall-pox,  the  poison 
of  the  one  being,  by  no  combination  of  circumstances,  capable  of  pro- 

*  The  variable  amount  and  extension  of  fever  at  different  times  may  be  gathered 
from  the  following  table,  showing  the  number  of  cases  which  have  entered  the  Royal 
Infirmary  of  this  city  during  the  present  century,  which  I  extract  from  a  paper  lately 
published  by  Dr.  Cliristison. — (Edinburgh  Med.  Journal,  Jan.  1858.) 

Table  showing  the  Annual  Number  of  Fever  Cases  in  the  Royal  Infirmary  since  the  beginning 

of  the  century. 


12 

Months  to  Dec.  1800, 

329 

12  Months  to  Dec.  1820,  63S 

12  Months  to  Oct.  1889,  1235 

"   ISOl, 

161 

"   ly21,  327 

"   1840,  782 

"   l^(^2, 

156 

"   1S22,  355 

"   1S41,  1372 

"   ls03, 

282 

"   1823,  102 

"   1842,  842 

"   181)4, 

328 

"   1824,  177 

"   1^4:3,  20S0 

"  isn5. 

1T5 

"   1825,  341 

"   1844,  3339 

"   1806, 

95 

9  Months  to  Oct.  1826,  450 

"       "   184J.  088 

"   1S07, 

110 

12  Months  to  Oct.  1S27,  1875 

"      "   1*^6,  693 

"   1808, 

111 

"   1828,  2018 

"   1847,  36^8 

"   1809, 

1S6 

"       "   1829,  771 

"   ls4s,  4693 

"      "   isio. 

143 

"   1880,  .346 

"   1849.  726 

"   1811, 

96 

"       "   1S;31,  758 

"   1>50,  520 

•'   1812, 

103 

"   1S82,  1394 

"      "   ls.'il,  959 

"   1813, 

75 

"      ■'   1833,  .s78 

"   18.i2,  691 

"   1M4, 

87 

"   1884,  C90 

"       "   1853,  574 

"   ISI.% 

96 

"       "   1885,  S26 

"   18.H,  168 

"   1S16, 

105 

"   1-86.  652 

"   1S5.5,  201 

•'     l'^17, 

4>5 

"   3>37,  1224 

'•   ls56,  180 

"   1818, 

1.546 

"   1888,  2244 

"      "   1857,  126 

"   1819, 

108S 

858  DISEASES   OF  THE   BLOOD. 

ducing,  inducing,  or  exciting  the  others."  He  gives  the  following 
characters  which,  according  to  hiin,  serve  to  distinguish  these  four  kinds 
of  fever. 

"  Fehrkula, — A  disease  attended  by  chilliness,  alternating  with  sense 
of  heat,  headache,  white  tongue,  confined  bowels,  high-coloured  scanty 
urine,  hot  and  dry  skin,  and  frequent  pulse,  terminating  in  from  two  to 
seven  days,  and  having  for  its  cause  excess,  exposure,  over-fatigue,  etc. — 
i.  e.,  the  cause  of  febricula  is  not  specific. 

"  Relapsing  Femr. — A  disease  arising  from  a  specific  cause,  attended 
by  rigors  and  chilliness,  heatiache,  vomiting,  white  tongue,  epigastric 
tendei'ness,  confined  bowels,  enlarged  liver  and  spleen,  higli  coloured 
urine,  frequent  p'ulse,  hot  skin,  and  occasionally  by  jaundice,  and  termi- 
nating in  apparent  convalescence  in  from  five  to  eight  days;  in  a  week 
a  relapse — i.  e.,  a  repetition  of  the  symptom  present  dui'ing  the  primai'v 
attack.  '  After  death,  spleen  and  liver  are  found  considerably  enlarged  ; 
absence  of  marked  congestion  of  internal  organs.' 

"  T//phoid  Fever. — A  disease  arising  from  a  specific  cause,  attended 
by  rigors,  chilliness,  headache,  successive  crops  of  rose  spots,  frequent 
pulse,  sonorous  rale,  diarrhoea,  fulness,  resonance  and  tenderness  of  the 
abdomen,  gurgling  in  the  right  iliac  fossa,  increased  splenic  dnlness, 
delirium,  dry  and  brown  tongue,  and  prostration,  and  terminating  by 
the  thirtieth  day.  After  death,  enlargement  of  the  mesenteric  glands, 
disease  of  Peyer's  patches,  enlargement  of  the  sjjleen,  disseminated 
ulceiations,  disseminated  inflammations. 

"  T[iphus  Ferer. — A  disease  arising  from  a  specific  cause,  attended 
by  rigors,  chilliness,  headache,  mulberry  rash,  frequent  pulse,  delirium, 
dry  brown  tongue,  and  prostration,  and  terminating  by  the  twenty-first 
day.  x\fter  death,  disseminated  and  extreme  congestions  ;  in  young  ])er- 
sons,  enlargement  of  tlie  spleen." — [Medical  Times — Twentieth  Paper.) 

Dr.  Dundas  of  Livei-pool  has  advanced  another  doctrine,  entirely 
opposed  to  that  of  Dr.  Jenner.  llis  views  on  the  subject  of  fever  are 
essentially  these  :— Not  only  are  there  no  specific  ditferences  between 
the  various  kinds  of  continued  fever,  but  there  are  none  between  con- 
tinned,  intermittent,  and  remittent  fevers.  All  these  disorders,  according 
to  Dr.  Dundas,  are  essentially  one  disease,  and  may  all  be  cured  by  one 
remedy,  viz.,  quinine.  Given  in  doses  of  ten  grains,  repeated  at  intervals 
of  two  hours,  until  five  or  six  doses  had  been  taken,  he  says  that  it 
arrested  or  cut  short  a  continued,  as  it  did  an  intermittent  fever.  These 
statements,  deliberately  brought  forward,  and  still  maintained,  by  Dr. 
Dundas,  who,  in  Brazil  and  in  this  country,  has  had  abundant  oppor- 
tunities of  carrying  out  the  practice,  supported,  moreover,  by  confii-ma- 
tory  cases,  published  by  difterent  medical  men  in  Liverpool,  determined 
me  to  give  this  practice  a  fair  trial. 

During  the  months  of  November,  December,  and  January  1851-2,  I 
treated  nineteen  cases  of  continued  fever  in  the  clinical  wai'ds,  of  which 
four  were  febricula,  one  relapsing,  three  typhoid,  and  eleven  typhus 
fever.  In  a  disease  so  common  as  fever,  I  have  thought  it  necessary  to 
condense  the  facts  as  much  as  possible,  from  the  lengthy  and  accurate 
reports  taken  in  the  hospital  books.  All  these  cases,  however,  were 
examined  with  the  utmost  care,  and  all  the  phenomena  noted,  especially 
in  reference  to  the  two  doctrines  I  have  placed  before  you, — viz.,  those 


CONTINUED   FEVER.  859 

of  Dr.  Jenncr  and  of  Dr.  Dundas.  P^irther,  to  avoid  repetition,  I  have 
simply  stated  that  the  quinine  treatment  was  employed  ;  but  in  every 
case  this  treatment  was  practised  exactly  in  the  manner  recommended 
by  the  last-named  physician.  The  effects  we  observed  to  be  produced 
by  the  quinine  I  shall  notice  afterwards. 


FEBRICULA. 

Case  CXC.*— Margaret  Divine,  £et.  42— admitted  26tii  Nov.  1851.  "Was  attacked 
with  rigors  on  tlie  23d,  after  complaining  for  two  days  before  of  headache  and 
general  debility.  On  admission  complained  of  pain  in  the  limbs,  and  general  dull 
pains  over  the  bod}'.  Had  no  appetite,  but  great  thirst,  with  a  dry  furred  tongue; 
she  is  very  subject  to  pyrosis ;  skin  was  hot  and  dry,  pulse  80,  strong ;  a  slight 
murmur  accompanied  the  firet  sound  of  the  heart.  5  Sul.  Acetat.  Ainmon.  §i; 
Villi  Aniimoa.  ^ij;  Aqua,  2iij.     M.     To  take  one  table-spoonful  every  four  hours. 

Novembe)-  28Wi.— Better  to-day ;  pulse  72 ;  a  sediment  filling  one-fourth  of  the  glass 
is  deposited  in  the  urine ;  still  general  dull  pain  of  surfece.  29</(.— The  general 
pains  are  gone.  She  feels  quite  well,  and  wishes  to  rise ;  she  was  now  convalescent, 
but  owing  to  weakness,  was  not  dismissed  until  the  \oth  of  Decemler. 

Case  CXCI  *— Susan  Rennie,  wife  of  labourer,  a?t.  49— admitted  1 5th  December 
1851.  On  the  11th.  was  seized  with  severe  rigors,  followed  by  pain  in  the  lower 
part  of  the  back  and  the  limbs;  with  frequent  alternations  of  shivering  and  perspira- 
tion duiing  the  day ;  there  was  severe  headache,  with  loss  of  appetite,  and  oppres- 
sive thirst!  On  admission,  the  tongue  was  slightly  furred ;  she  had  constant  nausea, 
and  vomited  nearly  everything  she  took ;  the  skin  w^as  hot,  but  moist ;  there  was 
no  eruption  on  her  person  ;  she  had  a  short  cough,  with  trifling  expectoration.  Pulse 
76,  small.  She  continued  m  this  state  till  December  19th,  when,  after  sweating 
and  a  lengthened  sleep,  the  fever  left  her,  and  she  became  convalescent,  and 
was  dismissed  January  1.  The  treatment  consisted  of  salines,  anodynes,  and  stimu- 
lants. 

Case  CXCII.f— Thomas  Stevens,  set.  21,  servant  of  a  cowfeeder- admitted 
November  24.  1851.  On  the  afternoon  of  the  23d,  while  engaged  in  his  usual  work, 
he  was  seized  with  severe  rigors,  headache,  and  pain  in  the  back:  he  passed  a 
sleepless  and  uneasy  night,  and  on  attempting  to  resume  work  next  day,  found  him- 
self quite  unable  to  do  so,  from  return  of  the  rigors,  and  aggravation  of  the  head- 
ache. Had  not  been  exposed,  so  far  as  he  knew,  to  contagion.  Had  been  already 
a  patient  in  the  house  several  times,  having  suffered  from  fever  on  three  different 
occasions.  On  admi.ssion,  the  tongue  was  moist  and  clean,  and  the  appetite  was 
not  much  impaired,  but  he  had  very  oppressive  thirst.  Bowels  had  been  irregular 
some  time  before  admission.  On  examination  of  the  chest,  slight  bronchitis  of  the 
left  side  was  found  to  be  present,  and  the  sputum  was  thick,  viscid,  and  muco- 
purulent. Skin  was  very  dry  and  hot,  he  complained  of  pain  in  the  head,  princi- 
pally in  the  frontal  region,  and  of  a  throbbing  character.  Pulse  72,  of  good  strength. 
He  was  ordered  a  full  dose  of  castor  oil,  which  produced  copious  evacuations  from 
the  bowels;  and  following  mixture:  — 5  Vini  Antimonii  §ss;  Sol.  Mur.  Morph. 
I'l-  Aqiue,  3VSS.  M.  Take  ^  ss  every  second  hour.  He  continued  to  complain 
of  headache  and  general  restlessness,  and  the  pulse  kept  about  80,  very  full  and 
strong,  till  the  evening  of  the  2.5th,  when  he  began  to  perspire  a  little ;  and  on  the 

*  Reported  by  ^fr.  J.  L.  Brown,  Clinical  Clerk. 
\  Reported  by  Mr.  "W.  il.  Calder,  Clinical  Clerk. 


860  DISEASES   OF   THE    BLOOD. 

forenoon  of  the  2Gth,  he  had  profuse  sweating.  On  the  30th,  the  antimonial  solu- 
tion was  stopped ;  he  improved  rapidly,  and  was  dismissed  quite  well,  on  the  8th  of 
December. 

Case  CXCIIL* — Andrew  Downan,  ret.  11,  tobacco-boy — admitted  January  14th, 
1852.  On  the  llth  was  attacked  by  violent  headache,  lost  all  appetite  for  food,  but 
felt  exceedingly  thirsty ;  his  skin  felt  very  hot,  and  he  complained  of  general  languor 
and  debility.  Had  no  distinct  rigors,  or  other  premonitory  symptoms.  Had 
suffered  from  typhus  fever  about  five  years  ago,  at  wliich  time  he  was  nine  weeks  in 
the  house.  On  admission,  tongue  was  dry,  of  florid  red  colour,  but  thinly  coated 
with  a  wliite  fur,  through  which  the  red  papillae  were  very  conspicuous.  No  appe- 
tite, but  considerable  thir.st ;  skin  hot  and  dry,  without  eruption ;  has  had  no  sweat- 
ing since  he  became  ill ;  but  had  profuse  diaphoresis  the  morning  after  admission, 
when  the  skin  became  cool  and  moist,  and  the  pulse  fell  to  the  natural  standard. 
He  continued  two  days  in  the  house,  at  the  end  of  whicli  time  he  felt  well  enough  to 
get  out  of  bed,  and  leave  the  ward.     He  did  not  return. 

Commenta)-i/.—Fuhv\c\\]sL  was  the  most  common  form  of  continued 
fever  during  the  early  part  of  tlie  winter  session  in  Ediiiburo-h,  185 1-2, 
and  the  four  cases  above  given,  constitute  good  examples  of  the  disorder 
as  it  existed  in  the  city  during  tliat  period.  It  will  be  observed  that 
the  fever  in  all  of  them  was  very  strong,  and  the  rigoi's  well  marked, 
although  the  pulse  was  not  greatly  accelerated.  It  is  impossible  to  dis- 
tinguish such  cases  at  the  commencement  from  typhus — a  circumstance, 
as  we  shall  see,  of  great  importance,  when  the  question  comes  to  be, 
whether  or  no  we  can  arrest  the  progress  of  a  continued  fever,  after  it 
nas  fairly  set  in.  It  ought  to  be  a  sine  qua  non  in  all  such  trials,  not  to 
commence  the  treatment  until  the  seventh  day.  If^  for  instance,  we  had 
commenced  Dr.  Dundas's  treatment  with  the  above  cases,  we  might 
have  been  led  to  believe  in  its  efficacy,  whereas  we  shall  see  that  the 
typhoid  and  typhus  cases  exhibited  a  very  different  result. 


RELAPSING    FEVER. 

Case  CXCIV.* — Edward  Anderson,  a  Swede,  set.  25,  hawker — admited  Dec. 
15th,  1851.  Seized  with  rigors  on  the  8th;  had  great  pain  in  the  head,  back,  and 
over  the  body  generally,  and  felt  languid  and  depressed,  though  he  was  not  com- 
pelled to  take  to  bed  till  the  14th.  On  admission,  tong-ue  thickly  coated ;  no  appetite ; 
much  thirst;  bowels  constipated;  slight  pain  of  head;  pulse  70,  of  natural  strength; 
skin  hot,  but  moist,  presenting  a  well-marked  eruption  of  small  roundish  and  oval 
spots  of  a  rose-red  tint,  slightly  raised  above  the  surfoce  of  the  skin,  entirelj'  dis- 
appearing under  pressure;  widely  scattered,  but  most  abundant  on  the  thorax. 
December  16th. — Slept  badly;  pulse  75,  natural  strength;  sweating  a  good  deal ; 
much  thirst,  but  total  disinclination  for  food ;  spots  more  numerous.  To  have  an 
effervescing  draught  and  six  ounces  of  wine ;  also  half  an  ounce  of  the  following 
mixture  at  bed-time: — Tind.  Hyoscyami,  3i;  Tlnct.  Kino,  3ij;  Aq.  3  ij.  Con- 
tinued to  improve  daily  after  this  date ;  and  had  no  feverish  accession  while  he 
remained  in  the  ward.  Was  dismissed  on  the  29th  at  his  own  desire,  as  he  was 
anxious  to  resume  his  occupation,  though  still  rather  weak.  The  several  systems 
were  carefully  examined  before  dismissal,  and  found  normal 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


CONTINUED   FEVER.  8G1 

He  was  re-admitted  on  the  5th  of  January,  1852.  Had  resumed  his  work,  but 
on  the  1st  inst,  24  days  after  the  first  rigor  in  the  former  attack,  was  again 
seized  witli  shivering,  and  felt  pain  all  over  the  body,  but  especially  complained  of 
pain  in  the  throat,  and  difficulty  of  swallowing.  There  was  also  considerable  dyspnoea. 
On  admission,  tongue  dry  and  coated ;  mucous  membrane  of  fauces  and  pharynx 
much  congested,  and  covered  with  a  thin  layer  of  pus;  bowels  constipated;  slight 
pain  over  abdomen  generally,  but  especially  in  the  right  iliac  region;  voice  husky 
and  indistinct;  much  cough  of  a  convulsive  character;  little  expectoration;  no  abnor- 
mal physical  signs  on  examining  the  chest;  pulse  110,  full  and  hard;  skin  hot  and 
flushed ;  and  over  the  abdomen  there  were  a  few  scattered  spots  of  the  same  shape, 
and  rose-red  tint  as  before.  Vini  Antimon.  §  i ;  Aq.  §  vj.  M.  §  i  to  be  taken 
every  second  hour.  January  Qth. — Pain  on  pressure  in  iliac  region  increased ;  had 
little  sleep;  pulse  90,  full,  but  softer.  Acetate  of  Ammonia,  with  Morphia — six 
leeches  to  right  iliac  region.  January  8tJi. — (8th  day,  or  32d  from  first  attack), 
sweating  a  little  last  night;  no  change  in  urine;  no  pain  on  pressure  over  the 
abdomen.  January  9ih. — Eruption  very  distinct,  and  continuing  well  marked  for 
24  hours,  after  which  it  gradually  faded.  January  12th. — (36th  day)  more  feverish 
to-day,  and  complains  of  more  pain  in  the  throat;  pulse  120,  sharp  and  vibratory; 
urine  natural.  After  this  date  he  began  to  improve  gradually,  and  was  quite 
convalescent  on  February  1st. 

Commentary. — I  have  called  tlie  above  a  case  of  relapsing  fever, 
simply  because  after  the  febrile  state,  counting  from  the  fii-st  rigor, 
bad  continued  for  full  seven  days,  there  was  complete  recovery  ushered 
in  by  diaphoresis.  So  Avell  was  this  man,  that  he  insisted  on  going  out 
and  resuming  his  occupation  as  a  hawker.  On  the  24th  day,  however, 
he  was  again  seized  with  all  the  symptoms  of  the  primary  attack,  includ- 
ing, on  both  occasions,  a  distinct  exanthematous  eruption  of  rose-coloured, 
lenticular,  elevated  spots.  I  am  aware  it  may  be  contended  that  this 
was  a  case  of  typhoid  fever.  Dr.  Jenner  would  probably  so  consider  it 
on  account  of  the  eruption,  the  iliac  tenderness,  and  its  termination 
about  the  30th  day.  But  if  the  circumstance  of  a  complete  recovery  and  a 
distinct  relapse,  is  to  be  considered  as  a  sufficient  cause  for  distinguish- 
ing a  fever,  it  is  scarcely  to  be  conceived  that  these  occurrences  could 
ever  be  better  characterised  than  in  the  above  case.  There  is  this  diifer- 
ence,  that  the  relapse  occurred  on  the  24th,  and  not  on  the  14th  day. 
This,  however,  I  have  seen  frequently  happen  in  the  epidemic  of  relaps- 
ing fever  which  occurred  in  this  city  during  1843.  Though  most  com- 
mon on  the  14th  day,  this  period  was  passed  over,  and  the  first  relapse 
occurred  on  the  21st  or  24th  day.  One  or  more  relapses  are  not  unfre- 
quent,  and  it  would  appear  as  if  the  period  of  the  first  had  been  passed 
over. 

Dr.  Christison  has  pointed  out  that  this  form  of  fever  is  identical  Avitli 
inflammatory  fever,  or  the  synocha  of  Cullen,  and  in  his  article  on  Fever 
in  the  Library  of  Medicine,  he  has  shown  their  similitude,  especially  as 
he  liad  observed  it  in  the  Edinburgh  Epidemic  of  1817  to  1820,  and 
1826-27.  During  the  great  epidemic  of  1843-44,  I  had  abundant 
opportunities  of  studying  it,  not  only  in  others,  but  in  my  own  case, 
having  been  attacked  a  fortnight  after  my  appointment  as  Physician  to 
the  fever  hospital.  On  that  occasion,  Dr.  Christison,  who  attended  me, 
at  once  pronounced  the  disease  to  be  the  synocha,  which  he  had  seen 
twenty  years  previously,  and  confidently  predicted  the  relapse,  which 


862  DISEASES   OF   THE   BLOOD. 

occurrecl  on  the  fourtcentli  day,  when  I  imagined  myself  to  be  convalescent. 
That  remarkable  epidemic  has  been  carefully  described  in  the  writings 
of  Alison,  Craigie,  Corniack,  Halliday  Douglas,  Wardell,  and  others. 


TYPHOID    FEVER    TREATED    BY    QUININE. 

Case  CXCV.* — Miles  Murray,  tet.  25,  I'abourer — admitted  Xovember  1,  1851. 
First  seized  with  rigors  on  the  eveniug  of  the  2d,  followed  by  strongly  ruarked 
febrile  symptoms.  No  contagion.  On  admission,  features  livid  and  anxious;  skin 
dry  and  hot;  no  eruption.  Severe  frontal  headache;  pain  in  the  back,  and  over 
the  whole  body.  Slight  "subsultus  tendinum."  Tongue  moist,  but  furred;  no 
appetite,  but  excessive  thirst.  Pulse  84,  full,  but  soft,  occasionally  intermittent. 
Short  dry  cough,  and  slight  dulness  on  right  side  of  chest;  no  unusual  rales. 
Ordered  an  aiitimonial  mixture;  six  leeches  to  he  applied  to  the  head.  November 
8th. — Slept  well  during  the  night ;  no  delirium.  Skin  still  dry  and  hot ;  no  erup- 
tion ;  tongue  more  dry  than  yesterday.  Pulse  82,  full,  but  soft.  Ordered  quinine, 
in  ten-grain  powders,  every  second  hour.  Kov.  9th,  Vespere  (7th  day). — He  has 
taken  the  powders  regularly  since  ordered ;  no  marked  effect  produced  except  on 
the  pulse,  which  has  come  down  eight  or  ten  beats  after  each  powder,  its  strength 
also  being  much  reduced ;  there  has  been  much  sweating  to-day.  Still  severe 
headache;  no  delirium.  Urine  passed  this  afternoon  exhibits,  under  the  microscope, 
amorphous  lithates;  but  the  deposit,  on  standing,  is  inconsiderable.  Nov.  llth. — 
Has  taken  in  all  205  grains  of  the  quinine.  Slight  tingling  in  the  ears  this  morning, 
but  only  transient.  Is  dull  and  stupid  to-day.  Countenance  has  still  a  worn  and 
exhausted  aspect.  Slight  cough,  and  a  few  scattered  sibilant  rales  on  auscultation. 
Pulse  76,  small,  and  soft.  Suspend  the  quinine.  Wine  four  oz,  mixture  loith  the  sp. 
cether.  nitr.  and  sol.  ammon.  acetat.  Mjv,  IQth. — Drowsiness  increased  since  last 
report,  but  without  any  other  marked  change.  No  delirium.  Nov.  20th  (18th 
day). — Urine  to-day  loaded  with  lithates.  Countenance  rather  livid.  Skin  not 
very  hot ;  thirst  moderate.  No  eruption  has  apj^eared.  Nov.  2ls' {I9t\i  day). — 
Feverish  sj^mptoms  returned  No  decided  delirmm,  but  much  drowsiness,  and  total 
indifference  to  what  is  going  on  around  him.  Pulse  80,  full  and  soft.  Xov.  23d, 
Vespere  (21st  day). — Complains  to-day  of  uneasy  symptoms  in  epigastrium,  with 
much  nausea.  Had  slight  vomiting  in  the  afternoon.  Nov.  2-iih  — Had  an  emetic 
ordered  last  night,  which  produced  copious  vomiting ;  nausea  and  pain  in  epigas- 
trium relieved,  followed  bj'  profuse  sweating.  Nov.  30th  (28th  day). — Has  had 
considerable  diarrhoea  during  the  last  four  days;  checked  by  the  lead  and  opium 
pills,  and  tannin.  Slight  delirium  to-day;  skin  hot  and  dry,  pulse  96,  full,  regular; 
cough  more  troublesome;  bronchitic  rales  abundant  all  over  the  chest.  Decem- 
ber 1st. — Much  sweating  to-day;  strength  greatly  prostrated;  cough  oppressive, 
and  expectoration  brought  up  with  extreme  difficulty ;  foeces  and  urine  passed  in 
bed.  Has  four  oz.  of  wine  daily,  and  an  expedoraM  mixture.  Dec.  Gth. — Weakness 
increasing  :  almost  constant  sweating,,  but  no  further  change.  Four  oz.  of  brandy 
in  addition  to  the  loine.  Dec.  1th  (35th  day). — Was  more  re-stless  than  usual  last 
night,  but  there  is  now  no  delirium.  A  bed-sore  is  threatening  over  the  trochanter 
of  the  right  fCmur.  Pulse  102,  small  and  weak.  Dec.  10th. — Cough  occurring  in 
paroxysms:  weakness  increasing.  Dec.  I2th  (-iOth  day). — Pulse  to-day  130,  small 
and  vibratory:  skin  cool  and  moist;  appetite  little  better.  J}  Quhm  Disulph.  gv. 
iv ;  Fiant  pulv.  tales,  vj.      One  every  tliree  hours.     After  taking  four  of  the  powders, 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


CONTINUED   FEVER.  863 

the  pulse  fell  to  102,  small  and  jerking.  Quinine  stopped,  and  brandy  and  wine 
resumed.  Next  day  (41st  of  fever),  he  began  to  shiver  about  3  p.m.,  and  presented 
all  the  phenomena  of  a  paroxysm  of  ague,  the  skin  continuing  pungently  hot  for 
about  three  hours,  but  witliout  sweating.  In  the  evening  the  skin  was  comparatively 
cool,  and  the  patient  felt  languid  and  drowsy.  He  was  ordered  to  resume  the 
quinine,  five  grains  every  three  hours.  Dec.  lith  (42d  day). — No  return  of  shiver- 
ing, or  febrile  symptoms.  After  this  date  he  began  to  improve  steadily ;  and,  with 
the  exception  of  slight  sore  throat,  and  return  of  short  dry  cough  for  a  few  days, 
had  not  a  bad  symptom  during  the  remainder  of  his  stay  in  the  house.  He  was 
dismissed  perfectly  well  on  the  19th  of  January,  having  been  73  days  in  the  ward, 
and  SO  days  having  elapsed  since  the  occurrence  of  the  first  rigor. 

Commentary. — This  case  was  observed  and  recorded  with  the  greatest 
care,  and  I  had  no  difficulty  in  considering  it  to  be  a  case  of  typhoid 
fever,  unusuallv  prolonged,  perhaps  on  account  of  the  pulmonary  com- 
phcation.  There  were  several  distinct  exacerbations,  coming  on  with 
marked  rigors,  at  intervals  of  seven  days,  followed  by  increased  febrile 
symptoms.  At  one  period  this  man's  life  was  despaired  of,  the  piofuse 
sweatings,  the  diarrhoea,  extreme  prostration,  with  partial  pneumonia, 
and  general  bronchitis,  constituted  symptoms  of  a  most  alarming  charac- 
ter, through  which,  however,  Avith  the  as.sistancc  of  stimuli,  liberally 
administered,  he  eventually  safely  struggled.  This  also  was  the  first 
case  of  fever  in  which  the  quinine  treatment  was  tried.  It  so  happened, 
that  having  ordered  six  doses,  of  ten  grains  each,  to  be  administered, 
and  not  seeing  him  on  the  following  day,  the  drug  was  by  accident  con- 
tinued consecuti\ely  for  eighteen  doses,  at  intervals  of  two  hours  each. 
At  the  end  of  that  time,  no  eft'ect  having  been  produced  on  the  fever,  it 
was  continued  in  five  grain  doses,  so  that  in  all  he  took  205  grains  of 
quinine.  Notwithstanding,  not  only  did  the  fever  march  on,  but,  as  we 
have  seen,  the  mo.st  alarming  prostration  was  introduced.  No  eruption 
could  be  detected  during  the  whole  progress  of  the  disease,  though  daily 
looked  for  with  the  utmost  care. 

Case  CXCVI.* — Marianne  Howison,  ret.  11 — admitted  January  16,  1851.  Rigors 
appeared  on  the  10th,  followed  bj'  febrile  symptoms.  Mother  and  sister  had  died 
immediately  before  of  fever.  On  admission,  pulse  130,  full  and  strong;  intense  head- 
ache; tongue  dry  and  brown;  complete  anorexia,  and  great  thirst;  skin  hot,  no 
eruption.  On  the  Yith,  the  treatment  with  ten-grain  doses  of  quinine  was  ordered. 
\%th. — Five  powders  were  given;  and  the  report  to-day  is :  headache  gone ;  pulse 
94,  soft;  skin  moist  and  cool;  tongue  moist  and  red.  On  the  19<A,  restlessness  and 
heat  of  skin  returned.  On  the  2Uh,  fever  was  as  intense  as  when  she  was  admitted. 
2f)th. — Diarrhoea,  ilth — Considerable  abdominal  pain  on  pressing  right  iliac  region ; 
six  leeches  applied;  |  vi  of  wine.  i\st. — Diarrhoea,  which  had  formerly  continued 
only  twenty-four  hours,  has  been  present  continuously  for  the  last  three  days. 
February  Ist. — Pulse  weak;  sordes  on  lips  and  tongue;  intellect  confused;  no 
diarrhoea.  Feb.  3d. — Pulse  weak  and  irregular,  140:  is  insensible.  Feb.  Ath. — Very 
restless  during  the  night;  still  insensible;  pulse  150,  small  and  jerking;  slight 
hemorrhage  from  the  gums.     Died  at  seven  p.m. 

Sectio  Cadaveris. — Fifty-six  hours  after  death. 

The  mucous  surface  of  the  lower  third  of  the  .small  intestine  was  scattered  over 
*  Reported  by  G.  A.  Douglas,  Clinical  Clerk. 


864:  DISEASES   OF   THE   BLOOD. 

with  round  and  oval  elevations,  becoming  more  crowded  together  near  the  coecum. 
The  former  were  of  the  size  and  form  of  a  split  pea,  the  latter  varied  from  the  size  of 
sixpence  to  that  of  an  almond.  In  the  lower  portion,  some  of  the  elevated  patches 
were  softened  and  sloughing,  and  in  one  or  two  places  the  sloughs  had  separated, 
forming  ulcerations.  The  upper  third  of  the  large  intestines  presented  also  numerous 
round  papular  elevations,  similar  to  those  in  the  smaller  intestines — the  whole  exhi- 
biting tlie  various  well-known  changes  of  typhoid  elevations  and  ulcerations  in  a 
characteristic  manner — the  peritoneum  corresponding  to  some  of  the  ulcerations 
unusually  congested,  but  there  was  no  peritonitis.  Some  of  the  mesenteric  glands 
enlarged  and  softened ;  other  organs  healthy. 

Commentary. — This  was  a  well-marked  case  of  typhoid  fever,  which 
was  fatal  on  the  twenty-fifth  day ;  and,  on  dissection,  the  intestinal  lesion, 
characteristic  of  the  disease,  was  discovered.  Here  also  the  quinine 
treatment  was  tried,  with  the  eflect  at  first  of  moderating  some  of  the 
symptoms,  although  on  the  following  day  they  returned  with  increased 
intensity.  As  in  the  last  case,  no  eruption  could  be  discovered  on  this 
girl,  though  carefully  looked  for.  It  is  further  worthy  of  observation, 
that  the  mother  and  sister  had  died  of  a  similar  disease.  The  contagious 
natui'e  of  this  form  of  fever  is  still  doubtful,  as  many  insist  that  the 
intestinal  lesion  is  dependent  on  purely  endemic  causes. 

Case  CXCYII.*— John  Anderson,  ast.  21,  sailor— admitted  29th  December,  1851. 
On  the  4tli  of  December,  having  been  exposed  to  cold  during  his  passage  from 
Elsinore,  he  was  seized  with  rigors,  diarrhoea,  ^nd  thirst,  whicli  continued  several 
days.  From  this  condition  he  was  gradually  recovering  when  the  ship  entered  the 
harbour  of  Leith  on  the  2-1  th.  Tliat  night  he  was  again  attacked  with  rigors, 
great  tliirst,  and  diarrhosa,  followed  on  the  27th  by  intense  sudden  pain  in  the 
abdomen,  vomiting,  and  constipation.  On  admission  the  features  were  shrunk  and 
hard;  skin  cold  and  clammy;  tongue  red  and  furred;  severe  griping  pain  in  the 
abdomen,  which  is  shrunk ;  no  tympanitis ;  bowels  costive ;  scanty  urine ;  no  head- 
ache; pulse  126,  feeble  and  vibrating.  Twenty-four  leeches  ivere  ajjpUed  to  the  abdo- 
men; one  ojnum  pill  every  two  hours.  Dec.  30. — Unrelieved;  mind  wandering; 
bowels  freely  opened  without  relief;  pulse  very  rapid,  and  almost  imperceptible. 
Died  at  one  p.m. 

Scctw  Cadaveris. —  Twenty-three  hours  after  death. 

Peritoneum  purple,  congested,  having  flakes  of  lymph  upon  the  surface.  It  con- 
tained several  ounces  of  dirty  turbid  yellow  fluid,  having  a  slight  foecal  odour. 
Stomach  and  duodenum  normal.  About  the  middle  of  the  jejunum  a  small  ulcer 
one-half  of  an  inch  by  one-eighth  in  size,  penetrating  all  tlie  coats  of  the  intestine; 
edges  pale  and  not  raised.  Mucous  membrane  of  the  lower  part  of  ileum  and  coecum 
mottled  with  slate-colored  patches ;  Peyer's  patches  prominent,  and  several  ragged 
ulcers  situated  in  their  course,  and  in  some  of  the  solitary  glands ;  ulcers  flat,  with 
smooth  edges.  Intestines  contained  fluid  foeces  of  a  yellow  colour,  resembling  pea- 
soup. 

Commentary. — This  was  another  undoubted  case  of  typhoid  fever, 
%vith  intestinal  disease,  terminating  by  peritonitis,  the  result  of  a  perfo- 
rating ulcer.     The  leading  facts  werecomm  unicated  to  me  with  great 

*  Reported  by  Mr.  A.  Dewar,  Clinical  Clerk. 


'continued  fever.  865 

clearness  after  the  boy's  death  by  the  captain  of  the  vessel,  in  whose  log 
was  recorded  the  day  of  the  attack,  the  remission,  and  the  renewed 
attack  on  the  twenty-first  day.  He  also  had  obsei-ved  no  eruption  on 
the  skin,  but  of  course  his  information  on  such  a  point  was  of  no  great 
value. 

The  three  cases  now  given  have  enabled  you  to  study  the  principal 
phenomena  presented  by  typhoid  fever.  With  regard  to  its  diagnosis, 
if  vou  rely  on  the  characters  prominently  given  by  Dr.  Jenner,  especially 
with  retjard  to  the  eruption,  it  must  be  evident  you  will  be  frequently 
deceived.  It  so  happens  that  in  none  of  the  three  cases  was  an  erup- 
tion observed,  although,  in  two,  it  was  carefully  sought  for;  and  in  one 
of  these  latter  the  nature  of  the  disease  was  placed  beyond  all  doubt  by 
dissection,  which,  after  all,  is  the  only  certain  proof  of  typhoid  fever.  I 
have  been  in  the  habit  of  considering  the  most  trustworthy  symptoms 
distinguishing  this  form  of  fever  from  typhus,  to  be  the  remissions  ;  a 
peculiar  character  of  the  countenance  expressive  of  abdominal  pain  ;  the 
diarrhoea  (especially  when  the  stools  resemble  pea-soup);  and  marked 
tenderness  on  pressing  deep  down  into  the  right  iliac  lesion.  I  acknow- 
ledge, however,  that  these  symptoms,  in  the  absence  of  an  epidemic  of 
typhoid  fever,  are  often  deceptive,  even  when  the  disease  has  continued 
beyond  the  thirtieth  day. 

Typhoid  fever  is,  on  the  whole,  a  rare  disease  in  Edinburgh.  It  is 
common,  however,  on  the  opposite  coast  of  Fife,  and  at  Linlithgow.  The 
late  Dr.  John  Reid  used  to  remark,  when  he  was  pathologist  to  the 
Infirmary,  that  all  the  bodies  he  opened  affected  with  typhoid  ulcera- 
tions of  the  intestines,  came  from  one  or  other  of  these  places.  On  the 
other  hand,  in  Paris,  and  in  many  places  on  the  continent,  it  is  the  pre- 
vaibng  form  of  fever.  In  the  fever  wards  of  this  Infirmary  you  have  the 
most  extensive  opportunities  of  studying  typhus;  in  the  hospitals  of  the 
continent,  and  especially  at  Paris,  Berlin,  Prague,  and  Vienna,  vou  will 
see  typhoid  or  enteric  fever  on  a  large  scale.  These  facts  serve  to  clear 
up  much  of  the  confusion  which  has  entered  into  the  discussions  con- 
cerning continued  fever  by  foreign  and  domestic  writers.  They  also 
explain  why  the  doctrine  of  Broussais,  who  conceived  tvphus  to  be 
gastro-enteritis — although  everywhere  on  the  continent  adopted  for  a 
time — was,  from  the  first,  rejected  as  false  by  this  school.  At  the  same 
time  there  have  been  certain  epidemics  in  Edinburgh  during  which 
typhoid  fever  has  been  prevalent,  as  there  have  been  always  cases  of  true 
typhus  mixed  up  with  the  enteric  fever  of  the  continent.  Thus,  in  the 
epidemic  of  1846-7,  an  unusual  number  of  typhoid  cases  were  minified 
with  the  typhus;  and  I  have  more  than  once  seen  distinguished  phvsi- 
cians  and  teachers  on  the  continent  much  puzzled  bv  finding  no  morbid 
lesion  in  fatal  cases  of  fever,  which,  from  my  previous  knowledo-e  of  the 
disease  in  Edinburgh,  I  had  no  difficulty  in  recognising  as  beino-  those 
of  genuine  typhus. 

Now,  it  is  an  interesting  inquiry  to  ascertain  what  are  the  causes 
which  should  occasion  such  a  general  typhoid  fever  abroad,  and  such 
a  general  typhus  in  this  country.  For  my  own  part,  I  have  been  led 
from  long  observation  of  the  fever,  both  here  and  on  the  continent,  to 
form  the  opinion  that  it  is  in  some  way  connected  with  the  diet,  which, 

55 


866  DISEASES   OF   THE   BLOOD, 

among  the  lower  orders,  is  very  different  in  France  or  Germanv  from 
wbat  it  is  in  this  country.  Acid  wines  and  food,  impoverished  diet, 
excessive  use  of  vegetables  and  fruit,  predispose  on  the  continent  to 
intestinal  disorders.  I  have  thought  this  theory  strengthened  bv  the 
fact,  that  when,  in  1846-7,  typhoid  fever  was  so  largely  mingled  with 
typbus  in  Edinburgh,  owing  to  a  failure  in  the  potato  crop,  various  kinds 
of  substitutes  were  employed  by  the  people,  and  scurvy  became  common. 

TYPHUS    FEVER    TREATED    BY    QUIXIXE. 

Case  CXCVIIL* — Mrs.  ilacdonald,  a  nurse  in  the  Infirmarv,  £et.  50 — admitted 
jSTovember  lOth,  1851.  Seven  days  ago  was  unusually  exposed  to  cold,  and  two 
days  afterwards  experienced  vomiting,  pain  in  the  back,  and  epigastrium,  with  head- 
ache, and  prostration  of  strength,  which  last  symptom  was  apparently  increased  by 
a  purgative  taken  on  the  8th.  On  admission  the  skin  was  exceedingly  hot ;  pulse 
102.  strong :  tongue  white  and  ftirred ;  gi'eat  thirst,  and  headache ;  anorexia  and 
nausea;  shght  bronchitis.  On  the  llih,  an  emetic  teas  ordered,  and  hco  hours  after 
its  operation  the  quinine  treatment  to  be  followed.  On  the  12/7;,  it  is  reported  that 
she  took  four  quinine  powders  of  10  grains,  at  intervals  of  two  hours,  but  vomited 
the  fifth.  Three  others,  however,  were  retained  during  the  night,  so  that  70  grains 
have  been  administered.  At  present,  she  is  in  no  way  reheved.  Skin  hot  and 
dry;  pulse  100,  strong:  tongue  furred;  pains  in  head  and  epigastrium  unabated. 
Eight  leeches  to  be  applied  to  the  head,  and  Quin.  Sulph.  gr.  v.  every  tv:o  hours, 
yov.  13tfi. — Has  taken  five  more  quinine  jtowders.  Pulse  now  78,  full;  considerable 
vomiting,  and  pains  in  epigastrium ;  other  symptoms  the  same.  Cold  douches  to  the 
head  ;  warm  fomentations  to  the  epigastrium.  Pill  of  bismuth  and  opium,  every  four 
hours.  Nov.  1-ith. — Head  and  stomach  much  relieved.  It  is  reported  that  last 
night  the  limbs  were  partially  convulsed,  and  her  eyes  fixed,  a  state  that  lasted 
seven  minutes.  Kov.  loth. — Confusion  of  intellect  and  restlessness  Pulse  rapid 
and  weak,  ^ivofvjine.  Kov.  llth. — Has  remained  in  the  same  condition.  Slight 
puffing  of  the  cheeks  observed  on  expiration.  Xov.  18th. — Puffing  of  cheeks  more 
marked ;  unable  to  move  the  right  arm ;  great  prostration.  Wine  §  vj.  Blister  to 
the  head.     Xov.  Idth. — Died  comatose.     There  has  been  no  eruption. 

Commentary. — Xo  examination  of  this  woman's  bodv  could  be  obtained, 
and  we  are  therefore  in  doubt  as  to  whether  an  exudation  had  or  had  not 
taken  place  between  the  membranes  of  the  brain.  The  cerebral  compli- 
cation, however,  was  in  this  case  well  marked.  At  first,  indeed,  there 
was  nothing  more  than  usual ;  but  the  vomiting  was  obstinate,  and 
latterly  the  convulsion  and  partial  paralysis  indicated  distinctly  the 
organ  aifected.  Having  previously  resolved  to  try  the  quinine  treatment, 
it  was  given  energetically  in  this  case,  but  without  any  eft'ect  on  the  pro- 
gress of  the  fever.  It  may  even  be  contended  that  it  did  harm,  seeing 
we  had  a  cerebral  complication  to  deal  with.  Of  this,  however,  at  an 
early  period,  we  could  not  judge,  although  it  appears  to  me  that  the 
quinine  practice  is  contra-indicated  in  such  cases. 

Case  CXCIX.f— George  Johnson,  boot-maker,  set.  21— admitted  8th  December, 
1851.     Had  severe  rigors  on  29th  November,  which  were  followed  by  the  usual 

*  Reported  by  Mr.  J.  L.  Brown.  Clinical  Clerk, 
t  Reported  by  ilr.  A.  Dewar,  Clinical  Clerk. 


COXTIXUED   FEVER.  867 

feverish  svmptoms.  No  exposure  to  coutagiou.  On  admission,  tongue  densely 
furred,  coated,  and  cracked ;  no  appetite ;  intense  tbirst ;  skin  hot  and  drj^ ;  con- 
fused in  liis  ideas,  without  great  pain  in  the  head ;  pulse  lOS.  full.  Dec.  9</i.— Slept 
very  ill,  and  continues  tlie  same  as  \-esterday.  Pulse  120,  full.  R.  01.  Bicini,  3  vj. 
Vespere.—  'B.  Sulph.  Quince,  3j;  Div.  in  pulv.  vj.  One  every  two  hours.  Bowels 
freely  moved  in  the  afternoon;  great  heat  of  skin;  much  mental  excitement;  pulse 
120,  full  and  strong;  no  eruption.  Dec.  10th. — Slept  well;  no  restlessness;  skin 
cool  and  moist;  no  headache;  slight  singing  in  the  ears ;  pulse  87,  of  good  strength. 
Pulse  rose  to  88  during  the  day,  and  in  the  evening  was  full  and  strong.  Quinine 
repeated;  10  grains  given  at  first,  then  13  grains  every  tico  hours.  Dec.  llth. — Pulse 
84,  of  good  strength ;  thirst  great;  skin  moist;  no  eruption.  Dec.  12</t  (14th  day). 
— Thirst  less;  some  appetite;  no  eruption;  slight  deposit  in  urine.  Improved  from 
this  time,  aud  was  dismissed  January  5th. 

Commentary. — This  was  a  slight  case  of  fever  from  the  beginnino-,  with 
no  ahirming  symptoms,  recovering  on  the  fourteenth  day.  "Whether 
this  result  was  in  any  way  owing  to  the  quinine  is  doubtful,  for,  as  we 
shall  see,  there  were  other  cases  very  similar,  in  which  the  fever  was  of 
no  longer  duration.  "When  first  given,  it  certainly  brought  down  the 
pulse,  and  all  the  symptoms  abated.  On  their  return,  therefore,  the 
treatment  was  again  had  recourse  to,  and  the  dose  increased  to  thirteen 
grains.  On  this  occasion,  however,  no  further  benefit  was  obtained  ;  and 
it  appeared  to  me  that  the  disease  terminated  with  critical  sediment  in 
the  urine,  on  the  fourteenth  day,  in  the  usual  manner.  There  was  no 
eruption  in  this  case. 

Case  CC.*— John  Craik,  blacksmith,  83t.  23— admitted  January  5,  1852.  On 
December  28tli,  had  severe  rigors,  followed  by  feverish  symptoms,  and  during  the 
night,  severe  cough,  and  much  expectoration.  On  admission,  tongue  red  and  moist ; 
slight  sore  throat ;  no  appetite ;  constipation ;  pulse  80,  of  good  strength ;  severe 
cough,  and  considerable  expectoration,  tinged  with  blood ;  mucous  rales  are  heard 
over  chest,  chiefly  at  base  of  lungs ;  skin  soft  and  dry ;  no  eruption,  or  exposure  to 
contagion.  January  7th. — Bowels  freely  opened;  cough  veiy  severe.  Ordered 
saline  mixture;  blixier  to  front  of  chest.  Jan.  Sth  (llth  day). — Very  restless; 
delirious;  drowsy  and  stupid;  cough  abated;  pulse  108,  weak.  Vesjyere. — Pulse 
121,  quick;  skin  hot  and  dry.  Quinine  treatment  ordered.  Jan.  9th. — Skin  cool  and 
moist;  pulse  90,  weak;  tongue  moist  aud  red;  extreme  deafness.  Jan.  lOih. — 
Slight  diaphoresis.  Jan.  llth  (14th  day  of  fever). — Skin  hot  and  dry;  flushed  and 
delirious ;  marked  rose-coloured  eruption  over  chest  and  abdomen ;  great  thirst ; 
sordes  on  lips  and  teeth  ;  tougue  red  and  moist,  dark  in  centre.  Jan.  12ih. — Deliri- 
ous; eruption  remains;  sordes  disappearing;  skin  hot  and  dry;  cough  severe; 
crepitation  distinct  at  base  of  right  lung;  no  dulness,  but  marked  resonance. 
Ordered  antimonial  mixture.  Jan.  l^th. — Countenance  flushed;  pulse  rapid  and 
weak;  great  prostration.  Blister  to  right  side;  iifine  |  iv.  Jan.  lith. — Sj'mptoms 
urgent.  Jan.  loth. — Great  thirst;  tongue  foul;  crepitation  gone,  and  the  respira- 
tion is  heard  very  indistinctly;  vocal  resonance  well-marked.  Jan.  llth. — 
Improving;  no  dulness,  nor  increased  vocal  resonance;  some  sibilant  rales;  .slight 
deposit  in  urine.  Steady  improvement  until  February  20,  when  there  was  oedema 
of  lower  limbs ;  urine  normal.     Is  now  quite  convalescent.     Dismissed. 

*  Reported  by  Mr.  W.  H.  Broadbent,  Clinical  Clerk. 


868  DISEASES   OF   THE   BLOOD. 

Commentary. — In  this  case  it  will  be  observed  tbat,  altbougli  tbe 
quinine  produced  at  first  an  apparent  improvement,  the  fever,  with 
delirium  and  the  usual  symptoms,  shortly  returned,  and  ran  a  rather 
protracted  coui'se,  owing  to  the  pulmonary  complication. 

Case  CCI.* — Anne  Dowie,  aet.  18,  servant — admitted  December  10th,  1851. 
Seized  with  pain  in  the  head,  heat  of  skin,  and  general  debility,  Dec.  3d.  Xext  day 
general  pain  over  the  body,  which  has  contmued  since.  On  admission,  pulse  120, 
feeble ;  tongue  dry,  red,  and  fissured ;  no  appetite ;  great  thirst ;  bowels  constipated ; 
skin  hot,  and  covered  with  a  clammy  sweat,  and  presenting  on  the  chest  and  arms  an 
eruption  of  numerous  minute  petechial  spots,  which  have  existed  for  some  days; 
slight  cough  and  expectoration;  scattered  bronchitic  rales  over  chest.  Bee.  Will. — 
ITie  quinine  treatment  ica.s  ordered.  After  the  fifth  dose  of  10  grs.,  slight  deafness, 
ringing  in  the  ears ;  one  more  dose  taken,  after  which  the  medicine  was  stopped. 
Dec.  12ih. — Pulse  80,  "excessively  small  and  weak;"  surface  cooler.  In  the  after- 
noon, the  pulse  was  86,  strength  much  increased ;  skin  warm  and  moist ;  tongue 
dry,  rough,  and  fissured ;  much  thirst ;  respirations  43  in  the  minute ;  slight  sub- 
sultus.  18fJi. — Pulse  84,  of  good  strength ;  skin  moist;  eruption  unchanged ;  lips 
covered  with  sordes ;  tongue  dr}-  and  cracked.  On  the  I4ih.  she  had  smart  diarrhoea, 
which  was  checked  by  an  astringent  mixture,  loth  (12th  day). — Appearance  of 
patient  much  better ;  pulse  88,  of  good  strength;  eruption  faded;  tongue  cleaner. 
I'ith  (14th  day). — Cough  troublesome;  a  good  deal  of  opaque  dirty-looking  muco- 
purulent matter  expectorated  ;  moist  rales  heard  on  auscultation ;  thirst  and  anorexia 
continue ;  urine  turbid,  but  without  sediment.  19(h  (16lh  day). — Urine  loaded  with 
lithates ;  patient  improving.  After  this  date  she  recovered  rapidly,  and  was  dis- 
charged on  the  15th  January,  quite  well 

Commentanj. — This  was  a  well-marked  case  of  petechial  typhus,  in 
which  the  quinine  treatment  was  tried,  without  apparently  in  any  way 
arresting  its  course,  although  the  physiological  action  of  the  drug  upon 
the  pulse  was  remarkably  well  characterised. 

Case  CCIL* — Isabella  Adamson,  set.  20,  servant — admitted  December  19th,  1851, 
with  eczema  of  the  scalp  and  face.  Eigors  appeared  Jan.  4,th,  followed  hj  febrile 
symptoms.  Rose-coloured  exanthematous  spots  appeared  on  the  chest  and  arms  on 
the  9//i.  On  the  \Qth,  the  treatment  by  quinine  commenced.  On  the  Wih,  the  immediate 
efiects  of  the  quinine  have  disappeared,  and  the  report  is — Pulse  100,  full  and  com- 
pressible; had  no  sleep;  pain  in  head  very  intense;  no  sweating;  tongue  furred  and 
cracked;  eruption  darker.  \Uh. — Confusion  of  the  intellect;  vertigo;  pulse  110, 
weak  and  intermitting;  sordes  on  lips  and  tongue;  subsultus  tendinum.  lltli. — 
Head  symptoms  have  been  relieved  by  a  blister ;  and  she  now  began  slowly  to  im- 
prove. On  the  24</i,  pulse  SO ;  returning  appetite;  sordes  disappeared.  On  the  '2Wi, 
convalescent. 

Commentary. — This  also  was  a  remarkably  well-characterised  case  of 
fever  of  considerable  severity,  evidently  caught  in  the  ward,  running  its 
usual  course,  notwithstanding  the  quinine  treatment  was  commenced  so 
early  as  the  sixth  day.  The  eruption  here  presented  rose-coloured  spots 
at  the  commencement,  becoming  darker  afterwards.  Seven  cases  of 
continued  fever  treated  by  quinine  have  thus  been  recorded,  which  we 
may  now  contrast  with  six  cases  treated  in  the  ordinary  way. 

*  Reported  by  Mr.  "W.  H.  Broadbent,  Clinical  Clerk. 


COXTINUED   FEVER.  869 


TYPHUS    FEVER    TREATED    "WITHOUT    QUIKIXE. 

Case  CCIII.* — Anthony  Kerracliar,  labourer,  set.  20 — admitted  Xovember  12, 
1851.  On  the  Tth,  had  rigors,  followed  by  confusion  of  head  and  general  feverish 
symptoms.  No  exposure  to  contagion.  On  admission,  tongue  furred  and  white ; 
intense  thirst ;  no  appetite  ;  expression  anxious,  only  slight  headache ;  no  eruption. 
Xov.  13. — Cough  severe;  dulness  at  lower  part  of  left  lung ;  cough  mixture.  Xov.  20. 
— Feverishness  gone;  sleeps  well;  expression  good.     Dismissed  on  Dec.  8,  1851. 

Case  CCIY.* — Laurence  Cochrane,  labourer,  a?t.  43 — admitted  December  1st, 
1851.  Had  first  severe  rigors,  Nov.  28t]i,  followed  by  febrile  symptoms.  No 
exposure  to  contagion.  Had  fever  six  years  ago.  On  admission,  tongue  furred  and 
moist ;  appetite  gone ;  constipatiou ;  pain  in  back  and  loins,  and  great  weakness. 
Complains  of  cough ;  no  expectoration ;  chest  resonant,  but  crepitation  is  heard  at 
base  of  left  lung;  pulse  100,  fvdl  and  regular.  Bee.  2d. — Bowels  well  moved;  pain 
unrelieved;  appetite  returned;  no  eruption.  Dec.  l'2(h. — Fever  disappeared,  but 
very  weak.     Dismissed  Jan.  I'ith. 

Commenfary. — Both  these  cases,  althouo-h  complicated  with  pul- 
moiiarv  disorder,  i-an  tlieir  usual  course,  and  in  this  respect  resembled 
Case  CXCIL,  iii  which  quinine  was  given.  In  neither  was  there  any 
eruption. 

Case  CCY.f — Isabella  Stevenson,  a?t.  44,  -washerwoman — admitted  Xovember 
ICth,  1851.  On  the  3d,  first  experienced  pain  in  the  head,  followed  by  sweating,  but 
says  she  had  no  rigors.  She  was  in  bed,  complaining  principally  of  cephalalgia, 
during  the  whole  of  last  week.  On  admission,  the  skin  is  dry  and  hot,  but  at  night 
alwaj'S  bathed  in  perspiration.  Xo  eruption ;  tongue  furred ;  no  appetite ;  thirst 
moderate;  intense  headache,  with  occasional  stupor;  pulse  120,  small,  threadlike. 
Cold  to  the  head  and  siinndants.  On  the  \2th,  crepitation  was  heard  in  the  left  lung 
posteriorly.  Vith. — Great  dyspnoea ;  moist  and  dry  rales  over  anterior  of  chest. 
These  symptoms  increased,  and  she  died  Xov.  15th. 

Sectio  Cadaver  is. — Forty-eight  hours  after  death. 

Both  lungs  anteriorly  were  emphysematous  in  the  highest  degree,  presenting 
numerous  bullte,  with  deep  fissures  between  them,  with  patches  of  collapsed  lung 
here  and  there.  If  anything,  the  left  lung  was  most  affected.  Posteriori}-,  both 
lungs  more  or  less  collapsed,  and  on  section,  the  lining  membrane  of  the  bronchi  was 
deeply  congested,  and  the  tubes,  on  pressure,  j-ielded  an  abundant  muco-purulent 
discharge.  Spleen  small,  weighing  one  ounce  and  a  half;  brain  and  other  organs 
health}-. 

Commentary. — Tin's  woman  came  into  the  ward  on  the  same  dav  as 
Case  CXCVIIL,  the  fever  was  equally  severe,  and  if  anything,  the  head- 
ache was  more  violent.  It  was  resolved  to  give  quinine  in  one  case  and 
treat  the  other  in  the  usual  way.     It  so  happened  that  both  died. 

Case  CCYI.f — Margaret  Menzies,  set.  16,  servant — admitted  December  28.  1851. 
Seized  with  lassitude  and  febrile  symptoms  on  the  2 2d,  but  without  distinct  rigors. 

*  Reported  by  Mr.  A.  Dewar,  Clinical  Clerk. 
f  Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


870  DISEASES  OP   THE   BLOOD. 

On  admission,  pulse  100,  full;  tongue  coated;  headache  and  vertigo;  skin  dry  and 
hot,  with  rose-coloured  ehiptical  spots  scattered  over  the  abdomen  and  chest,  which 
appeared  this  morning;  they  are  of  mulberry  colour  on  the  arms.  January  \st. — 
Urine  loaded  with  lithates ;  eruption  disappeared  ;  skin  cool ;  pulse  natural. 
Jan.  3d. — Convalescent. 

Case  CCVII.* — Christina  Swan,  servant,  ist.  25 — admitted  December  16,  1851. 
Had  rigors  on  the  14t]i,  followed  by  febrile  symptoms,  but  had  headache  and  other 
premonitory  symptoms  on  the  11th.  The  day  before  admission  (15th)  an  eruption 
appeared  on  the  body.  On  admission,  pulse  120,  small;  tongue  florid  at  edges, 
furred  at  the  sides  ;  no  appetite ;  great  thirst ;  cough.  The  entire  surface  is  covered 
with  a  mulberrj'-coloured  erui^tion,  in  small  crescentic  patches,  and  though  not  raised, 
strongly  resembling  that  of  rubeola.  Eyes  red  and  suffused,  not  sensitive  to  light. 
December  19th. — "U'as  delirious  last  night.  Mouth  and  teeth  covered  with  sordes ; 
tongue  dry  and  cracked;  is  now  insensible;  pulse  120,  small.  Subsultus  tendinum, 
bronchitis  on  both  sides,  with  pneumonia  in  lower  half  of  riglit  lung.  Dec.  25th. — 
Since  last  report,  constant  low  delirium,  which  to-day  is  somewhat  diminished. 
Cough  and  expectoration  very  troublesome.  Absence  of  respiration  from  right  back, 
with  pealing  vocal  resonance.  Pulse  rapid  and  weak ;  eruption  faded.  Blister  to 
head.  Wine  §  vj,  and  brandy  §  iv.  Dec.  29ih  — No  delirium,  but  lies  in  a  comatose 
state.  A  lateritious  sediment  in  the  urine  has  appeared,  and  a  swelling  in  the  right 
parotid  gland.  Pulse  98,  more  full.  January  1st. — Consciousness  returning ;  cough 
much  diminished,  and  respiration  audible  in  right  back ;  skin  cool.  An  abscess 
forming  in  the  neck,  below  right  side  of  jaw.  From  this  period  convalescence  was 
slowly  established  ;  the  abscess  was  resolved,  and  she  was  dismissed  February  2d. 

Commeyitary. — This  was  a  very  severe  case  of  typlins,  with  puhnonary 
complication,  which,  however,  by  means  of  stimulants  liberally  given, 
strnogled  through  on  the  twenty -first  day.  The  eruption  in  her  case 
was  verv  peculiar,  closely  resembling  that  of  rubeola,  which  it  was  main- 
tained to  be  by  several  persons  who  saw  it.  It  appeared  on  the  second 
dav  after  the  rigor.  But  there  was  none  of  the  intolerance  to  light,  or 
corvza  of  measles ;  and,  moreover,  she  and  her  friends  stated  that  she 
had  previoush^  had  the  disease.  Under  these  circumstances,  it  is  pro- 
bable that  it  constituted  the  "  mulberry  rash"  of  Jeuner,  appearing  early. 

Case  CCYIII.f — Bridget  M'Fadyen,  fet.  20,  labouring  woman— admitted  Decem- 
ber 17,  1851,  with  psoriasis  of  the  arms  and  legs.  Rigors  appeared  January  4, 
followed  by  slight  febrile  symptoms,  which  became  fully  established  on  the  10^/j. 
Wth. — Delirious;  face  flushed;  pulse  120,  rather  strong,  and  jerking;  no  eruption. 
11th. — Quite  unconscious.  Head  shaved,  and  blister  applied.  ISth. — Head  relieved  ; 
pulse  rapid  and  weak.  Ordered  4  oz.  of  wine.  On  the  24</i,  sediment  of  lithates  in 
urine.  She  gradually  improved  after  this  date,  and  on  the  26th  was  convalescent. 
No  eruption. 

Diagnosis  of  Continued  Fevers. 

On  reviewing  the  nineteen  cases  of  continued  fever  previously  given, 
with  a  view  of  determining  how  far  we  are  enabled  to  distinguish  its 

*  Reported  by  Mr.  J.  L^  Brown.  Clinical  Clerk. 

\  Reported  by  Mr.  W.  H.  Broadbent,  Clinical  Clerk. 


CONTINUED   FEVER.  871 

varieties  at  an  early  period,  it  will,  I  think,  appear  that  tliis  is  impossible. 
If  there  be  any  fact  connected  with  the  disease  better  established  than 
another,  it  is  that  at  the  onset  we  are  nnable  to  say  whether  any  given 
case  will  tarn  out  to  be  a  febricula  or  a  typhus,  a  relapsino;  or  a  tyjihoid 
fever.  If  yon  studv  carefully  the  symptoms  presented  by  Cases  CXCIL, 
CXCIV.,  CXCV.,  and  CC.,'  you  will  be  satisfied  of  this.  We  may, 
indeed,  when  acquainted  with  the  prevailing  type  of  an  epidemic,  often 
be  led  to  guess,  with  more  or  less  correctness,  as  to  its  probable  course, 
but  exactitude  is  impossible.  Should  the  fever  cease  on  the  seventh  day, 
then  it  may  be  febricula  or  relapsing  fever.  The  latter  is  determined 
by  the  return  of  the  disease  ;  but  I  know  of  no  circumstance,  beyond 
the  type  of  the  epidemic,  which  can  lead  us  to  predict  that  event.  On 
the  other  hand,  should  the  fever  continue  beyond  the  seventh  day,  then 
we  have  to  do  with  typhus  or  the  typhoid  "form.  Notwithstanding  all 
that  has  been  said  as  to  the  means  of  distinguishing  these  varieties  by 
means  of  the  eruption  or  of  the  abdominal  symptoms,  I  believe  that  in 
practice  it  will  be  found  to  be  impossible  before  the  twenty-first  day. 
We  have  seen,  in  the  three  cases  of  typhoid  fever  which  have  fallen 
under  our  observation,  that  no  eruption  existed  in  any  of  them.  ^^  ith 
regard  to  the  ten  cases  of  typhus  fever  also,  in  five  there  was  no  erup- 
tion (Cases  CXCYIIL,  CXCIX.,  CCIII.,  CCIV.,  CCVIII.) ;  in  three 
there  were  rose  spots  (Cases  CC,  CCIL,  CCYI.) ;  in  one  a  mulberiy  or 
measly  eruption  (Case  CCVII.)  ;  and  in  one  petechia;  (Case  CCI).* 
Then,  with  regard  to  diarrhoea,  it  is  only  diagnostic  of  typhoid  fever 
after  the  fourteenth  day.  Thus,  in  Case  CXCV.,  it  first  appeared  on  the 
twenty-eighth  day,  and  in  Case  CXCVI.,  on  the  fifteenth.  In  Case 
CXCVII.,  on  the  other  hand,  it  is  said  to  have  been  present  from  the 
first,  but  such  an  occurrence,  however  it  may  excite  our  suspicions,  is  far 
too  common  in  all  fevers  to  be  much  regarded  as  more  particularly  indi- 
cative of  typhoid  than  of  typhus  fever.     Fi'om  all  these  considerations, 

*  This  paragraph  lias  been  criticised  by  a  writer  in  the  "  British  and  Foreign  iledi- 
cal  Review"  for  October  1853,  who  is  a  strong  supporter  of  Dr.  Jenner's  opinions. 
It  may  be  worth  while,  in  turn,  to  anah'se  his  arguments.  He  admits  that  if  the 
eruption  is  not  distinctive,  the  objection  to  Dr.  Jenner's  views  would  be  well  founded. 
He  says,  however,  that  in  Cases  CXCIX.,  CCIII.,  and  CCVIII.,  the  eruption  may 
have  been  absent,  simply  on  account  of  the  youth  of  the  patients.  But  typhus  fever 
frequently  attacks  young  people,  and  if  the  diagnostic  eruption  can  only  be  depended 
on  in  persons  after  the  age  of  25,  its  value  cannot  be  very  great.  Case  CXCVIII.  is 
declared  to  be  a  cerebral  disease,  and  Case  CCIV.,  a  pulmonary  one.  Cerebral  and 
pulmonary  complications  were  undoubtedly  there,  but  I  can  assure  the  critic  that 
they  were  cases  of  typhus  fever  notwithstanding  Thus,  however,  he  disposes  of 
the  tive  cases  which  are  hostile  to  his  views.  Then,  as  to  the  three  cases  of  typlius 
(Cases  CC,  CCII.,  and  CCVI.),  with  rose  -spol.s,  he  denies  that  such  spots  are  exan- 
thematous.  But  if  not  exanthematous,  what  are  they  ?  Certainly  they  were  not 
macular  or  petechial.  Then,  because  it  is  said  in  Case  CCII.  that  they  became  darker 
afterwards,  and  in  Case  CCVI.  it  is  noted  they  are  of  mulberrj'  colour  on  the  arms, 
therefore  they  must  have  presented  the  ordinary  character  of  a  tj'phus  rash.  All  I 
can  say  is,  that  to  me  they  were  in  no  way  distinctive.  The  absence  of  eruption  in 
the  three  typhoid  cases  (CXCV.,  CXCVI,  and  CXCVII.),  is  thus  explained  by  the 
reviewer: — ''As  the  rose  spots  only  appear  in  85  per  cent,  it  is  not  impossible  that 
they  might  have  been  absent  in  these  three  consecutively,  and  ma}*  have  been  pre- 
sent in  the  next  fifteen."  But  if  so,  how  in  Edinburgh,  where  typhoid  fever  is  rare, 
is  our  diagnosis  to  be  a.ssisted  by  a  supposed  peculiar  form  of  eruption,  which  need 
not  occur  in  all  the  cases  of  the  disease  admitted  into  the  clinical  wards  for  perhaps 
twelve  mouths  ? 


872  DISEASES   OF   THE    BLOOD, 

the  distinctions  which  have  been  made  out  between  the  various  forms  of 
continued  fever,  are  for  tlie  most  part  retrospective,  and  can  only  be 
determined  in  the  advanced  stages.  It  is  of  the  utmost  importance  to 
take  tin's  into  consideration,  in  endeavouring  to  estimate  the  value  of 
particular  kinds  of  treatment. 

The  same  arguments  which  apply  to  the  uncertainty  of  diagnosis,  may 
be  urged  against  the  general  doctrine,  that  these  forms  of  fever  are 
dependent  upon  separate  poisons,  run  a  different  course,  and  are  governed 
by  laws  as  distinct  as  those  which  regulate  the  various  kinds  of  eruptive 
fever.  Without  denying  the  existence  of  various  kinds  of  continued 
fever,  I  am  of  opinion  that  this  doctrine  has  not  been  establislied.  On 
the  contrary,  I  believe  that  internal  complications,  and  the  accidental 
circumstances  of  season,  diet,  constitution,  and  other  causes  of  a  like 
nature,  modify  fever  in  particular  individuals  at  different  times,  and  that 
to  these  the  variations  obsei-ved  are  in  many  cases  attributable.  More- 
ovei',  I  am  satisfied  tliat  typhoid  and  t}  phus  fever  may  occur  together 
epidemicall}',  run  into  one  another,  and  be  mutually  communicable. 
This  was  very  well  shown  in  the  Edinbufgh  epidemic  of  1846-7,  in 
which  both  diseases  occurred  together  at  the  same  time,  and  in  the  same 
localities,  some  individuals  coming  fi-om  the  same  house  affected  with 
typhus,  and  others  with  typhoid,  the  latter  having  intestinal  lesion  after 
death,  as  proved  by  dissection. 

In  an  elaborate  paper  by  Dr.  Charles  Murchison,*  he  endeavours  to 
prove  that  typhus  and  relapsing  fevers  are  caused  by  ovei'crowding,  with 
deficient  ventilation  and  destitution.  Typhoid  fever,  on  the  other  hand, 
he  considers  to  be  caused  by  emanations  fi'om  decaying  organic  matter 
or  by  organic  impurities  in  Avater,  or  by  both  of  these  causes  combined. 
The  arguments  he  has  bi'ought  forward  in  support  of  this  view  merit 
careful  consideration,  and  should  be  remembered  in  any  future  inquiiy 
into  the  origin  of  epidemics.  At  the  same  time,  the  facts  which  came 
imder  my  notice  in  the  remarkable  epidemic  of  this  city,  already  referred 
to,  cannot,  I  think,  be  explained  by  any  such  supposition. 

Morbid  Anatomy  of  the  Edinburgh  Epidemic  Fever  during  the  Winter 
Session  1846-7,  u<hen  Typhoid  Disease  was  2>revalent. 

During  this  epidemic,  I  opened  the  bodies  of  sixty-three  individuals 
who  had  died  of  typhus  and  typhoid  fever,  with  the  following  results  : — 

Spleen.— The  organ  most  frequently  affected  was  the  sple'en.  In  the 
majority  of  cases  it  was  more  or  less  enlai'ged  and  softened,  presenting  a 
mahogany-brown  colour,  and  creamy  consistence  ;  so  that  when  pressed, 
the  whole  of  its  parenchyma  could  be  squeezed  out  of  its  capsule.  In 
ten  cases  the  spleen  contained  yellow  fawn-coloured  discolorations  with 
abrupt  margins,  sometimes  diff\ised  in  masses  varying  in  size  fioin  a 
walnut  to  that  of  a  hen's  egg,  at  others,  disseminated  in  miliarv  spots 
through  the  organ.  In  two" cases,  these  altered  masses  of  the  spleen's 
substance  had  softened  and  burst  into  the  peritoneum,  causing  fatal 
peritonitis.  In  another  case,  a  distinct  line  of  separation  was  ob'served 
to  be  forming  round  a  mass  about  the  size  of  a  walnut. 

*  Medico-Chirurg.  Trans  of  Loudon.     Vol.  xii. 


CONTINUED    FEVER.  873 

On  examining  this  altered  texture  in  the  spleen  with  a  power  of  250 
diameters  linear,  it  was  found  to  consist  of — 1st,  numerous  molecules 
and  granules ;  2d,  free  nuclei  ;  3d,  compound  granular  cells  of  various 
sizes ;  4th,  fragments  of  the  fibrous  tissue  and 
fusifoini  corpuscles  of  the  organ.  The  granu- 
lar cells  were  frequently  ruptui-ed,  more  or  less 
broken  down,  and  appeared  to  me  at  tliat  time 
to  constitute  the  structural  character  of  a  new 
formation  which  had  been  described  by  Roki- 
tanski  and  other  Gei-man  pathologists,  as 
typhus  deposit.  This  deposition,  according  to 
them,  bears  the  same  relation  to  the  constitu- 
tion of  the  blood  in  cases  of  typlius  fever,  as 
tubercle  and  cancer  do  to  the  tubercular  and        J^ig- -i"^-  xr^.-njv. 

cancerous  cachexia3.  Although  the  facts  described  bv  Rokitanski  and 
others  are  quite  correct,  as  well  as  his  description  of  the  structure  of  this 
altered  tissue  Avhich  I  confirmed  in  184G-V,  fuither  observation  has  con- 
vinced me  that  these  alterations  are  not  peculiar  to  typhus,  and  do  not 
constitute  a  distinct  form  of  exudation.  They  consist,  in  point  of  fact, 
of  a  peculiar  degeneration  of  the  splenic  pulp,  which  follows  a  greater 
or  less  increased  growth  of  the  glandular  cells,  the  morbid  anatomy  of 
which  is  displayed  in  a  series  of  preparations  I  placed  in  the  University 
Museum,  where  they  can  be  studied. 

Lungs. — The  organs  most  frequently  affected  after  the  spleen  were 
the  lungs.  The  most  common  lesion  was  bronchitis,  the  bronchial  lining 
membrane  being  of  a  deep  mahogany  or  purple  colour,  more  or  less 
infiltrated  with  serum  or  exudation.  The  fine  bronchial  tubes  Avere  fre- 
quently filled  with  a  muco-purulent  matter,  and  in  a  few  cases  were 
choked  up  with  a  reddish-brown  gelatinous  substance,  more  or  less  fluid 
— probably  a  modified  form  of  the  exudation  described  by  Remak,  as 
discovered  by  him  in  the  sputum.  The  apices  of  the  lungs  were  very 
commonly  axlematous,  yielding  on  section  a  copious  grayish  fiothy 
fluid.  In  fifteen  cases,  the  lungs  were  more  or  less  consolidated  by  exu- 
dation, which  seldom  presented  the  characters  of  normal  hepatization. 
It  was  sometimes  of  a  dirty  yellow  tint,  at  others  of  a  brownish  choco- 
late colour,  existing  in  masses  of  irregular  outline,  and  of  variable  size, 
resembling  the  discoloured  portions  of  the  splenic  pulp,  formerly  alluded 
to.     In  three  cases  there  was  pulmonaiy  apoplexy. 

The  dirty  yellow  or  chocolate-coloured  exudation  into  the  lungs  was 
ascertained,  on  microscopic  examination,  to  consist  of, — 1st,  numerous 
molecules  and  granules,  filling  up  the  air  vesicles,  and  infiltrated  into 
the  areolar  tissue  ;  2d,  naked  nuclei ;  3d,  enlarged  and  isolated  epithelial 
cells,  with  multiplying  nuclei  ;  and  4th,  several  compound  gramilar  cor- 
puscles. This  uoaterial  was  also  supposed  to  belong  to  the  so-called 
typhous  deposits,  but  is  more  probably  in  part  an  altered  exudation, 
dependent  on  the  constitution  of  the  blood,  and  partly  a  desquamation 
of  the  epithelium,  with  tendency  to  multiplication  of  inclosed  nuclt-i. 

Intestines. — The  intestines  presented  the  lesion  so  well  described  by 


Fig.  495.  Structure  of  a  decolorized  mass  in  the  spleen. 

Fig.  496.  The  same  after  the  addition  of  acetic  acid.  250  diam. 


871 


DISEASES   OF   THE   BLOOD. 


Bretoiinean,  Louis,  Cruveilhier,  and  others  (dotliinenteritis,  typhoid  ulcer, 
etc.),  in  nineteen  cases.     It  consisted  of  a  peculiar  alteration'of  the  round 


^Si 


li_  497 


rig  498 


■'tis 


Vis.  499. 


and  oval  glandular  patches  of  the  small  intestine,  exhibiting  in  its  first 
stage  a  flesh-coloured  mass,  raised  above  the  mucous  membrane,  pre- 
senting in  the  round  patches  the  form  of  a  pimple,  or  a  split  pea,  and  in 
the  oval  ones  an  abrupt  elevation,  resembling  an  inverted  dish.  In  the 
second  stage  this  mass  was  more  or  less  softened,  especially  round  the 
edges,  exhibiting  a  tendency  to  separate  and  slough.  In  the  third  stage, 
the  slough  had  separated,  leaving  an  ulcer,  with  abrupt  edges,  equal  in 
area  to  the  size  of  tbe  gland  afieeted,  but  varying  in  depth,  occasionally 
passing  through  the  muscular,  and  resting  on  the  peritoneal,  coat  of  the 
intestine.  In  this  latter  case,  the  peritoneum  externally  often  presented 
a  red  or  violet  patch  of  congested  vessels,  indicating  the  ulcer  below. 
The  elevated  patches  were  observed  occasionally  to  extend  as  high  as 
the  duodenum,  and  as  low  as  the  rectum.  In  one  case  numerous 
dothinenteritic  elevations,  about  the  size  and  shape  of  a  split  pea, 
extended  all  over  the  ascending  and  transverse  colon.  In  a  few  cases 
the  isolated  follicles  in  the  large  intestine  were  observed  swollen  and 
empty,  pi-esenting  in  their  centre  a  dark  blue  or  black  spot.  In  others, 
the  round  and  oval  patches  of  the  small  intestine  exhibited  a  grayish  or 
slate-blue  appearance.  Perforation  of  the  intestine  from  ulceration, 
causing  fatal  peritonitis,  occurred  in  three  cases.  Dysentery,  with  flakes 
of  lymph  attached  to  the  mucous  surface  over  the  ascending  and  trans- 
verse colon,  was  associated  with  intense  dothinenteritis  in  one  case. 
Oval  and  round  cicatrices,  exhibiting  ditferent  stages  of  the  healing  pro- 
cess of  the  intestinal  typhous  ulcer,  were  observed  in  two  cases. 

On  examining  the  matter  found  in  the  intestinal  slands  in  the  above 
cases,  it  was  shown  to  consist  of  numerous  molecules  and  granules,  asso- 
ciated with  free  nuclei  and  cells  of  the  glandular  sacs,  which  were  unusu- 
ally distended,  and  filled  with  cell  elements,  in  various  stages  of  develop- 
ment and  disintegration.  In  this  respect  it  closely  resembled  the  altered 
substance  of  the  spleen,  formerly  described,  and  indeed  appeared  to  con- 
sist of  the  same  glandular  lesion. 

Mesenteric  Glands. — In  all  the  cases  where  the  intestinal  ulcerations 
were  recent,  tlie  mesenteric  glands  were  enlarged,  soft,  and  friable,  and 

Fig.  497.  Appearance  of  exudation  and  epitlielial  cells  in  the  lung  in  a  case  of 
typhoid  pneumonia. 

Fig.  493.  Another  portion  of  the  same  lung,  after  the  addition  of  acetic  acid. 
Fig.  499.  Portions  of  normal  epithelium  separated  from  the  air  vesicles.    250  diarn. 


CONTIXUED   FEVER.  875 

of  a  ofravish  or  reddish-purple  colour.  Some  of  these  glands  reached 
the  size  of  a  heu's  egg.  On  section  they  presented  a  finely  g-ranular 
surface,  of  a  dirty  yellow -grayish  or  dark  fawn  colour,  and  their  sub- 
stance was  generally  soft  and  friahle,  but  sometimes,  in  one  or  more 
parts  of  the  swollen  gland,  broken  down  into  a  lluid  of  creamy  con- 
sistence. 

On  examining  this  creamy  matter,  or  the  fluid  squeezed  from  the 
gland,  with  a  power  of  250  diameters  linear,  it  was  found  to  contain 
mmierous  cells,  generally  spherical,  varying  in  diameter  from  the  l-150th 
to  the  l-35th  of  a  millimetre.  In  some  cases  numerous  nuclei  were  con- 
tained in  the  cell,  occupying  three-fourths  of  its  interior,  generally  about 
the  l-200th  of  a  millimetre  in  diameter.  At  other  times  from  one  to 
four  of  these  nuclei  were  seen  scattered  within  the  cell.  On  the  addi- 
tion of  acetic  acid  the  cell-wall  was  rendered  very  transparent,  whilst 
the  nuclei  were  unatfected.  Many  of  them  were  free,  and  at  first  looked 
like  altered  blood  corpuscles,  from  which  they  were  at  once  distin- 
guished by  the  action  of  acetic  acid.     (See  Figs.  200  to  202,  p.  172.) 

Blood. — The  blood,  in  the  great  majority  of  cases,  "was  fluid,  and  of  a 
dirty  brownish  colour.  In  those  instances,  however,  where  the  disease 
had  been  protracted,  and  especially  in  such  as  presented  well-marked 
glandular  disease,  firm  coagula  w  ere  found  in  the  heart  and  large 
vessels. 

Other  Lesions. — AYith  regard  to  the  other  lesions  observed  in  the  63 
bodies,  it  may  be  said  that  in  two  there  were  glossitis,  and  laryngitis 
with  tonsillitis ;  in  one,  abscess  of  the  kidney  ;  and  in  one,  abscess  of 
the  posterior  mediastinum.  The  brain  did  not  appear  to  participate 
much  in  the  disease.  It  presented  only  occasional  congestion,  with 
slight  etfusion  into  the  subarachnoid  cavity,  or  into  the  lateral  ventricles. 
In  seven  bodies  no  lesion  whatever  could  be  discovered. 

Such  is  a  summary  of  the  appearances  observed  in  sixty-three  bodies 
of  patients  who  died  of  fever  during  the  prevalence  of  the  typhoid  form 
of  the  disease,  during  1846-7.  The  proportion  of  typhoid  to  typhus  cases 
I  have  now  no  means  of  ascertaining.  On  the  whole,  however,  the 
account  given  is  a  faithful  description  of  the  frequency  Avith  which  the 
individual  lesions  occurred,  and  of  their  minute  structure. 

AVith  regard  to  the  nature  of  typhoid,  as  of  all  other  forms  of  fever, 
we  know  little  ;  but,  from  what  has  been  said,  it  is  impossible  to  avoid 
seeing,  that  the  spleen,  mesenteric  and  intestinal  glands,  are  especially 
liable  to  be  aftected.  Xow  these  glands  constitute  part  of  an  apparatus 
which,  I  believe,  secretes  the  blood  (see  Leucocythemia)  ;  and  if  so,  we 
begin  to  catch  a  glimpse,  at  all  events,  of  the  connection  between  altera- 
tions of  these  structures  and  of  the  blood  in  fever.  Further  researches, 
however,  are  required  to  determine  the  nature  of  such  connection,  as 
well  as  how  far  in  this  disease  the  glands  operate  upon  the  blood,  and 
the  blood  upon  the  glands. 

Of  the  numerous  questions  which  will  be  found  discussed  in  syste- 
matic works  relating  to  the  pathology  and  mode  of  propatration  of  con- 
tinued fever,  I  shall  only  here  allude  to  one,  namely,  AVhether  it  be  or 
be  not  advisable  and  right  to  admit  fever  cases  into  the  general  ward  of 
a  hospital.  My  reply  is  decidedly  in  the  aflirmative,  being  satisfied  it  is 
far  better  in  every  point  of  view  to  dilute  the  contagious  element,  rather 


876 


DISEASES   OF   THE   BLOOD. 


than  to  concentrate  it  by  providing  special  wards  for  typhus  cases.  Pre- 
vious to  1825,  a  few  fever  cases  were  treated  in  each  clinical  ward  of 
this  Infirmary  without  injury  to  the  other  patients,  the  disposition  of  the 
fever  beds  being  represented  in  shadow,  in  Fig.  500.     The  space  around 


Fitr.  500. 


them  was  partially  isolated  by  a  screen  partition,  seven  feet  high,  with  a 
door  at  each  end.  At  present  the  arrangement  of  fever  beds  in  the 
clinical  wards  is  represented,  Fig.  501.     Each  bed  has   1100  cubic  feet 


of  space,  and  8i-  feet  of  head  room.     There  is  a  window  on  each  , 
every  fever  bed,  and  a  space  of  six  feet  between  it  and  the  ad] 
ones.     The  result  of  this  system  has  been   most  satisfactorv,  as 
the  last  ten  years  there  has  been  no  spi'ead  of  fever  in  the  wards, 
on  one  occasion,  which  was  traced  by  Dr.  Christison  to  the  rules 
house  having  been  neglected.* 


side  of 
oining 
during 
except 
of  the 


Treatment  of    Continued  Fever. 

The  general  treatment  of  continued  fever  which  I  have  found   most 
*  Monthly  Journal  of  Medical  Science,  March  1850. 

Fio:.  500.  A  clinical  ward  of  the  Royal  Infirmary  in  1817,  GO  feet  by  24,  showing 
the  arrangement  of  fever  beds,  and  the  screen  which  isolated  them. — (Christison.) 

Fig.  .501.  Clinical  ward,  No.  XL,  1858,  81  feet  by  24,  showing  the  present 
arrangement. — ( Clwistison. ) 


COXTIXUED    FEYER.  877 

useful,  an<l  which  you  have  seeu  practised  in  this  Infirmary,  consists, 
during  the  stage  of  excitement,  of  giving  saline  antimonials,  adminis- 
tering slight  laxatives  if  occasion  require  them,  and  ordering  the  head  to 
be  shaved  and  cold  applied.  Wine  and  stimulants  are  required  at  a 
later  period  when  the  pulse  becomes  weak.  In  prolonged  cases,  the 
effect  of  pressure  on  the  skin  from  decubitus  must  be  carefully  guarded 
against,  whilst  the  ditferent  complications  which  arise  will  require  care- 
ful management. 

Salines  and  Laxatives. — At  an  early  period  of  the  disease,  when  the 
skin  is  liot  and  the  pulse  rapid  and  strong,  the  saline  mixture  generally 
ordered  is  the  following  : — IJ  Sol.  Tart.  Antim.  3  ss  ;  Liq.  Amman. 
Acet.  3  ij  ;  Aquce,  3  vss.  M.  Fiat  mist.,  a  tahle-sjioonful  to  be  taken 
every  four  hours.  Should  a  laxative  or  purgative  be  required,  not  other- 
wise, castor  oil  is  the  one  usually  employed.  AVater  or  thin  lemonade 
may  be  taken  ad  libitum. 

Cold  to  the  Head. — The  oppressive  headache  of  fever  is  greatly  alle- 
viated by  cold  applications  to  the  head.  Indeed  none  but  those  who 
have  experienced  it  can  understand  the  feeling  of  relief  and  grateful 
sensation  of  ease  which  is  in  this  way  produced.  The  best  method  of 
applying  cold  I  have  found  to  be  as  follows  :— A  washdiand  basin 
should  be  placed  under  the  ear  on  one  side,  and  the  head  allowed  to  fall 
over  the  vessel  by  bending  the  neck  over  its  edge.  Then  from  a  ewer  a 
stream  of  cold  water  should  be  poured  gently  over  the  forehead,  and  so 
directed  that  it  may  be  collected  in  the  basin,  care  being  taken  not  to 
wet  the  dress  or  bed-clothes.  It  should  be  continued  as  long  as  it  is 
agreeable  to  the  patient,  and  repeated  frequently.  In  hospitals,  and 
more  especially  in  fever  wards,  this  method  requires  too  much  attend- 
ance. You  will  have  observed,  indeed,  that  I  seldom  order  cold  to  the 
head,  experience  having  taught  me  that  it  is  more  frequentlv  converted 
into  warmth  to  the  head.  For  notwithstanding  every  injunction  to  the 
contrary,  all  that  is  done  in  these  cases  is  to  moisten  a  piece  of  double 
rag  or  lint  in  cold  water,  and  lav  it  upon  the  warm  head  of  the  patient. 
In  a  few  seconds  it  is  converted  into  a  warm  and  steaming  fomentation, 
and  too  frequently  allowed  to  remain  in  this  condition  for  hours.  Hence, 
unless  cold  can  be  applied  properly  (and  in  large  hospitals  that  can 
scarcely  be  expected  without  procuring  a  nurse  for  every  two  or  three 
patients)  it  is  better  not  to  order  it  at  all.  It  has  occurred  to  me,  how- 
ever, that  a  water-pipe  might  be  conveyed  round  the  walls  of  fever- 
wards,  with  a  vulcanised  india-rubber  tube  and  stop-cock  attached,  so 
that  with  a  little  contrivance  the  patients  might  procure  a  How  of  cold 
water  and  regulate  it  for  themselves.  I  am  satisfied  that  much  relief 
would  be  in  this  way  obtained. 

To  secure  the  application  of  cold  efficiently,  it  is  necessary  that  the 
head  be  shaved.  In  all  severe  cases  this  is  indispensable.  Such  practice, 
however,  is  often  stoutly  opposed  by  the  friends  of  young  women,  who 
are  unwilling  that  they  should  lose  a  handsome  growth  of  hair.  I  have 
occasionally  compromised  the  matter  by  allowing  the  long  hair  to  float 
in  cold  water,  and  act  by  capillary  attraction  on  the  scalp,  so  as  to  keep 
up  a  refreshing  feeling  of  coolness. 

Wine  and  Stimulants. — AVhen  after  being  rapid  and  stroncr,  the  pulse 
falters,  becomes  soft  and  weak,  very  often  without  losing  its  frequency, 


878  DISEASES   OF  THE   BLOOD. 

it  will  become  necessary  to  administer  wine  or  other  stimulc'ints.  The 
quantity  of  wine  usually  given  is  from  three  to  six  ounces  a  day ;  hut  in 
some  cases  marked  by  unusual  depression,  or  when  the  individual  has 
been  accustomed  to  alcoholic  drinks,  a  larger  quantity,  or  instead,  from 
one  to  four  ounces  of  spirits  may  be  required.  Nothing  is  more  difficult 
than  to  lay  down  rules  as  to  the  extent  to  which  stimulants  ought  to  be 
given  in  certain  cases,  or  as  to  the  period  when  thej^  should  be  adminis- 
tered. The  pulse,  strength  of  constitution,  previous  habits  of  the  patient, 
but  above  all  the  tvpe  of  the  prevailing  epidemic,  must  be  your  chief 
guides.  Nothing,  perhaps,  is  more  indicative  of  experience  and  practical 
tact  in  the  treatment  of  fever  than  the  judicious  use  of  stimulants  in 
this  disease,  and  certainly  there  is  no  other  method  of  acquiring  the 
necessary  knowledge  than  that  of  carefully  watching  their  etfects  in  a 
large  number  of  patients.  Among  all  the  agents  at  your  command, 
there  are  none  which  will  enable  you  to  conduct  a  case  of  fever  to  a 
favourable  termination  more  successfully  than  stimulants,  when  properly 
managed.  Indeed,  it  is  easy  to  conceive  that  in  a  disease  where  loss  of 
appetite,  and  abstinence  from  food,  constitute  essential  phenomena,  a 
period  must  arrive  sooner  or  later,  when  artificial  support  is  absolutely 
required.  You  should  be  careful,  however,  not  to  prolong  tlieir  use 
more  than  is  necessary.  Very  singular  anecdotes  still  linger  about  the 
clerks'  rooms  of  this  infirmary,  of  instances  where  whole  bottles  of  whisky 
were  consumed  daily  by  fever  patients  ;  and  where,  notwithstanding  their 
recovery,  owing  to  some  mistake  in  the  ordei'-book,  the  whisky  was  still 
supplied,  and  disappeared  with  surprising  legnlarity. 

Regulation  of  the  Diet. — During  the  early  period  of  fever,  the  patient 
generally  loathes  all  kind  of  food.  Care  must  be  taken,  however,  that 
after  a  few  days  have  elapsed,  nourishment  should  be  introduced  in  the 
form  of  drink,  and  diluted  milk,  toast  and  water,  thin  panada  or  similar 
fluids  given,  with  a  little  toast  or  biscuit.  Should  collapse  come  on, 
together  with  the  stimulants,  chicken  broth  or  good  strong  beef-tea 
should  be  administered.  I  am  inclined  to  think  that  the  danger  from 
fever  is  not  the  result  of  over,  but  of  under,  nourishment,  which,  by 
reducing  the  strength,  leaves  the  patient  less  capable  of  struggling  with 
the  subsequent  weakness.  I  have  especially  noticed,  with  regard  to 
relapsing  fever,  that  those  who  have  fed  well  in  the  interval,  have  been 
less  affected  by  the  re-accession.  The  body  is  also  drained  of  its  saline 
constituents,  whilst  such  as  enter  with  the  food  are,  with  it,  cut  off; 
hence  I  have  found  it  useful  to  add  a  large  amount  of  common  salt  to 
the  beef-tea,  which  also  renders  it  more  sapid  and  agreeable  to  the 
patient,  and  serves  to  clear  away  the  accumulation  of  fur  and  sordes 
that  gather  about  the  mouth.  On  the  other  hand,  when  convalescence 
comes  on,  we  should  take  care  not  to  indulge  the  appetite  too  much. 

With  regard  to  the  complications  of  fever  I  have  nothing  further  to 
say,  than  that  they  must  be  treated  according  to  circumstances,  always 
keeping  in  remembrance  that  active  depleting  means  are  never  useful, 
and  seldon*  fail,  by  diminishing  the  vital  powers,  to  augment  the  collapse 
and  increase  the  danger. 

Can  we  cut  short  a  Continued  Fever? — There  can  be  little  doubt  that 
it  is  of  immense  importance  to  cut  short  the  disease,  if  possible.  "With- 
out speaking  too  positively,  I  have  been  induced  to  believe  in  this  possi- 


CONTINUED   FEVER.  879 

bility,  under  certain  circumstances,  by  means  of  emetics.  A  fortnight 
after  being  appointed  Physician  to  the  Fever  Hospital  of  this  city,  in 
1844,  I  ex{)enenced  lassitude,  headache,  and  that  peculiar  cold  feeling  in 
the  back,  which  generally  usher  in  fever.  I  took  an  emetic  of  antimony 
and  ipecacuanha,  and  on  the  following  day  was  well.  Three  weeks 
afterwards,  I  experienced  the  same  symptoms;  but  tljinking  it  possible 
that,  after  all,  the  emetic  had  not  really  been  the  cause  of  their  removal, 
I  allowed  the  disorder  to  proceed,  which  terminated  in  a  prolonged 
relapsing  fever,  with  three  distinct  relapses.  I  think  I  have  observed 
the  same  thing  in  other  cases;  and  now,  as  a  rule,  whenever  called  in  at 
the  early  period  of  fever,  I  alwavs  order  an  emetic.  This  practice,  so 
far  as  I  have  observed,  never  does  harm,  often  good ;  and,  although  the 
point  is  of  course  impossible  to  demonstrate,  it  has,  1  think,  been  suc- 
cessful in  checking  at  the  onset  many  cases  of  fever. 

With  regard  to  cutting  short  continued  fever  by  quinine,  as  con- 
tended for  by  Dr.  Dundas,  I  regret  to  say  that  the  trial  you  have  seen 
made  of  it  has  entirely  failed.  In  none  of  the  seven  cases  (Cases  CXCV., 
CXCVL,  CXCVIII.;  CXCIX.,  CC,  CCL,  and  CCII.)  in  wliich  it  was 
given,  notwithstanding  the  physiological  action  of  the  drug  was  Avell 
marked,  did  it  in  any  way  shorten  the  disease,  or  produce  on  its  pro- 
gress, so  far  as  I  could  ascertain,  any  amelioration  whatever.  On  the 
other  hand,  it  may  be  argued  that  in  one  case  (Case  CXCVIII.),  it  was 
injurious,  by  increasing  the  cerebral  complication.  Dr.  Christison  also 
tried  it  in  one  case,  and  Dr.  W.  Robertson  in  eight  cases,  both  with  a  want 
of  success.  Thus,  in  sixteen  cases  it  has  been  carefully  and  energetically 
tried,  with  uniform  failure  in  all. 

Therapeutic  Action  of  Quinine  in  Fever. — The  effects  produced  by 
large  doses  of  quinine  are  worthy  of  observation.  AVith  these  I  became 
first  familiar  in  the  wards  of  M.  Piorry,  in  La  Pitie  Hospital,  Paris, 
during  the  year  1838.  At  that  time  quinine  was  given  in  enormous 
doses,  with  a  view  of  cutting  short  intermittents,  and  diminishing  the 
size  of  the  spleen.  In  this  way  I  frequently  saw  50  grains  of  quinine 
or  100  grains  of  salicine  given  in  one  dose,  the  administration  of  which 
was  followed  by  the  same  effects  you  have  observed  to  follow  repeated 
doses  of  10  grains  in  the  Ro3al  Infirmary.  In  both  cases  the  principal 
phenomena  induced  are  vertigo,  dizziness  of  vision,  ringing  in  the  ears, 
often  complete  deafness,  with  confusion  of  ideas,  occasionally  coma  with 
contraction  of  the  pupil.  At  the  same  time  the  force  and  frequency  of 
the  heart's  contractions  are  diminished,  and  the  pulse,  from  being  i'20, 
strong  and  full,  was  frequently  reduced  in  a  few  hours  to  80  beats,  which 
were  soft  and  even  weak.  The  skin  at  the  same  time  becomes  cool  and 
often  moist  from  slight  diaphoresis.  This  sedative  action  on  the  heart 
is  apparently  the  result  of  the  comatose  condition  produced  by  the 
primary  action  on  the  brain,  as  is  proved  by  the  fiict  that  the  disappear- 
ance of  the  cerebral  induces  cessation  of  the  circulatory  phenomena.  In 
large  doses,  therefore,  quinine  is  a  narcotic.  At  all  events,  its  principal 
action  seems  to  be  on  the  nervous  system,  througli  which  it  seems  to 
operate  on  the  blood-vessels  and  blood.  Of  late  years  it  has  been  called 
an  anti-periodic,  from  the  specific  effects  it  exercises,  not  only  on  inter- 
mittents, but  on  all  diseases  which  exhibit  a  tendency  to  return  at 
periodic   intervals,  as   certain    cases   of  epilepsy,   neuralgia,   and   even 


880  DISEASES   OF   THE   BLOOD. 

relapsing  fever.  This  property  is  altogether  peculiar,  and  is  distinct 
from  what  ought  to  be  understood  by  febrifuge,  unless  indeed  the  state- 
ments and  views  of  Dr.  Dundas  should  be  subsequently  confirmed. 

Quinine  is  also  spoken  of  as  being  a  tonic  when  given  in  small  doses. 
This  property  seems  to  have  been  attributed  to  it  on  account  of  its  bitter- 
ness, as  well  as  its  remarkable  effects  in  the  cure  of  ague.  But  whether 
it  increases  the  appetite,  stimulates  the  digestive  organs,  or  in  any  other 
way  operates  by  increasing  the  tone  of  the  system  and  improving  the 
nutritive  powers,  is  a  circumstance  which,  though  generally  adopted  as 
true,  admits  of  strong  doubt.  If  quinine  be  a  narcotic  in  large  doses,  it 
is  the  only  one  of  that  class  of  remedies  which  is  tonic  in  small  doses. 
No  doubt  it  is  very  frequently  given  to  convalescents  and  weaklv  per- 
sons, who  get  better  under  its  use,  but  whether  this  is  owing  to  the 
quinine,  or  would  not  have  occurred  equally  well  without  it,  is  a  matter 
very  difficult  to  determine.  Of  one  thing  I  am  satisfied,  namely,  that  it 
is  far  inferior  in  tonic  pi'operties  to  many  metallic  and  other  vegetable 
drugs,  and,  consequently,  a  medicine  with  such  known  valuable  anti- 
periodic  properties,  the  supply  of  which  also  is  yearly  diminishing,  should 
not  be  wasted  in  endeavouring  to  produce  effects  so  very  doubtful  as  the 
tonic  virtues  which  have  been  ascribed  to  it.  For  many  years,  there- 
fore, I  have  not  given  quinine  as  a  tonic,  and  have  yet  to  meet  with  a 
case  where  it  is  necessary  to  administer  it  in  order  to  increase  the 
strength  of  the  system. 


REMITTENT  FEVER— CAN  IT  BE  SEPARATED  FROM  ACUTE 
HYDROCEPHALUS  ? 

Case  CCIX.* — Blanche  Scott,  SBt.  3  years,  of  scrofulous  habit — admitted  into  the 
clinical  ward  November  lOtli,  1851.  Her  mother  states  that  she  enjoyed  good 
health  until  a  fortnight  ago,  when  she  was  attacked  with  severe  diarrhoea — the 
stools  being  thin,  of  a  dirty  green  colour,  offensive  odour,  and  mingled  with  slimy 
matter.  She  became  dull  and  peevish  during  the  day,  but  restless  and  uneasy  at 
night,  when  the  skin  became  hot,  and  the  countenance  flushed.  The  diarrhoea  and 
fever  continued  eight  or  ten  days,  accompanied  with  loss  of  appetite  and  great  thirst. 
During  the  last  four  days  there  has  been  delirium;  loss  of  consciousness ;  occasional 
moaning;  uneasy  gestures  in  demand  for  drink;  hands  frequently  raised  to  the  head, 
with  a  slight  scream;  constant  picking  of  the  nose  and  angles  of  the  mouth  with 
her  fingers;  latterly,  retching  and  vomiting,  and  passage  of  the  urine  and  foeces 
in  bed. 

Symptoms  on  Admission. — On  admission  she  presents  tlie  following  symptoms : 
— Unconsciousness  of  surrounding  objects,  not  recognising  even  her  mother ;  pupils 
not  contractile  to  light ;  slight  strabismus  of  right  eye ;  frequently  puts  her  hands 
to  the  head,  which  is  rolled  about  uneasily ;  continual  grinding  of  the  teeth,  low 
moaning,  and  occasional  muttering.  Tip  of  tongue,  which  is  all  that  can  be  seen, 
very  dry,  and  of  scarlet  colour ;  loss  of  appetite ;  constant  thirst;  vomiting;  involun- 
tary discharge  of  fcEces  and  urine ;  on  pressing  the  abdomen  uneasiness  evidently 
experienced,   and  moaning  increased.     Skin  hot  and  dry;    no  eruption;    a  small 

♦  Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


REMITTENT   FEVER.  881 

abscess  at  the  back  of  the  neck,  with  a  sanious  discharge.  Action  of  heart  feeble 
and  fluttering.  Pulse  140,  .small,  and  occasionallj^  intermittent.  Breathing  short 
and  hurried ;  no  rales.  The  head  to  be  shaved,  and  a  blister  to  be  ajjplied  over  the 
scalp.     To  have  3  ij  0/  sherry  wine. 

Progress  of  the  Case. — Xovember  V2th. — The  fever  increased  towards  night, 
and  she  was  very  restless.  This  morning  it  has  abated.  Skin  now  cool;  pulse  120, 
stronger  and  regular ;  no  strabismus ;  still  unconscious.  Pus  has  formed  below  the 
blistered  cuticle.  JN'oy.  \ith — Accession  of  fever  last  night;  the  pulse  rising  to  160, 
and  becoming  sharp  This  morning  consciousness  has  returned;  fever  abated: 
tongue  dry,  brown,  and  cracked;  swallows  without  difficult}-;  pulse  120.  Nov. 
loth. — There  are  still  accessions  of  fever  at  night,  and  remissions  in  the  morning. 
The  scalp  is  swollen  and  boggy  to  the  touch,  and  pus  oozes  from  it  on  making 
pressure.  All  movement  of  the  head  causes  the  child  to  cry.  Xo  tenderness  of 
abdomen.  Bowels  are  opened  three  times  daily.  Fceces  are  more  consistent,  of 
dull  green  colour,  and  offensive  smell  Pulse  110,  more  full.  Three  parallel  inci- 
sions were  made  through  the  intiltrated  scalp,  by  which  a  considerable  quantity  of 
pus  was  evacuated.  To  take  5j  of  cod-liver  oil  three  times  a  day.  Chicken  diet. 
Continue  the  wine.  From  this  period  she  rapidly  improved.  The  remittent  fever 
ceased  on  the  13th.  Extensive  sinuses  formed  in  the  scalp,  covering  the  occiput 
and  neck,  which,  however,  gradually  healed  on  the  application  of  a  sulphate  of  cop- 
per lotion.  Slight  bronchitis  appeared  on  the  25th.  The  appetite  soon  after  became 
very  good;  her  strength  improved.  The  incisions  in  the  scalp  had  perfectly  cica- 
trised on  the  1st  of  December,  and  on  the  11th  she  was  discharged;  the  abscess  in 
the  neck,  however,  not  having  quite  healed. 

Commentary. — In  this  case  the  fever  was  of  a  distinctiv  remittent 
type — the  accessions  being  very  marked  at  night,  and  the  remissions 
very  considerable  in  the  morning.  It  commenced  with  intestinal,  which 
were  followed  by  cerebral  symptoms.  Was  it  a  case  of  gastro-enteriti.s, 
or  of  cerebral  meningitis,  or,  as  these  disorders  are  called  by  some, 
remittent  fever,  or  acute  hydrocephalus?  Xo  doubt  these  two  separate 
diseases  exist ;  bnt  if  you  ask  me  by  what  symptoms  von  mav  distin- 
guish one  from  the  other  in  children  at  an  early  period,  I  should  be  at 
a  loss  to  reply.  In  the  whole  range  of  practical  medicine,  this  must  be 
allowed  to  constitute  a  question  of  the  greatest  difficulty  to  decide. 
Indeed,  I  am  inclined  to  consider  that  it  cannot  be  done  until  the  disease 
is  so  far  advanced  as  to  render  the  cerebral  symptoms  unequivocally 
predominant.  In  systematic  works  on  the  practice  of  physic,  you  will 
find  the  diagnostic  characters  of  the  two  diseases  set  forth  with  wonder- 
ful order  and  propriety ;  but  if  you  depend  on  these  at  the  bedside,  vou 
will,  in  the  majority  of  cases,  be  greatly  disappointed. 

Xow,  if  the  symptoms  observed  in  the  case  before  ns  be  taken  into 
consideration,  it  will  be  seen  that  they  partake  of  the  characters  of  both 
diseases.  Such  I  believe  to  be  really  the  case,  the  old  distinctions  between 
remittent  fever  and  hydrocephalus  having  no  basis  on  morbid  anatomy. 
The  formei-,  however,  is  connected  with  irritation  in  the  dio-estive  oro-ans, 
the  latter  with  cerebral  congestion  or  inflammation.  It  is  clear  that 
these  two  lesions  may  be  conjoined  in  difterent  cases  in  various  degrees 
and  hence  the  different  aspects  presented  in  practice.  The  so-called 
remittent  fever  and  acute  hydrocephalus  of  authors,  then,  cannot  be  sepa- 
rated, and  in  most  instances  are  mingled  together.  The  case  of  Si;ott 
was  one  of  this  description,  commencing  with   symptoms  of  intestinal 

56 


882  DISEASES   OF  THE   BLOOD. 

derangement,  accompanied  by  fever  of  a  remittent  type,  complicated  at 
a  later  period  by  cerebral  congestion  of  an  asthenic  character ;  in  short, 
the  hydrocephaloid  disease  of  Marshall  Hall. 

The  treatment  was  in  accordance  with  this  view  of  the  case,  consisting 
of  small  quantities  of  wine,  good  noui-ishment,  blisters  to  the  scalp,  and 
subsequently  cod-liver  oil.  Several  of  you  expressed  the  opinion  that 
this  was  a  case  of  hydrocephalus,  and  a  few  were  inclined  to  give  mer- 
cury. As  to  hydrocephalus,  much  depends  on  what  is  meant  by  that 
term.  If  by  it  is  understood  cerebral  meningitis,  then  it  was  not  hydro- 
cephalus ;  but  if  it  means  certain  cerebral  symptoms,  independent  of  any 
particular  lesion,  then  it  was.  Such  symptoms,  however,  may  arise  from 
exhaustion,  as  well  as  from  over-excitement,  and  the  one  we  had  to  do 
with  was  certainly  a  case  of  this  kind,  coming  on,  as  it  did,  after  pro- 
tracted diarrhoea  and  fever. 

As  to  mercury,  1  have  no  hesitation  in  saying,  had  we  depended  on  it, 
as  some  recommend  should  be  done  in  similar  ca.^es,  the  patient  would 
never  have  recovered.  It  has  been  said  that  mercury  is  the  sheet-anchor 
of  the  practitioner  in  hydrocephalus.  I  have  never  seen  it  beneticial  in 
nndoubted  cases  of  cerebral  meningitis,  and  the  diagnosis  in  the  vast 
majority  of  instances  is  so  uncertain  as  to  warrant  the  suspicion,  that 
the  recoveries  which  have  taken  place  were  not  those  of  true  inflamma- 
tion. In  this  little  girl,  notwithstanding  the  delirium,  the  coma,  the 
screams,  the  tossing  the  hands  towards  the  head,  the  strabismus,  and  the 
insensible  contracted  pupil — all  of  which  have  been  placed  among  the 
principal  evidences  of  hydrocephalus,  the  treatment  was  brought  to  a 
successful  conclusion  by  stimulants  and  nourishment.  I  do  not  tell  vou 
that  this  will  always  succeed  ;  but  whenever  such  symptoms  follow  pro- 
tracted diarrhoea,  and  are  accompanied  by  remittent  fever,  I  am  satisfied 
you  may  place  more  reliance  on  such  treatment,  aided  by  the  powers  of 
nature,  than  upon  the  vaunted,  but  in  my  opinion  hypothetical,  powei'S, 
of  mercury. 


IXTERMITTEXT  FEVER. 

Case  CCX.* — Tertian  IidenniUent  cured  by  Quinine. 

History. — John  Kelly,  a  labourer — admitted  into  the  clinical  ward  October  20th, 
1851.  Had  always  enjoj^ed  good  health  until  three  months  ago,  when  he  was 
attacked  with  intermittent  fever  in  Lincolnshire,  while  working  at  the  harvest. 
At  first  it  assumed  the  quotidian  type,  but  after  three  weeks  it  became  tertian,  and 
continued  three  weeks  longer.  Then  being  at  Morpeth,  there  was  an  interval  of  a 
fortnight.  On  leaving  Morpeth  he  was  much  exposed  to  cold  and  wet;  the  disease 
returned,  and  has  continued  up  to  the  present  time. 

Progress  of  the  Case. — The  day  after  admission,  he  had  a  well-marked  attack 
of  fever.  The  cold  stage  continued  fifteen  minutes,  and  the  hot  and  sweating  stages 
three  quarters  of  an  hour,  followed  by  languor  and  depression.  He  was  ordered  to 
take  five  grains  of  sulphate  of  quinine  three  times  a  day,  and  a  scruple  of  the  drug 
two  hours  before  the  next  expected  paroxysm.      He  had  two  other  attacks  on  the 

*  Reported  by  Mr.  TT.  M.  Calder,  Clinical  Clerk. 


INTERMITTENT   FEVER.  883 

24tli  and  26tli,  the  latter  being  very  slight.     On  the  28th  there  was  no  attack,  and 
the  sci'uple  dose  was  suspended.     Discharged  cured  November  5th. 

Commentary. — The  cause  of  intermittent  fever  is  tolerably  svell  ascer- 
tained. It  is  found  in  all  countries  which  are  low,  swampy,  and  humid, 
and  in  localities  where  the  ground  is  marshy,  and  presents  a  moist  allu- 
vial soil,  especially  in  the  neighbourhood  of  extensive  woods.  We  must 
not  suppose,  however,  that  marshes  and  a  moist  alluvial  soil  are  the  only 
causes  of  intermittent,  for  in  India  it  sometimes  prevails  in  hilly  districts, 
at  a  considerable  elevation,  and  is  known  by  the  name  of  hill-fever.  We 
may  therefore  conclude  with  Dr.  Fergusson,  that  the  cause  of  intermittent 
is  a  condition  of  the  atmosphere  occasioned  by  evaporation  from  the 
earth's  surface,  by  solar  rays  rather  than  by  currents  of  air.  The  fre- 
quency of  the  disease  during  the  autumn  months  is  in  favour  of  this  theory. 

The  occurrence  or  absence  of  intermittent  fever  in  particular  districts, 
according  as  the  circumstances  just  alluded  to  be  present  or  absent — be 
induced  or  prevented — is  another  proof  of  its  correctness.  Thus  it  is 
not  a  common  affection  in  Paris,  but  in  1838  I  saw  it  very  frequent  in 
the  wards  of  M.  Piorry,  at  La  Pitie  Hospital.  It  arose  among  the  work- 
men of  the  St.  Germains  and  Paris  Railway,  who,  at  a  particular  part  of 
the  line,  which  was  low  and  marshy,  caught  the  disease  in  great  num- 
bers. They  nearly  all  came  to  La  Pitie,  as  M.  Piorry  cured  the  disease 
rapidly  by  large  doses  of  quinine,  and  was  in  consequence  celebrated 
among  them  ;  and  thus,  whilst  numerous  cases  were  always  present  in 
that  hospital,  it  was  very  rare  in  Paris  generally.  On  the  other  hand, 
there  are  many  places  in  which  ague  was  once  common,  where  it  is  now 
rare,  from  the  draining  of  marshes,  or  local  improvements  in  cities. 
Thus  it  was  formerly  common  in  London,  in  the  district  which  surrounds 
the  Tower,  but  disappeared  when  the  ditch  was  allowed  to  become  dry. 
I  have  also  been  told  that,  in  Edinburgh,  when  the  valley  which  now 
separates  the  old  from  the  new  town  was  a  marsh,  ague  was  frequent. 
At  present  it  is  very  rare,  and  never  met  with  except  in  individuals  who 
have  caught  the  disease  elsewhere  and  travelled  to  this  city. 

With  regard  to  the  nature  of  intermittent  fever,  we  know  nothing, 
although  we  infer  that  the  peculiar  condition  of  the  atmosphere  alluded 
to  causes  a  peculiar  change  of  the  blood,  on  which  the  disease  essentially 
depends — but  the  nature  of  that  change — why  it  should  occasion  aii 
intermittent  instead  of  a  continued  effect — why  it  should  produce  in 
different  people  a  quotidian,  a  tertian,  or  a  quartan,  etc.  etc., — of  all  this 
we  are  ignorant.  I  cannot  see  that  its  pathology  has  in  any  way  been 
advanced,  by  endeavouring  to  connect  it  with  diseased  spleen.  No  doubt 
this  organ  is  frequently  enlarged  in  ague,  and  in  chronic  cases  becomes 
hypertrophied  and  indurated.  But  it  is  also  especially  liable  to  undergo 
changes  of  texture  in  continued  fever,  as  we  shalf  subsequently  see. 
Piorry  contends  that  congestive  enlargement  of  the  spleen  is  the  primai'v 
change,  and  that  the  general  fever  is  a  result.  He  has  brought  forward 
numerous  cases,  showing  that,  in  ague,  this  organ  may  be  demonstrated 
by  percussion  to  be  enlarged,  and  that  recovery  is  commensui'ate  with 
its  diminution  in  bulk.  He  cites  one  case  where  an  individual  was 
knocked  down  in  the  street  by  the  shaft  of  a  carriage  which  struck  him 
on  the  left  side  over  the  spleen,  and  in  whom  the  resulting  fever  was 


884  DISEASES   OF   THE   BLOOD. 

distinctly  intermittent.  This  may  Lave  been  a  coincidence.  Careful 
observation,  however,  has  satisfied  me  tliat  there  is  no  uniform  rela- 
tion between  the  enlargement  of  the  spleen  and  the  intensity  of  intermit- 
tent fever,  as  M.  Piorry  supposes.  We  have  seen  that  in  lencocjthemia 
the  spleen  has  been  much  hypertrophicd,  and  no  ague  occasioned.  On 
the  other  hand,  without  denying  that  lesions  of  the  spleen  are  very 
common  in  connection  with  ague,  we  are  unable,  in  the  present  state  of 
pathology,  to  determine  whether  this  be  a  cause  or  an  effect,  or  to 
indicate  why  lesion  of  this  organ  should  sometimes  be  connected  with 
an  intermittent,  at  others  with  a  continued  fever. 

The  treatment  which  experience  has  proved  to  be  most  certain  and 
rapid,  is  that  by  quinine ;  and  I  am  satisfied  that  tolerably  lai'ge  doses 
are  more  efficacious,  than  small  ones  frequently  repeated.  I  usually 
give  five  grains  three  times  a-day,  and  a  scruple  two  hours  before  the 
occui'rence  of  the  attack,  and  have  never  seen  a  case  which  resisted  this 
treatment.  Much  larger  doses  have  been  given.  Thus  I  have  seen 
Piorry  give  fifty  grains  for  a  dose,  with  the  effect  in  recent  cases  of  at 
once  cutting  it  short,  and  rapidly  reducing  the  engorgement  of  the 
spleen ;  but  a  permanent  and  quick  cure  I  believe  to  be  equally  well 
effected  by  the  medium  dose  formerly  recommended.  Quinine  in  large 
doses  produces  very  inconvenient  etiects,  such  as  cephalalgia,  vertigo, 
tinnitus  aurium,  deafness,  and  other  symptoms,  which,  should  any  cere- 
bral complication  exist,  may  render  it  fatal.  During  the  prevalence  of 
intermittent  at  La  Pitie,  in  1838,  a  man  was  treated  with  large  doses  of 
the  drug,  and  the  head  symptoms  attributed  to  its  stimulant  action.  He 
died,  and  on  examination,  acute  meningitis  was  found  with  exudation  of 
lymph  on  the  membranes. 

Some  years  ago.  Dr.  Douglas  Maclagan  introduced  the  sulphate  of 
bebeerine  as  a  substitute  for  quinine,  and,  at  the  time,  I  tried  it,  with 
great  success.  Of  late  years,  however,  it  seems  to  have  lost  its  vir- 
tues;  whether  from  change  in  the  mode  of  preparation,  or  otherwise, 
I  do  not  know.  Certainly  its  good  effects  cannot  now  be  depended  on. 
Salicine  is  a  useful  drug  in  intermittent,  and  from  numerous  experiments 
I  saw  made  with  it  in  the  wards  of  La  Pitie,  in  1838,  it  may  be  depended 
on  when  given  in  double  the  quantity  of  quinine.  Li  some  chronic 
cases  which  have  resisted  quinine,  arsenic  has  been  found  useful.  I  have 
frequently  seen  in  the  south-west  of  England,  a  case  cured  at  once  by  a 
scruple  of  Cayenne  pepper  suspended  in  watei-.  Indeed,  a  vast  number 
of  remedies  have  been  found  occasionally  beneficial  in  intermittent  fever, 
but  there  are  none  so  uniformly  successful  as  quinine. 


ERUPTIVE  FEVERS. 

There  are  certain  diseases  which,  in  an  arbitrary  classification,  may  be 
considered  as  febrile  eruptions,  or  as  eruptive  fevers.  They  comprehend 
especially  scarlatina,  erysipehis,  variola,  and  rubeola.  Occasionally 
roseola,  herpes,  or  other  cutaneous  eruptions,  may  be  attended  with 
fever,  but  they  are  separated  from  the  others  by  their  non-contagious  or 
non-infectious  nature.     Plague  and  glanders,  on  the  other  hand,  are  true 


SCARLATINA.  885 

eruptive  fevers ;    and,  with   the  others  mentioned,  obey  certain   laws, 
which  may  be  shortly  noticed. 

1.  They  may  be  infectious  and  contagious.  By  infection  is  understood 
the  power  of  being  propagated  through  the  inhalation  of  air  tainted  by 
the  breath  or  pei'spiration  of  the  atfected  person.  By  contagion  is 
understood  communication  of  disease  by  actual  contact. 

2.  The  present  theory,  with  regard  to  the  cause  of  these  diseases,  is, 
that  it  depends  upon  a  morbid  poison,  a  small  quantity  of  which  enter- 
ing tlie  blood  produces  in  that  fluid  a  peculiar  change  which  is  analogous 
to  that  of  fermentation.  To  distinguish  this  change  in  animal  from 
what  occurs  in  vegetable  fluids,  the  term  zijmosis  has  been  introduced  bv 
Mr.  Farr  (from  ^ufxow,  to  ferment). 

8.  Some  of  these  animal  poisons,  if  excluded  from  the  air,  or  care- 
fully dried,  will  retain  their  communicating  property  for  a  longer  or 
shorter  time.  This  enables  us  to  preserve  matter  for  artificial  inocu- 
lation. Hence  also  they  have  been  supposed  capable  of  attaching  them- 
selves to  fomites — that  is,  substances  of  a  rough  surface  or  downy  tex- 
ture, such  as  wool,  cotton,  wearing  apparel,  dust,  etc.  It  is  on  this 
theory  that  quarantine  regulations  are  founded,  the  whole  of  which, 
together  with  the  facts,  real  or  supposed,  that  support  them,  require  a 
thorough  revision. 

4.  All  the  animal  poisons  are  distinguished  by  peculiarities  in  their 
mode  of  incubation  and  development.  Thus  a  period  of  latency  exists 
between  exposure  to  the  poison  and  accession  of  the  fever,  or  first  rio-or. 
Again,  the  eruption  appears  at  different  periods  after  the  fever  is 
declared.     Thus — 

Period  of  Latency  Appears  after  first  Rigor 

from  from 

Scarlatina 4  to     8  days IS  to  24  hours. 

Erysipelas 4  to     1  days 24  to  60  hours. 

Variola 8  to  14  days 48  hours. 

Rubeola 7  or     8  days 72  hours. 

5.  All  the  eruptive  fevers,  strictly  so-called,  invariably  run  a  natural 
course,  and  cannot  be  cut  short.     It  follows  that — 

6.  The  treatment  of  febrile  eruptions  has  for  its  object  conducting 
these  cases  to  a  favourable  termination.  To  this  end  exactly  the  same 
general  rules  are  to  be  followed  as  I  previously  gave  when  speaking  of 
continued  fever,  and  the  same  indications  exist  for  the  use  of  salines  and 
laxatives,  cold  to  the  head,  wine  and  stimulants,  and  regulation  of  the 
diet.  These  I  need  not  again  repeat,  and  I  shall  confine  njy  observa- 
tions at  present  to  the  more  special  treatment  of  the  diseases  we  have 
studied  in  the  wards. 


Scarlatina. 

Case  CCXI.* — Mary  Clark,  ret.  17,  servant — admitted  20th  December  1851.  On 
the  afternoon  of  the  17th  her  throat  became  sore,  and  in  the  evening  she  was 
attacked  with  rigors,  followed  by  pain  in  the  head  and  back,  and  other  febrile 

*  Reported  by  Mr.  "\T.  H.  Broadbent,  Clinical  Clerk. 


886  DISEASES   OF   THE    BLOOD. 

symptoms.  Last  night  she  first  observed  a  red  rash  upon  her  chest  and  ai'ms ;  this 
is  of  a  reddish  brown  colour,  and  resembles  the  ordinary  eruption  of  scarlatina ;  it 
disappears  upon  pressure.  Pulse  126  and  feeble;  fauces,  tonsils,  and  back  of 
pharynx  red  and  congested ;  has  great  thirst  and  anorexia ;  tongue  moist,  with  a 
white  fur  in  middle,  through  which  the  red  papilke  project;  bowels  costive;  urine, 
sp.  gr.  1030,  contains  no  albumen — a  deposit  takes  place,  containing  epithelial  scales 
and  crystals  of  triple  phosphate.  5  Tlnct.  Hyoscyain.  jss;  Liq.  Ammon.  Acet.  et 
Aqtiiz  puree  Aa.  5  iij.  M.  |j  tertid  qudque  hord.  Dec.  22. — Eash  disappeared  from 
arms,  but  is  still  visible  on  the  chest ;  pulse  86,  and  soft ;  less  pain  in  the  throat, 
although  fauces  and  palate  are  still  congested.  Dec.  24. — Convalescent,  and  she  was 
dismissed  on  the  27th  of  December  cured. 

Case  CCXIL* — Isabella  Husketli,  aet.  22,  a  woman  of  abandoned  character,  and 
addicted  to  intemperance,  was  admitted  19th  December  1851,  in  a  state  of  high 
delirium.  It  was  ascertained  that,  on  the  lith,  she  had  been  seized  with  rigors  fol- 
lowed by  great  debility,  catarrh,  and  general  febrile  symptoms.  On  the  following 
day  an  eruption  apjjeared  on  her  skin.  On  admission,  she  was  in  a  state  of  violent 
delirium,  and  required  to  be  tied  down  in  bed.  Her  eyes  were  sufliised,  and  very 
sensitive  to  light;  pulse  120;  tongue  dry  and  parched,  florid-red  at  the  edges,  with 
the  papQlfe  projecting  tltrough  a  white  fur  in  the  centre ;  teeth  covered  with  sordes ; 
great  pain  in  throat,  increased  on  swallowing ;  submaxillary  glands  tender  on  pres- 
sure, but  not  enlarged ;  eats  nothing,  but  has  great  thirst ;  bowels  costive ;  skin  hot 
and  pungent ;  arms  and  chest  covered  with  a  bright  scarlet  exanthematous  eruption. 
Six  leeches  applied  to  the  throat — saline  mixture.  Dec.  20. — Delirium  continues; 
pulse  125;  pain  in  throat  relieved.  Yespere. — Delirium  greatly  increased.  Nine 
leeches  applied  to  ienqiles,  and  to  have  a  draught  of  morpthia,  and  svme  wine.  Dec. 
21. — Slept  during  night,  and  is  nearly  sensible  to-daj-;  tongue  diy  and  florid;  erup- 
tion fading;  considerable  sore  throat.  Blister  to  be  apijUed  to  the  throat.  On  the 
2.3d  the  eruption  had  quite  disappeared.  The  throat  symptoms,  however,  gradually 
increased.  On  the  evening  of  the  26th,  the  breathing  was  observed  to  be  very 
short  and  hurried,  and  on  the  morning  of  the  27th  the  patient  died. 

Commentary. — The  first  case  is  an  instance  of  mild  scarlatina,  run- 
ning its  ordinary  course,  and  terminating  in  recovery  on  tbe  seventh, 
day.  The  second  case  is  an  example  of  severe  scarlatina,  occurring  in  a 
woman  addicted  to  intemperance,  and  in  wliom  all  the  symptoms  of 
typhus  fever,  associated  with  sore  throat,  were  present,  proving  fatal  on 
tbe  thirteenth  day.  Of  all  tbe  eruptive  fevers,  scarlatina  is  the  most 
rapid  in  its  invasion,  and  the  most  variable  in  its  course.  Great  watch- 
fulness is  therefore  demanded  on  the  part  of  the  practitioner,  especially 
when  the  crisis  is  to  be  expected,  so  tbat  if  prostration  comes  on  rapidly, 
or  other  untoward  symptoms  appear,  he  may  be  prepared  to  meet  them. 
Perhaps,  also,  scarlatina  is  the  most  infectious  of  the  eruptive  fevers,  so 
that  complete  separation  of  the  patient  from  the  other  members  of  a 
young  family  is  at  all  times  to  be  insisted  on  as  soon  as  possible. 

A  chief  peculiarity  of  scarlatina  is,  that,  in  addition  to  the  general 
fever  and  characteristic  eruption,  the  tonsils  and  mucous  membrane  of 
the  mouth  and  pliarynx  are  also  apt  to  be  inflamed.  This  occa.sions 
difficulty  of  deglutition,  with  soreness  of  the  throat,  symptoms  which 
require  for  relief  topical  remedies,  such  as  fomentations,  astringent  and 
slightly  acid  gargles,  or  a  linctus,  etc.     If  sloughing  or  ulceration  occur, 

*  Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


i) 


SCARLATINA.  887 

tlie  application  of  tlie  stronger  acids,  or  tlic  nitrate  of  silver,  is  often 
necessary.  The  difficulty  of  deglutition  sometimes  impedes  the  intro- 
duction of  food  into  the  stomach,  and  in  this  way  assists  in  producing 
prostration,  and  prevents  the  administration  of  stimulants  or  medicine. 
It  uiay  also,  in  severe  cases,  impede  respiration,  and  assist  in  producing 
asphyxia  directly.  A  fatal  result,  however,  when  it  does  occur  during 
the  primary  attack  of  scarlatina,  is  geueially  dependent  on  the  same 
causes  which  induce  it  in  typhus  fever — namely,  congestion  of  the  brain, 
as  indicated  by  delirium,  passing  into  coma,  and  followed  by  prostration 
of  the  vital  powers.  In  addition  to  the  throat  complication,  there  are 
various  others,  all  of  which  may  require  a  special  treatment.  In  the 
vast  majority  of  cases,  a  general  treatment,  directed  in  the  first  place  to 
subduing  the  excess  of  fever,  and  afterwards  to  suppoiting  the  strength, 
is  indicated. 

Many  efforts  liave  been  made  by  different  practitioners  to  check  or 
modify  the  intensity  of  the  disease  by  administering  various  drugs,  or 
carrying  out  particular  kinds  of  treatment.  Hence,  during  certain 
epidemics,  or  in  its  visitations  to  particular  educational  institutions, 
various  practitioners  have  been  sanguine  enough  to  believe  that  their 
especial  mode  of  practice  has  been  more  successful  than  any  other.  I 
do  not  consider  it  uecessary  to  direct  your  attention  to  the  numerous 
plans  which  have  beeu  thus  proposed,  because  all  of  them  have  been 
only  partial  in  their  operation,  and  no  one  of  them  has  been  more 
successful  than  another.  You  must  remember  that  the  causes  of  scarla- 
tina are  as  mysterious  and  unknown  as  are  those  producing  any  kind  of 
fever;  and  that  its  fatality,  like  that  of  fever,  is  to  be  traced  to  consti- 
tutional circumstances  in  individuals,  to  unhealthy  localities,  or  to  the 
so-called  type  of  the  particular  epidemic.  Nothiug,  therefore,  is  more 
difficult,  under  such  circumstances,  than  to  judge  whether  the  non-fatality, 
observed  at  one  time,  or  in  a  certain  establishment,  is  referable  to  this 
or  that  practice.  At  all  events,  I  have  been  unable  to  satisfy  myself 
that  any  general  rule  of  empirical  or  rational  practice  is  to  be  derived 
from  the  contradictory  accounts  which  have  from  time  to  time  been 
made  public  on  this  subject. 

Dr.  Andrew  Wood,  who  has  had  great  experience  as  physician  to 
Ileriot's  Hospital  and  other  educational  establishments  in  this  city, 
recommends  the  following  treatment : — Several  common  beer  bottles, 
containing  very  hot  water,  are  placed  in  long  worsted  stockings,  or  long- 
narrow  flannel  bags,  wrung  out  of  water  as  hot  as  can  be  borne.  These 
are  to  be  laid  alongside  the  patient,  but  not  in  contact  with  the  skin. 
One  on  each  side,  and  one  between  the  legs,  will  generally  be  sufficient ; 
but  more  may  be  used  if  deemed  necessary.  The  patient  is  to  lie  between 
blankets  during  the  application  of  the  bottles,  and  for  several  hours 
afterwards.  In  the  course  of  from  ten  minutes  to  half  an  houi-,  the 
patient  is  thrown  into  a  most  profuse  perspiration,  when  the  stockings 
may  be  removed.  In  mild  cases,  the  eflect  is  easily  kept  up  by  means 
of  draughts  of  cold  water,  and  if  necessary,  by  the  use  of  two  drachm- 
doses  of  Sp.  Mindereri  every  two  houis.  In  severe  cases,  where  the 
pulse  is  very  rapid — the  beats  running  into  each  other — where  the  erup- 
tion is  either  absent  or  only  partial,  or  of  a  dusky  purplish  hue — where 
the  surface  is  cold — where  there  is  sickness  or  tendency  to  diarrhoea — 


888  DISEASES   OF  THE   BLOOD. 

■where  the  throat  is  aphthous  or  ulcerated,  and  the  cervical  glands  swol- 
len, then  he  follows  up  the  use  of  the  vapoui'-bath  by  four  or  five  giain- 
doses  of  carbonate  of  ammonia,  repeated  every  three  or  four  hours. 
Should  this  be  vomited,  then  brandy  mav  be  given  in  doses  proportioned 
to  the  age  of  the  patients.  Carbonate  of  ammonia  he  considers  to  act 
beneficially  :  1st,  by  supporting  the  powers  of  life;  2d,  by  assisting  the 
development  of  the  eruption  ;  and,  3d,  by  acting  on  the  skin  and  kidneys. 
Wliere  the  vapour-bath  was  used  early  in  the  disease,  and  its  use  con- 
tinued daily,  or  even  twice  or  thrice  a-day,  according  to  circumstances, 
he  has  found  that  the  chance  of  severe  sore  throat  was  greatly  obviated. 
In  regard  to  supervening  dropsy,  he  considers  that,  by  the  use  of  the 
vapour-bath,  Avith  the  other  necessary  precautions  as  to  exposure,  diet, 
etc.,  its  recurrence  is  I'endercd  much  moie  rare.  In  the  treatment  of  the 
dropsical  cases,  it  was  also  very  useful,  and  in  some  instances  might  be 
trusted  to  entirely.  Dr.  Wood  also  condemns  all  depleting  treatment, 
and  even  purgatives,  during  the  first  ten  davs,  thinking  them  not  only 
not  required,  but  positively  dangerous,  as  tending  to  interfere  Avith  the 
development  of  the  eruption.  In  the  later  stages,  as  Avel!  as  in  the 
dropsy,  however,  he  thinks  purgatives  are  often  beneficial.  Shortly  after 
this  treatment  was  proposed  at  a  meeting  of  the  JSJedico-Chirurgical 
Society  of  this  city,  1  tried  it  in  the  following  case  : — 

Case  CCXIII.*— Margaret  Welsh,  ai-t.  18— admitted  2d  July  1852.  She  is  a 
servant  girl,  and  had  alwa3-s  enjo3-ed  good  health  until  June  29th,  when  she  expe- 
rienced distinct  rigors,  followed  by  sore  throat  and  febrile  symptoms.  She  admits 
having  called  previously  on  a  family  in  which  the  disease  existed.  On  the  evening 
of  the  30th,  a  bright  red  rash  appeared  on  the  skin,  and  has  continued  ever  since. 
On  admission,  the  scarlatinal  eruption  is  well  characterised  on  the  chest  and  arms. 
The  skin  is  hot;  pulse  full,  hard,  and  132  iu  the  minute.  Tongue  furred,  with 
elongated  red  papilte  projecting  through  the  white  crust ;  great  difficulty  in  deglu- 
tition ;  throat  sore ;  tonsils  and  mucous  membrane  of  pharynx  swollen  and  red. 
There  are  also  cephalalgia,  slight  deafness,  and  restlessness  at  night.  Respiratory 
functions  normal ;  urine  healthy ;  catamenia  regular.  She  was  ordered  by  the  resi- 
dent clerk  eight  leeches  to  the  head,  a  saline  antimonial  mixture,  and  eight  grains  of 
Dover's  pov\'der.  On  iirst  seeing  her  the  following  day,  3(Z  July,  I  found  her  in 
much  the  sam(i  condition  as  is  described  in  the  previous  report ;  the  skin  still  being 
hot  and  dry,  and  the  eruption  very  vivid  on  the  chest  and  arms.  Hot  bottles  were 
ordered  to  be  applied,  encased  in  worsted  stockings  wrung  out  of  hot  water,  as 
recommended  by  Dr.  Andrew  Wood.  July  Mh. — A  slight  perspiration  followed  the 
use  of  the  vapour-bath  last  night.  To-day,  the  rash  has  partly  disappeared  from  the 
arms,  but  is  now  present  on  the  legs  as  well  as  chest.  Pulse  130,  small;  urine  not 
coagulable.  An  astringent  gargle  for  the  throat — the  laj^our-hath  to  he  again  applied. 
July  5(h. — Profuse  perspiration  resulted  last  night  from  the  use  of  the  vapour-bath. 
To-day  the  rash  has  entirely  disappeared;  but  there  is  great  tenderness  of  the  skin 
and  in  the  joints  on  motion.  July  9th. — Has  continued  much  in  the  same  condition, 
but  to-day  the  appetite  has  somewhat  returned,  and  she  has  eaten  a  good  breakfast. 
Her  joints  are  swollen,  and  there  is  still  considerable  pain  on  moving  them.  Desqua- 
mation commencing;  throat  ulcerated,  and  to  be  touched  with  a  weak  solution  of 
nitric  acid;  pulse  84,  soil;  |  iv  of  wine  daily.  July  26ih. — Since  last  report  has 
been  slowly  gaining  strength,  but  is  still  far  from  well.     The  urine  lias  been  care- 

*  Reported  by  Mr.  J.  R.  Williams,  Clinical  Clerk. 


SCARLATINA.  889 

fully  examined  daily,  and  has  never  presented  coagulability  on  the  addition  of  heat 
or  nitric  acid.  To-day  a  distinct  blowing  murmur  was  discovered  with  the  first 
sound  of  the  heart,  loudest  at  the  base,  and  propagated  along  the  vessels  of  the  neck; 
pulse  76,  of  good  strength.  August  Ath. — Went  out  a  little  to-day,  and  in  the  even- 
ing the  feet  commenced  to  swell.  August  6</i.— Swelling  of  feet  increased.  To 
have  a  squill  a7id  digitalis  2}ill  three  times  a-day.  August  dth. — (Edema  of  feet  con- 
tinues; urine  healthy.  Venesedio  ad  ?  viij.  August  llih. — CEdema  of  feet  disap- 
peared. This  morning  had  a  rigor.  Was  ordered  an  emetic.  August  \2lh. — To-day 
is  feverish,  with  great  thirst  and  heat  of  skin;  pulse  128,  strong.  A  saline  mixture 
ordered.  August  llih. — Febrile  symptoms  continue,  with  tenderness  over  epigas- 
trium ;  and  eight  leeches  were  ordered  to  be  applied  there.  The  cardiac  dulness  is 
extended.  No  friction,  but  a  blowing  murmur,  as  formerly  noticed  at  the  base  of 
heart ;  respiration  somewhat  embarrassed.  August  20th. — Respiration  normal ;  no 
tenderness  over  epigastrium ;  pulse  100,  regular  and  soft.  The  urine  all  this  time 
has  been  tested  daily,  but  has  never  been  coagulable.  To- day,  however,  a  deposit 
exi-sted  in  the  urine,  and  several  casts  of  the  tubuli  uriniferi  may  be  observed  in  it 
with  a  microscope.  September  1th. — Since  last  report  she  has  been  convalescent, 
and  all  her  symptoms  have  gradually  disappeared.  The  blowing  murmur  over  base 
of  heart  is  still  present,  but  not  so  loud,  and  the  increased  dulness  has  disappeared. 
Dismissed. 

Commentar?/. — In  this  case,  tlie  disease,  instead  of  being  sliortened  or 
rendered  milder,  was  nnnsually  prolonged,  and  was  followed  by  rheuma- 
tism, dropsy  of  the  inferior  extremities,  and  by  pericardial  effusion.  The 
febrile  symptoms  terminated  by  critical  deposition  in  the  urine  so  late  as 
the  fifty-second  day.  i\lthough  admitted  June  29,  she  was  not  strong 
enough  to  be  dismissed  from  the  Infirmary  until  September  7th.  This 
Avas  certainly  an  unfortunate  case  to  commence  the  trial  of  a  new  treat- 
ment; and  yet  the  girl  had  been  always  health}',  and  there  was  nothing 
to  indicate  at  the  commencement  that  the  sequelic  would  be  so  severe  or 
so  prolonged. 

I  persevered  with  this  plan  in  four  or  five  other  cases,  but  in  all  of 
them  it  failed  to  bring  about  speedy  resolution.  At  last  I  came  to  the 
conclusion  that  the  heat,  damp,  and  exposure,  which  it  was  difticult  to 
avoid,  tended  especially  in  the  class  of  servants  and  young  women  who 
entered  the  Infirmary,  to  rheumatism.  I  then  adopted  quite  an  opposite 
treatment,  kept  the  skin  dry  and  cool,  and  have  had  every  reason  to  be 
satisfied  with  the  result.  Several  very  severe  cases  which  entered  the 
wards  during  the  winter  and  summer  months  of  1856-57  were  treated 
in  this  way  with  the  best  results,  of  which  the  following  are  examples  : — 

Case  CCXIV.* — Thomas  Corrigan,  a^t.  19,  a  labourer — admitted  September  19th, 
1856.  He  first  felt  sore-throat  on  the  evening  of  the  16th,  followed  on  the  18th  by 
rigors  and  febrile  sj^mptoms.  To-day  the  rash  first  appeared,  and  on  admission 
presents  a  dusky-red  colour,  covering  the  face,  neck,  arms,  haunches,  and  thighs. 
The  throat  is  much  swollen  externally  on  both  sides.  The  mouth  is  with  great  diffi- 
culty opened,  when  the  tonsils  are  greatly  enlarged  and  ulcerated.  The  back  of  the 
tongue  is  swollen  and  covered  with  a  thick  crust;  anteriorly  it  is  red  and  dry.  Pulse 
116,  full  and  bounding.  Respirations  27  in  the  minute.  Deglutition  difficult. 
Skin  dry  and  pungently  hot.     Urine  turbid,  and  of  a  reddish-brown  colour,  not 

*  Reported  by  Mr.  H.  M.  Maclaurin,  Clinical  Clerk. 


890  DISEASES   OF   THE   BLOOD. 

altered  on  the  addition  of  heat.  Chlorides  scanty.  Other  organs  healthy.  Warm 
fomentatmis  to  he  applied  to  the  throat,  and  to  use  the  steam  inhaler.  $  Vin.  Antim. 
§ss;  Aquce  Acet.  Amnion.  %y,  Aqvxe  f  ivss.  M.  Sumai  r,  ss  quartii  qziaque  hord. 
September  20th. — Has  been  occasionally  delirious.  Other  symptoms  the  same.  To 
omit  fomentations,  inhalations,  and  mixture.  IJ  Acid.  Sulph.  Dil  3  ij ;  Syrupi  3  j ; 
Infus.  Rosar.  3  vij.  M.  Sumat  3  ss  qiiartd  qudque  hard.  September  21st. — Delirium 
has  been  violent  during  the  night.  At  present  pulse  76,  full  and  strong.  Deglutition 
and  respiration  somewhat  easier.  5  Vin.  Cokhici  3  ij ;  Spirit.  uEther.  Nit.  f  iij ; 
Aqu(e  §  vss.  M.  Sumat  semiunciam  quartd  qudque  hard.  September  22d. — ^Urine 
to-day  clear ;  chlorides  more  abundant ;  no  albumen.  Pulse  69,  not  so  full.  Tongue 
still  dry.  Rash  has  disappeared.  Sept.  23d. — Urine  natural.  Desquamation  of  the 
skin  commencing.  Swelling  of  tonsils  and  sore  throat  greatly  diminished.  From 
this  time  he  rapidly  recovered,  and  was  dismissed  quite  well  October  9th. 

Case  CCXY.* — Ehza  Campbell,  net.  24,  a  married  woman,  of  weak  constitution, 
with  two  children,  the  eldest  of  whom  is  recovering  from  scarlatina,  was  admitted 
December  19th,  1856.  On  the  12th  she  experienced  lassitude  and  general  malaise. 
On  the  15th  she  had  rigors,  followed  by  febrile  symptoms,  and  pain  in  the  back.  On 
tne  morning  of  the  16th,  a  rash  appeared  over  the  breast  and  other  parts  of  the  body. 
On  the  18th  her  husband  observed  that  her  mind  was  wandering,  and  next  day 
brought  her  to  the  Infirmary.  On  admission,  there  is  a  uniform  scarlatina  eruption 
over  the  back,  abdomen,  and  arms.  On  the  legs  there  are  numerous  spots  of  purpura 
extending  up  the  thighs.  Skin  hot  and  dry.  Moutli  dry.  Tongue  brown  and  cracked 
in  the  centre.  The  jaws  are  separated  with  difficulty,  showing  the  uvula  and  fauces  of 
a  scarlet  colour,  without  swelling  of  the  tonsils.  Bowels  costive.  Pulse  108,  small 
and  weak.  Is  conscious,  though  rather  confused,  and  very  restless.  Other  organs 
healthy.  Ordered  §  iij  of  she^-ry  wine  and  §  iv  of  lemon  juice,  to  be  taken  during  the 
day,  with  strong  beef-tea.  An  injection  of  warm  water  to  unload  the  bowels.  December 
20th. — Violent  dehrium  during  the  night.  At  the  visit  pulse  160.  Head  to  be  shaved 
and  cold  applied.  December  2\st. — Had  several  hours'  sleep  during  the  night,  and 
awoke  better.  Pulse  110.  Eruption  fading.  Urine  dark  and  turbid,  with  a  copious 
sediment  of  urates.  To  have  3  ss  of  Sp.  ..Mher.  Nit.  every  two  hours,  and  §  ij  of 
Brandy,  in  addition  to  the  v:ine  daily.  December  22d. — The  rash  is  fainter.  Desqua- 
mation commencing.  Purpuric  spots  also  disappearing  Still  dryness  of  mouth  and 
cracked  tongue.  Deglutition  easy.  Continue  nutrients  and  diuretics.  From  this 
time  she  became  convalescent.  On  December  24th  there  were  still  traces  of  the 
eruption  in  some  places,  while  desquamation  was  advancing  in  others.  On  the  29th 
the  cuticle  separated  from  the  hands  entire.  She  remained  weak  for  some  time,  and 
was  not  strong  enough  to  be  dismissed  untU  January  24th,  1857. 

Commentary. — In  the  first  of  these  two  cases  there  was  violent  angina, 
in  addition  to  the  severe  fever,  with  delirium,  and  yet  the  disease  pursued 
its  natural  course,  crisis  occurring  on  the  seventh  day,  and  he  rapidly 
recovered  without  an  untoward  symptom.  In  the  second  case,  occurring 
in  a  woman  of  a  weak  habit  of  body,  who  had  been  underfed,  tlie  scarla- 
tina was  associated  with  purpura,  violent  head  symptoms,  but  no  angina. 
Strong  stimulants  and  nutrients  were  administered  from  the  first,  with 
diuretics  to  assist  elimination,  and  ultimately  she  did  well,  without  any 
sequela?,  although,  from  her  previous  weak  condition,  convalescence  was 
prolonged. 

*  Eeported  by  :Mr.  H.  M.  ilaclaurin,  Clinical  Clerk. 


SCARLATINA.  891 

It  has  frequently  been  observed,  that  the  urine  in  scarlatina,  especially 
wlien  dropsy  supervenes,  becomes  albuminous.  Dr.  James  W.  Begbie, 
who  has  with  great  pains  tested  the  urine  in  a  considerable  number  of 
cases,  considers  its  presence  almost  uniform.  Aware  of  what  he  has 
written  on  this  subject,  I  have  tested  the  urine  daily  in  certain  cases, 
without  observing  it.  This  non-persistent  coagulability  of  the  urine,  as 
well  as  various  deposits  which  appear  in  it  on  critical  days,  must,  wlien 
they  occur,  be  considered  as  an  evidence  of  the  excretion  of  morbid 
products  which  liave  circulated  in  the  blood.  Hence  they  are  common, 
not  only  in  scai'latina,  but  in  all  inflammatory  ati'ections  as  well  as  fevers. 
This  point  you  must  have  seen  me  very  observant  of  in  watching  for  the 
resolution  of  intlaminations  and  fever  at  the  bed-side. — (See  p.  141.) 
It  sometimes  happens,  however,  that  the  critical  discharge  is  compara- 
tively slight,  and  that  the  organic  elements  are  not  dissolved  so  as  to 
constitute  lluid  albumen.  This  appears  to  have  occurred  in  the  following- 
case,  for  whilst  morphological  evidence  of  the  crisis  existed  in  the  urine, 
in  the  form  of  cells  and  casts,  no  albumen  could  be  detected  by  heat  and 
nitric  acid. 

Case  CCXVI.*— Alexander  Johnston,  xt.  14— admitted  June  23,  1851.  Three 
days  ago  he  experienced  distinct  rigors,  followed  next  day  by  a  general  scarlatinal 
eruption.  On  admission  there  was  restless  delirium,  and  constant  moving  of  the  head 
from  side  to  side  on  the  pillow.  He  was  apparently  conscious  when  spoken  to,  but 
could  not  answer  questions ;  the  tongue  was  protruded  with  difficulty,  dry,  and  of 
bright  red  colour,  studded  with  florid  elevations ;  deglutition  was  much  impeded-; 
bowels  open;  pulse  130,  weak ;  urine  voided  with  difficult}',  and  diminished  in 
quantity,  sp.  gr.  1025 — not  acted  on  by  heat  and  nitric  acid;  skin  hot  and  dry, 
covered  with  the  bright-red  scarlatinal  eruption.  Ordered  salines  and  slighf,  diuretics. 
He  continued  in  the  same  condition,  the  augiua  increasing  and  the  coma  altei'nating 
with  delirium  becoming  more  pronounced  until  the  sixth  day.  During  this  period 
all  the  urine  passed  was  carefully  examined.  The  amount  was  diminished  (17  oz. 
per  day),  but  it  was  free  from  deposit,  and  unaffected  by  heat  or  nitric  acid  5  ^P- 
uEther.  Nit.  3  iij ;  Pot.  Acet.  3  ij ;  Tr.  Colchici,  %  ss ;  Aquce  §  iij.  Fiat  mist.  A  tea- 
siMonful  to  he  taken  every  four  hours.  On  the  following  day  all  coma  and  delirium 
had  disappeared.  He  answers  questions  when  put  to  him;  skin  cool;  eruption  faded; 
pulse  96,  weak ;  passed  30  oz.  urine,  which  is  turbid,  with  small  flakes  of  a  mem- 
branous character  floating  in  it.  On  the  eighth  day  the  quantity  of  vuine  excreted 
was  50  oz.,  and  was  still  more  loaded  with  sediments.  On  examining  the  urine  with 
a  microscope,  it  was  seen  to  contain — 1st,  membranous  flakes,  composed  of  aggre- 
gated rounded  particles,  apparently  agglutinated  together,  and  strongly  resembling 
some  forms  of  vegetable  tissue ;  2d,  rounded  and  irregular  masses  with  spicula  ;  3d, 
amorphous  molecular  masses.  (See  Fig.  67,  p.  85.)  The  whole  of  these  elements, 
on  being  analyzed  chemically  by  Mr.  Drummond,  were  found  to  consist  of  urate  of 
ammonia.  Next  day  the  urine  was  only  slightly  turbid,  and  on  the  following  one  it 
was  perfectly  clear.     From  this  time  the  hoj  gradually  recovered. 

Commentari/. — This  was  a  very  severe  case  of  scarlatina.  The  angina 
was  intense,  occasionally  rendering  deglutition  impossible.  There  was 
delirium  on  the  third  day,  alternatitjg  at  night  with  coma,  which  was 
often  profound.     The  worst  result  was  apprehended.     It  occurred  to  me 

*  Reported  by  Mr.  G.  Scott,  Clinical  Clerk. 


892  DISEASES   OF   THE   BLOOD. 

that  the  head  symptoms,  in  this  as  in  several  cases  of  typhus,  might 
probably  depend  not  so  much  upon  inflammation  of  the  brain  as  upon 
absorption  of,  and  poisoning  by  urea,  an  idea  that  appeared  supported  by 
the  diminished  quantity  of  the  renal  excretion,  as  well  as  its  freedom  from 
all  deposit.  Remembering  the  alleged  virtues  of  colchicura  in  increasing 
the  elimination  of  this  excretion,  I  ordered  it,  in  combination  with  diu- 
retics, and  the  result  was  remarkable;  for  on  the  next  day  not  only  had 
the  fever  diminished,  but  the  urine  was  increased  in  amount,  and  loaded 
with  urates  to  an  extent  and  in  a  form  I  had  never  previously  seen.  It 
may  be  argued  that  the  fever  had  teiiuinated  by  a  natural  crisis  on  the 
seventh  day  ;  but  I  cannot  help  thinking  that  in  this  case  nature  was 
assisted  by  the  colchicum  and  diuretics.  I  have  since  given  this  medi- 
cine in  various  cases  of  uraemia,  and  in  inflammations,  where  the  excre- 
tion of  urates  should  be  favoured,  at  the  period  of  crisis  with  the  best 
effects. 

P^RYSIPELAS. 

Case  CCXYII.*— Marion  Smails,  set.  28— admitted  Januarj-  8th,  1851.  She  stated 
that  on  the  morning  of  the  6th,  she  was  quite  well,  but  that,  after  being  out  for  some 
time,  she  felt  a  burning  pain  in  her  left  cheek,  and  observed  a  red  spot  upon  it.  This 
redness  gradualh'  extended  down  towards  the  neck,  and  was  accompanied  with  con- 
siderable swelling.  She  applied  a  mustard  poultice  to  her  cheek,  which  relieved  the 
pain  somewhat  at  first,  but  afterwards  caused  a  great  aggravation  of  it.  On  admis- 
sion, besides  the  local  pain,  she  complained  of  great  thirst  and  of  a  bad  taste  in  her 
mouth.  The  tongue  was  moist;  bowels  regular;  pulse  66,  full  and  strong.  The 
cheek  was  ordered  to  be  fomented  with  a  lotion  of  lead  and  opium.  January  Mth. 
— Swelling  and  redness  are  much  less,  as  is  also  the  pain.  Jan.  \1th. — Redness  of 
the  skin  completely  disappeared.  Complains  onlj^  of  a  slight  soreness  in  the  throat. 
Dismissed  cured. 

Case  CCXYIII.f — James  Maclaren,  set.  59,  a  porter,  of  intemperate  habits — 
admitted  November  16th,  18.51.  Eight  days  ago  was  seized  with  rigors,  followed  by 
intense  febrile  symptoms,  which  prevented  sleep.  On  the  13th  he  experienced  pain 
in  the  left  side  of  his  nose,  accompanied  by  redness  of  the  integuments,  which  rapidly 
spread  over  the  cheek,  ej'e,  and  brow  of  the  same  side.  On  the  tbllowing  morning 
the  redness  appeared  on  the  right  cheek,  and  in  the  evening  had  covered  the  whole 
face.  On  admission  there  is  great  thirst ;  loss  of  appetite  ;  furred  tongue :  hot  skin ; 
full  and  burning  pulse,  100  in  the  minute;  great  headache,  with  drowsiness;  tin- 
gling pain  in  the  face,  which  is  of  a  deep  red  colour,  in  some  places  approaching 
purple.  The  blush  extends  over  the  forehead  and  anterior  part  of  the  scalp,  and 
pits  on  pressure.  Two  bulke  have  broken,  and  recently  formed  scabs  on  the  right 
side  of  nose.  Ordered  an  antimonial  saline  mixture,  and  the  face  to  be  dusted  with 
flour.  November  17i!/i.— Last  night  there  was  low  muttering  delirium,  and  this  morn- 
ing vomiting.  In  the  evening,  pulse  of  the  same  frequency,  but  more  soft.  To  omit 
the  mixture.  Nov.  18<7«.— Redness  more  extended  over  the  scalp,  and  fresh  bulte 
have  appeared  on  the  forehead.      Pulse  80,   soft ;  constipation.      To  have  3  iij  of 

brandy  daily,  and  to  take  at  present  half  an  ounce  of  castor  oil.     Nov.  lOth To-day 

much  better.  Pulse  80,  of  good  strength;  swelling  of  eyes  diminished;  redness 
feding ;  bulla;  scabbing.  From  this  time  he  gradually  got  well,  and  was  dismissed 
cured,  November  30th. 

*  Reported  by  Mr.  T.  M.  Lownds,  Clinical  Clerk, 
f  Reported  by  Mr.  A.  L.  Mackay,  Clinical  Clerk, 


VARIOLA.  893 

Commentary. — The  first  of  these  cases  was  so  mild  as,  perhaps,  to 
merit  the  name  of  erythema.  The  latter  was  a  very  severe  one,  occur- 
ring in  a  man  of  intemperate  habits,  but  terminating  in  convalescence 
on  the  twelfth  day.  In  this  latter  case  a  study  of  the  symptoms  will 
show  we  have  again,  as  in  scarlatina,  all  the  phenomena  of  typhus  fever  ; 
and  when  erysipelas  proves  fatal,  so  in  like  manner  it  is  by  coma  and 
subsequent  collapse.  Erysipelas,  however,  is  opposed  to  scarlatina,  in 
being  the  least  infectious  of  the  eruptive  fevers,  in  being  the  least  tatal, 
and  in  running  a  much  slower  course.  In  many  other  respects  there  is 
a  close  analogy  between  them  observable  in  the  kind  of  fever,  the  sequelae, 
and  critical  discharge  of  coagulable  urine.  The  general  indications  for 
treatment  are  the  same.  The  special  treatment  is  directed  by  means  of 
topical  applications  to  diminish  the  local  inflammation.  For  this  purpose 
numerous  remedies  have  been  tried — such  as  dusting  the  part  with  flour, 
lotion  of  acetate  of  lead  and  opium,  cerates,  oil,  etc.  etc. — any  of  which 
serve  the  purpose  of  cooling  the  surface,  rendering  it  more  soft,  and 
diminishing  irritation. 

There  can  be  no  doubt  tliat  erysipelas  is  occasionally  a  fatal  disease, 
from  the  intensity  of  the  fever,  and  amount  of  integument  involved.  It 
is  generally  supposed  that,  when  it  attacks  the  face  and  scalp,  it  is  more 
dangerous  than  when  a  similar  amount  of  surface  in  any  other  part  is 
affected.  This  opinion  does  not  appear  to  be  founded  on  very  exact 
observation.  Even  when  the  scalp  is  extensively  invaded,  death  from 
erysipelas  is  a  rai'e  occurrence.  On  going  round  the  wards  of  the  Hotel 
Dieu  in  May  1851  with  M.  Louis,  I  saw  several  severe  cases  of  erysipelas 
of  the  scalp,  which,  I  was  told,  were  under  no  treatment  whatever — 
because,  as  M.  Louis  informed  me,  according  to  his  experience,  erysipelas 
of  the  scalp  was  never  fatal,  unless  it  occurred  in  individuals  of  bad  con- 
stitutions, or  was  associated  with  some  complication.  I  need  not  say 
that,  without  forming  any  such  exclusive  opinion  as  this,  it  must  be  very 
difficult,  in  a  disease  that  so  generally  tends  to  recovery,  to  judge  how 
far  this  or  that  remedy  is  beneficial.  Mr.  Hamilton  Bell  has  recom- 
mended fifteen  to  twenty-five  drops  of  the  Tr.  Ferri  Muriatis  every 
second  hour,  as  a  most  beneficial  remedy  in  erysipelas.  But  how  this 
medicine  is  more  successful  than  the  spontaneous  operation  of  nature,  it 
must  be  very  diflicult  to  demonstrate. 


Variola. 

Case  CCXIX.*— Mary  Hogan,  set.  7,  was  admitted  Dec.  9th,  1851.  Never  had 
been  vaccinated.  Felt  slightlj-  indisposed  Dec.  4tb ;  and  on  the  following  daj-  com- 
plained of  severe  headache,  pain  in  the  back,  nausea,  loss  of  appetite,  and  great  thirst. 
These  symptoms  continued,  and  on  the  afternoon  of  the  7th,  a  bright  red  blush  was 
observed  on  the  face  and  chest,  gradually  spreading  over  all  the  body.  On  the  8th 
the  red  blush  became  covered  with  numerous  minute  elevated  papulre  ;  and  on  the 
9th,  when  admitted,  numerous  vesicles  could  be  detected  on  the  face,  arms,  and  legs. 
Tongue  furred,  but  moist.  No  dysphagia.  Was  ordered  a  x>urgative  of  ndphaie  of 
magnesia.  December  \Wi. — The  vesicles  are  numerous  and  close  together  on  the 
face,   and   in   some   places   confluent.     Eyelids  much  swollen  and  nearly  closed. 

*  Reported  by  ilr.  J.  L.  Brown,  Clinical  Clerk. 


894  DISEASES   OF   THE    BLOOD. 

Bowels  are  open  ;  pulse  140 ;  tongue  florid.  The  hair  was  cut  short,  and  mild  mer- 
curial ointment,  thickened  with  starch,  spread  over  tlie  face.  She  was  also  vacci- 
nated. Dtc.  \Z(h. — Pustules  fully  maturated  and  umbilicated  over  the  trunk  and 
extremities.  The  mercurial  paste  forms  a  thick  indurated  crust  over  the  face.  Bee. 
lath. — Many  of  the  pustules  over  the  body  have  burst  and  discharged  their  contents. 
No  constitutional  disturbance.  No  pain  or  itching  of  the  face :  all  swelling  of  the 
eyelids  disappeared.  Dec.  ISth. — Pustules  have  all  burst,  except  a  few  on  tlie  feet, 
"^as  dismissed  January  6th,  cured.  The  face  scarcely  presented  any  trace  of  the 
disease,  and  afforded  a  remarkable  contrast  to  those  other  parts  of  the  skin  -which 
had  not  been  covered  with  the  paste. 

Case  CCXX.* — Michael  Hogan,  ajt.  9,  admitted  December  10,  1851.  a  brother  of 
the  former  case,  and  also  never  vaccinated.  Felt  unwell  on  the  8th,  with  shivering, 
pain  in  the  head,  and  usual  febrile  symptoms.  On  the  next  day  vomited,  and  then 
observed  an  eruption  on  the  skin.  On  admission,  the  face,  trunk,  arms,  and  legs  are 
spotted  with  bright  papules  at  considerable  distance  from  each  other,  and  he  says  the 
fever  has  considerably  abated.  On  the  15th  the  pustules  on  the  face  were  fuUy 
maturated,  and  here  and  there  a  few  of  them  were  observed  to  be  confluent  On 
the  18th  those  on  the  inferior  extremities  were  in  the  same  condition.  Last  night 
he  experienced  again  considerable  headache,  and  to-day  the  pulse  is  120,  full;  the 
skin  hot,  and  febrUe  symptoms  well  developed.  19ih. — Headache  violent  last  night, 
with  great  restlessness  and  insomnia;  but  to-day  these  symptoms  have  abated. 
From  this  time  convalescence  commenced,  but  he  recovered  slowly,  and  was  not 
strong  enough  to  go  out  untQ  December  19tb.  A  few  pits  existed  on  the  face, 
where  the  pustules  had  been  confluent. 

Commentary/. — The  general  treatment  of  small-pox  is  similar  to  tliat 
of  the  other  eruptive  t'evei"s.  There  is  a  special  treatment,  however, 
applicable  to  it,  which  deser\'es  some  consideration. 

The  Ectrotic   Treatment  of  Variola. 

Various  methods  have  been  proposed,  for  the  purpose  of  arresting  the 
development  of  the  eruption  in  variola,  and  preventing  the  cicatrices 
which  are  likely  to  form.  The  treatment,  called  ectrotic  (;xri-PojCzcj,  to 
render  abortive),  has  been  practised  principally  in  France.  Serres,  Bre- 
tonneau,  and  Velpeau,  cauterized  each  vesicle  as  it  appeared  with  nitrate 
of  silver,  which  immediately  arrests  its  further  progress.  This  is  a  very 
tedious  process,  while  painting  the  surface  with  a  solution  of  the  caustic, 
causes  so  much  pain  and  febrile  disturbance,  that  it  cannot  be  safelv 
employed.  Dr.  OlitFe,  of  Paris,  recommended  the  vigo-plaster  of  tlie 
French  Pharmacopoeia ;  and  having  seen,  in  some  of  the  journals,  that 
mercurial  ointment,  thickened  with  starch,  had  proved  very  serviceable 
in  the  practice  of  M.  Briquet,  and  others,  in  the  Paris  hospitals,  I  tried 
it  in  numerous  cases  which  were  admitted  into  the  wards,  and  have  seen 
the  good  effects  of  the  practice.  The  two  cases  you  have  just  had  an 
opportunity  of  observing,  however,  especially  demonstrate  this.  Case 
C  XIX.  presented  the  most  confluent  form  of  the  disease  I  ever  saw. 
The  entire  face  was  so  crowded  with  the  papules  and  minute  vesicles  of 
the  incipient  stage,  that  there  was  litei-ally  not  room  to  place  a  pin's 
head  anywhere  on  the  sound  skin.     It  was  evident  that  the  whole  sur- 

*  Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


VARIOLA.  895 

face  of  the  face  would  be  one  mass  of  suppuration  ;  and  sucli  of  you  as 
Lave  had  an  opportunity  of  observing  a  similar  case  of  the  disease,  must 
be  aware  of  its  horrible  aspect,  the  excessive  agony  produced,  the  great 
swelling  of  the  eyelids,  the  dreadful  suppuration  and  foetor  of  the  dis- 
charge, the  violent  secondary  fever,  and  the  frightful  cicatrices  Avith 
which  the  countenance  is  afterwards  covered.  In  this  case  none  of  these 
symptoms  were  present,  and  there  can  be  no  doubt  that  the  ectrotic 
treatment  really  checked  the  progress  of  suppuration  and  modified  the 
disease.  From  the  moment  the  plaster  was  applied,  all  smarting  and 
pain  in  the  face  ceased  ;  the  eyelids  were  never  swollen ;  no  supjniration 
occurred  ;  there  was  no  secondary  fever ;  and  on  the  mask  leaving  the 
face  there  was  no  pitting  or  suppuration.  In  other  parts  of  the  body 
the  eruption  passed  through  its  usual  stages,  and  the  girl  was  dismissed 
from  the  house  well,  thirty  days  after  the  first  commencement  of  the 
eruption.  Considering  this  case  was  likely  to  be  a  very  severe  one,  I 
felt  myself  authorised  to  use  every  means  in  my  power  to  check  the 
disease ;  and  as  it  has  been  asserted  that  vaccination,  even  after  the  com- 
mencement of  the  eruption,  modifies  its  progress,  I  caused  the  gii-1  to  be 
vaccinated  on  first  seeing  her.  At  that  time  the  face,  as  we  have  seen, 
was  closely  covered  with  papuke  and  vesicles ;  and  I  do  not  think  that 
vaccination  alone  could  have  produced  the  remarkable  result  we  have 
witnessed.  I  do  not  mean  to  deny  altogether  the  influence  of  vaccina- 
tion in  such  cases,  but  I  have  no  hesitation  in  ascribing  the  beneficial 
result  almost  entirely  to  the  ectrotic  treatment. 

To  satisfy  yourselves  still  more,  if  possible,  as  to  the  great  advantage 
of  this  treatment,  the  case  of  the  boy  (Case  CCXX.)  may  be  contrasted 
with  that  of  the  girl  (Case  CCXIX.)  who  also  had  never  been  vacci- 
nated. His  was  evidently  a  very  mild  case,  the  eruption  discrete,  and  the 
constitutional  disturbance  slight.  I  allowed  it  to  run  its  natural  course, 
and  the  result  was  in  every  respect  difl^'erent  from  that  in  which  the 
plaster  had  been  applied  to  the  face.  The  secondary  fever  was  tolerably 
smart,  the  subsequent  prostration  proportionally  severe  ;  recoverv  was 
delayed  to  the  thirty-ninth  day,  and  notwithstanding  the  generallv  dis- 
crete character  of  the  eruption,  a  few  pits  existed  on  the  face. 

Since  I  first  practised  this  ectrotic  treatment  in  small-pox,  I  have  met 
with  numerous  instances  in  which  slio-ht  salivation  followed  the  use  of 
the  mercurial  plaster.  Dr.  George  Paterson*  of  Tiverton,  however, 
published  a  case  in  which  the  salivation  from  the  employment  of  the 
strong  mercurial  ointment  was  excessive  and  dangerous.  I  quite  ao-ree 
with  that  physician  in  thinking  the  occasional  occurrence  of  such  violent 
salivation  would  seriously  compromise  the  otherwise  remarkable  advan- 
tages of  the  ectrotic  treatment. 

But  it  may  be  asked  whether,  after  all,  the  mercury  is  in  any  way 
necessary  to  the  success  of  this  treatment.  Its  original  propounders  iii 
Paris  may  indeed  have  supposed  that  the  absorbent  powers  of  the  drug 
constituted  the  true  cause  of  its  success,  but  it  seems  to  me  that  another 
explanation  may  be  oftered.  There  is,  for  instance,  a  close  analogy 
between  the  mode  of  healing  of  wounds  and  ulcers,  so  well  described  by 
Dr.  Macartney  of  Dublin — that  is,  the  so-called  "  modelling  process," — 
and  what  takes  place  in  the  ectrotic  treatment  of  small-pox.  In  the 
*  Montlily  Journal,  Dec.  1852. 


DISEASES   OF   THE   BLOOD. 

former,  cicatrices  are  far  less  liable  to  be  produced  than  after  healing  by 
the  first  or  second  intention,  and  in  the  latter  the  pitting  or  cicatrization 
is  prevented.  The  artificial  plaster  therefore  takes  the  place  of  the 
natural  scab  or  clot  of  blood,  protects  the  parts  below,  and  enables  them 
to  heal  slowly  but  more  perfectly  than  if  exposed  to  the  air  uncovered 
and  uncompressed  by  supeijacent  crusts.  If  this  be  the  correct  theory 
of  the  ectrotic  treatment,  the  mercurial  might  be  discarded,  and  any 
kind  of  plaster  which  would  concrete  on  the  face  might  be  expected  to 
produce  the  same  beneficial  result.  In  1854  I  determined  to  try  the 
etfects  of  such  a  plaster,  and  after  two  or  three  failures  succeeded  in  pro- 
curing one  that  answers  perfectly.  The  first  case  I  treated  with  simple 
lard,  thickened  with  starch  and  powdered  charcoal,  but  it  was  so  little 
coherent,  that  the  patient,  during  the  night,  rubbed  it  off  on  her  pillow 
or  with  her  hands,  and  on  her  recovery  slie  was  pitted  all  over.  In 
another  case  I  tried  carbonate  of  magnesia  saturated  with  oil.  But  this 
also  failed.  In  a  third  case,  however,  common  calamine  {zinci  carhonaft)^ 
saturated  with  olive  oil  (proposed  by  Mr.  Bird,  one  of  the  clinical  clerks), 
formed  a  coherent,  tough  crust,  which  remained  on  the  face,  and  was 
found  to  answer  well.  Numerous  cases  of  natural  small-pox  have  been 
since  treated  in  this  manner,  with  the  result  not  only  of  preventing  the 
pitting,  but  of  diminishing  the  local  and  general  symptoms,  exactly  in 
the  same  manner  as  I  have  formerly  detailed,  as  being  the  efiect  of  the 
mercurial  plaster.     The  following  is  one  of  these  : — 

Case  CCXXI.* — Alexander  Ross,  set.  13,  never  been  vaccuiated,  was  seized 
with  sliivering  on  the  7  th  January,  followed  by  the  usual  symptoms  of  fever. 
Entered  the  Infirmary  on  the  9th,  when  a  few  papules  were  observed  on  the  face 
and  arms.  On  the  12th  the  face  was  thickly  covered  with  vesicles,  which  from 
their  closeness  would  certainly  have  become  confluent.  The  mask  of  calamine  and 
oil  was  now  applied.  The  disease  ran  its  usual  course,  the  eruption  being  confluent 
on  the  arras  and  trunk.  Throughout  the  progress  of  the  case  the  application  of  cala- 
mine saturated  witli  oil  preserved  a  firm  and  coherent  crust,  and  was  renewed 
from  time  to  time.  The  patient  experienced  no  smarting  of  the  face,  there  was 
no  swelling  of  the  eyelids,  no  purulent  discharge,  or  local  unpleasant  symptoms  of 
any  kind.  The  secondary  fever  was  tolerably  smart,  delirium  being  present  two 
days.  On  the  22d  tlie  mask  came  oS",  leaving  a  clean  smooth  surface,  free  from  all 
trace  of  pitting.     Dismissed  quite  well  on  the  26th. 

The  following  formula,  after  numerous  trials,  has  been  found  to  con- 
stitute the  most  efficient  plaster: — Carbonate  of  zinc,  3  parts;  oxide  of 
zinc  1  part,  rubbed  in  a  mortar  with  olive  oil  to  a  proper  consistence. 
Dr.  Wallace  of  Greenock,  in  pursuing  this  treatment,  ascertained  that 
the  tincture  of  iodine,  which  has  been  recommended  as  an  ectrotic,  is 
of  little  use,  and  was  led  to  employ  as  the  best  application,  a  solution 
of  gutta  percha  in  chloroform,  first  used  by  Dr.  Stokes,  and  recom- 
mended by  Dr.  Graves  of  Dublin. 

The  general  subject  of  small-pox  opens  up  to  our  consideration  a 
multitude  of  considerations,  of  which  we  may  notice  three. 

1.  There  can  be  very  little  doubt  that  the  small-pox  is  again  becom- 
ing frequent  amongst  us,  a  circumstance  which  some  have  attributed  to 

*  Reported  by  Mr.  Bird,  Clinical  Clerk. 


VARIOLA.  89V 

deterioration  of  the  vaccine  lympli.  That  this  cause  does  operate  to  a 
certain  extent  is  very  probable ;  but,  for  my  own  part,  I  have  been 
led  to  the  conchision,  that  the  terror  for  the  disease  which  formerly 
prevailed  among  the  public,  has,  through  the  protective  discovery  of 
Jcnner,  and  the  eneigy  with  which  vaccination  was  originally  pursued, 
in  a  great  measure  declined,  and  that  this  is  the  principal  cause.  At 
present,  multitudes  of  the  lower  orders  no  longer  have  their  children 
vaccinated,  and  hence  why  our  hospitals  are  so  frequently  encumbered 
with  cases  such  as  those  we  have  just  witnessed.  We  have  no  remedy 
for  this  but  rendering  vaccination  imperative  by  penal  enactments,  as  is 
done  in  some  continental  states. 

For  the  mode  of  vaccination,  I  must  refer  you  to  the  account  given 
in  systematic  works  on  the  practice  of  medicine.  It  consists,  as  yon 
know,  of  making  a  puncture  just  sufficient  to  penetrate  the  epidermis 
of  the  skin,  and  to  enable  the  vaccine  lymph  to  be  applied  to  the  vas- 
cular dermis.  For  doing  this  surely  and  rapidlv,  the  little  instrument 
I  now  show  you,  invented  by  Dr.  Graham  "Weii-,"^  is  the  best  you  can 
employ.  It  consists  of  a  small  handle  of  ivory,  with  four  needle  points 
projecting  from  one  extremity,  and  a  small  curved  knife  for  collecting 
and  separating  the  vaccine  matter  at  the  other  (as  shown  in  the  cut). 
The  skin  is  opened  by  a  crucial  scratch  w^ith  the  needle  points,  which 
are  held  vertically,  and  are  lightly  applied,  so  as  merely  to  remove  the 
cuticle.  The  advantages  of  this  instrument  over  the  lancet  are,  that 
the  operation  is  done  more  speedily,  and  that  it  opposes  a 
larger  surface  for  the  absorption  of  the  lymph,  which  is  less 
liable  to  be  waslied  away  by  too  great  an  eft'usion  of  blood. 

2.  Sometimes  small-pox  occurs  epidemically  in  a  remark- 
ably benign  form.  It  then  presents  all  the  characters  de- 
scribed b}^  some  authors  as  varioloid.  Occasionally  it  occurs 
twice,  or  becomes  what  is  called  recurrent,  and  it  has  been 
known  to  arise  frequently  after  vaccination.  In  all  these 
circumstances,  when  mild,  it  so  resembles  chicken-pox,  as  not 
to  be  distinguished  from  it.  But  more  tlian  this,  it  was 
observed  in  the  epidemic  that  prevailed  in  Edinburgh  in  1819 
and  1820,  that  small-pox  and  chicken-pox  existed  together 
frequently  in  different  individuals  inhabiting  the  same  room, 
and  sleeping  in  the  same  bed.  Well  authenticated  cases 
occurred  of  individuals  inoculated  with  small-pox,  in  whom 
the  eruption  assumed  the  appearance  of  chicken-pox  ;  and 
again  persons  inoculated  with  chicken-pox  had  small-pox 
well  characterised.  The  work  of  Dr.  John  Thomson,  entitled 
"An  Account  of  the  Varioloid  Epidemics  in  Scotland,  1820," 
contains  many  facts  of  this  description,  which  were  Avell 
known  at  the  time,  and  an  account  of  numerous  experiments 
carried  on  in  the  Castle  garrison  of  this  place,  which  have 
never  been  controverted,  and  which  fully  establish  an  essential  '^'^''  ^"^ 
unity  in    the    nature    of  the   two    affections.      It   is    evidently  incon- 

*  Monthly  Journal,  184T-4S,  p.  69. 

Fig.  502.     Dr.  "Weir's  scarificator  for  vaccination. 
51 


898  DISEASES   OF   THE   BLOOD. 

sistent  to  suppose  that  two  distinct  contagions  should  exist  at  the 
same  time,  each  of  Avhich  is  protective  against  the  other.  Those  who 
admit  this  doctrine  must  maintain  tliat,  whenever  the  chicken-pox  con- 
tagion prevailed,  tlie  small-pox  contagion  was  excluded,  or  the  reverse ; 
or,  on  the  other  hand,  they  must  admit  that  variola  is  produced  by  the 
same  contagion  that  gives  rise  to  chicken-pox.  The  work  of  Dr. 
Thomson  furnishes  ample  proof  of  tlic  correctness  of  the  latter  proposi- 
tion. Dr.  Gregory  and  others  who  oppose  this  opinion,  do  so  on  the 
ground  of  the  incubative  stage  being  shorter;  the  whole  disease  less 
prolonged,  and  the  constitutional  symptoms  being  mild.  These  circum- 
stances, you  will  observe,  only  point  to  difference  of  degree  and  intensity, 
not  of  kind.  Dr.  Gregory  also  alleges  that  he  lias  seen  variola  occur 
after  cow-pox,  and  cow-pox  after  variola,  and  therefore  they  cannot  be 
identical.  So  far,  however,  does  tliis  appear  to  me  no  argument,  that, 
if  possible,  it  confirms  Dr.  Thomson's  observations.  The  variola  he 
speaks  of  occurring  after  cow-pox  is  evidently  modified  small-pox,  and 
cow-pox  may,  in  the  majority  of  cases,  be  reproduced  at  pleasure. 

3.  Dr.  Jcnner,  through  life,  was  of  opinion  that  cow-pox,  the  grease 
in  horses,  swine-pox,  and  small-pox,  were  only  modifications  of  each 
other.  He  believed  that  in  giving  to  man  cow-pox,  he  was  in  reality 
giving  to  him  small-pox  in  its  primitive  and  mildest  form.  Whether 
cow-pox  or  small-pox  is  the  original  form  has  been  disputed.  It  occurs 
to  me  as  more  probable  that  cattle  caught  it  from  man,  rather  than  man 
from  cattle,  an  opinion  conti)-med  by  the  experiments  of  Mr.  Ceely  of 
Aylesbury,  recorded  in  the  "Transactions  of  the  Provincial  Medical  and 
Surgical  Association,"  (vols.  viii.  and  ix.)  He  showed  that  by  operating 
on  tlie  mucous  surfaces  of  the  animal,  the  cow  readily  receives  the  poison 
of  human  sraall-pox,  which  the  constitution  of  the  animal  converts  into 
the  vaccine.  1  need  not  enter  at  length  into  the  discussion  which  has 
been  raised  on  this  subject.  Suffice  it  to  say,  that  the  identity  of  the 
t-\fo  diseases  appears  to  me  to  be  established  by  the  following  incontro- 
vertible facts : — 

1.  The  prevalence  at  the  same  period  of  the  cow-pox  among  cattle, 
and  the  small  pox  among  men. 

2.  The  transmission  by  coniar/ion  of  the  small-pox  to  cattle,  and  the 
consequent  development  of  cow-pox  in  these  animals. 

3.  The  transmission  by  inoculation  of  the  small-pox  to  cattle,  and  the 
resulting  development  of  cow-pox  in  those  animals. 

4.  The  transmission  by  inoculation  of  the  cow-pox  to  man,  and  the 
development  thereby  of  a  pustule  similar  in  character  to  the  vaccine  pox 
of  the  cow. 

5.  The  transmission  by  inoculation  of  the  cow-pox  to  man,  and  the 
consequent  development  of  an  eruption  similar,  if  not  identical  with 
small-pox. 

All  these  propositions  have  been  established  by  numerous  facts,  which 
you  will  find  ably  stated  in  the  "Report  of  the  Vaccination  Section  of 
the  Provicial  Medical  Association."  See  also  Mr.  Simon's  Government 
Report  on  the  "History  and  Practice  of  Vaccination,  1857." 


SYPHILIS.  899 

SYPHILIS   AXD   MERCURIAL   POISOXING. 
Case  CCXXII.* — Syphililic   Ulceration  of  the  Face. 

Anne  Bruce,  set.  24 — admitted  Jan.  10th,  1852.  Her  face  presented  a  most 
frightful  appearance,  being  covered,  as  well  as  the  neck  and  upper  part  of  the  chest, 
with  circular  masses  of  pustular  scabs.  These  varied  in  size,  from  a  fourpennj'  piece 
to  half-a-crown,  several  being  in  some  places  crowded  together.  Some  of  the  pro- 
minent scabs  were  dry,  others  soft,  with  foetid  pus  oozing  from  their  bases.  In  a 
few  places  they  had  fallen  ofi"  exposing  circular,  unhealthy-looking  ulcers.  Wher- 
ever the  skin  could  be  seen,  it  was  of  a  fiery-red  colour,  and  puckered  with  old 
cicatrices.  The  lower  lip  was  swollen  and  dragged  downwards,  and  the  left  lower 
eyelid  was  ulcerated  and  everted.  The  metacarpal  bones  of  the  left  hand  were 
enlarged,  and  the  skin  covering  them  red  and  painful.  Xo  ulceration  of  the  throat 
or  other  complaints,  with  the  exception  of  weakness.  External  appearance  highly 
cachectic. 

The  history  she  gave  of  her  case  is  as  follows :  About  five  years  ago  she  con- 
tracted primary  sores  from  her  husband,  who  had  suffered  from  a  very  malignant 
form  of  them  in  the  West  Indies.  Shortly  after,  she  was  attacked  with  a  minute 
pustular  eruption  of  the  skin.  This  shortly  disappeared,  but  was  succeeded  by 
occasional  blotches  on  the  skin,  which  sometimes  broke,  but  alwaj's  went  away 
slowh".  Eighteen  months  after  the  commencement  of  the  disease,  one  of  these 
appeared  on  her  chin,  when,  being  alarmed,  she  came  to  Edinburgh.  The  practi- 
tioner she  consulted  placed  her  under  a  mercurial  course,  and  she  was  salivated  for 
six  weeks.  The  disease  in  the  face,  instead  of  healing  slowly  as  formerly,  now 
ulcerated,  and  began  to  spread.  Six  months  afterwards,  she  was  again  salivated 
for  four  weeks,  but  the  whole  of  the  lower  half  of  the  face  was  now  involved,  and 
she  entered  the  clinical  ward  of  the  Royal  Infiruiarj-.  She  is  confident  that  these 
are  the  only  occa.sions  on  which  she  has  taken  mercury.  She  remained  in  tlie  house 
upwards  of  a  month,  and  went  out  with  the  face  nearly  well,  from  the  use  of  topical 
emollient  applications,  and  the  internal  use  of  small  doses  of  iodide  of  iTOtassium. 
Six  weeks  afterwards,  however,  she  was  exposed  to  cold  and  wet,  when  the  blotches, 
scabs,  and  ulcers  returned  in  the  face,  and  gradually  spread  to  the  neck  and  chest, 
as  formerly  described. 

She  was  ordered  four  grain  doses  of  Iodide  of  Potassium  in  a  mixture  containing 
§  i  of  tincture  of  Cardamoms,  and  3  vij  of  compound  infusion  of  Gentian.  The  face 
was  dressed  first  with  a  zinc  lotion,  afterwards  with  one  of  chloride  of  lime,  and 
subsequently  with  an  ointment  of  iodide  of  lead.  Gradually  the  further  ulceration 
was  checked,  and  the  ulcers  healed,  and  on  the  19th  of  February'  she  was  so  much 
relieved,  that  she  insisted  on  going  out.  I  saw  her  in  the  following  June,  with  the 
face  cicatrized  all  over,  but  quite  well. 

Commentary. — It  is  very  rarely  that  we  have  an  opportnnitv  of  seeing 
so  frisrhtful  a  case  of  mercurial  syphilis  as  the  one  just  noticed  ;  it  fully 
equalled  many  of  the  horrible  representations  I  now  show  you  in  the 
work  of  Divergie.  You  will  have  observed  fiom  the  history  of  this 
patient,  that,  previous  to  the  exhibition  of  mercurv,  she  was  subject  to 
the  slow  formation  of  boils,  which,  however,  spontaneously  disappeared. 

*  Reported  by  Mr.  G.  A.  Douglas,  Clinical  Clerk. 


900  DISEASES   OF   THE   BLOOD. 

Tlie  moment  her  system  was  saturated  with  that  drug,  the  boils  and 
ulcers  first  became  stationary,  and  then  commenced  spreading  over  the 
integument.  Tliis  is  an  important  fact  too  little  attended  to  by  those 
who  practise  the  mercui'ial  treatment. 

Case  CCXXIIL* — Syphilitic  Laryngitis. 

Margaret  Dickie,  a  staymaker,  a;t.  25 — admitted  September  9tli,  1851,  labouring 
under  occasional  vomiting,  frequent  cough,  with  haemoptysis,  and  copious  purulent 
expectoration.  There  was  considerable  sweating  at  night,  and  her  general  health, 
owing  to  want  of  sleep  aud  the  harassing  cough,  was  much  broken  down.  At  the 
commencement  of  the  winter  session  in  November,  I  found  her  taking  an  acid  mix- 
ture to  relieve  the  sweating,  a  cougli  mixture  to  diminish  the  cough,  together  with 
cod-liver  oil.  The  chest  had  also  been  blistered.  Careful  percussion  aud  ausculta- 
tion convinced  me  that  the  thoracic  physical  signs  were  perfectly  normal.  I  then 
examined  the  fauces,  which  were  covered  with  purulent  mucus,  but  presenting  here 
aud  there  red  and  prominent  follicles.  The  cough  was  also  ascertained  to  be  con- 
vulsive, the  voice  hoarse  and  broken,  and,  on  placing  the  stethoscope  over  the 
larynx,  a  loud  ringing  sound  accompanied  the  inspiration.  From  these  facts  I  had 
no  difficulty  in  diagnosing  laryngitis ;  and  on  ascertaining  that  the  woman  was  a 
prostitute,  and  addicted  to  drink,  there  could  be  little  doubt  that  it  was  of  syphihtic 
origin.  The  fauces  were  freely  touched  with  a  solution  of  nitrate  of  silver  (  3  ss  to 
§  j  of  water).  This  was  repeated  on  the  following  day,  and  on  the  next  the  upper 
part  of  the  glottis  was  touched,  causing  severe  convulsive  cough.  I  subsequently 
passed  the  sponge,  saturated  with  the  solution,  into  the  larynx  every  second  or  third 
day  during  the  month  of  November,  which  at  first  caused  very  severe  aud  prolonged 
convulsive  cough,  that  gradually  became  somewhat  diminished.  On  the  whole, 
however,  no  great  amendment  was  produced,  although  the  expectoration  and  cough 
during  the  intervals  were  lessened.  The  local  applications  were  then  suspended,  but 
it  soon  appeared  that  they  had  been  beneficial  in  checking  the  symptoms,  from  their 
severity  again  increasing,  especially  the  amount  of  expectoration  streaked  Avitb  blood, 
and  the  want  of  sleep  at  night  owing  to  the  severity  of  the  cough.  In  the  second 
week  of  December,  therefore,  the  topical  applications  were  resumed,  together  with 
occasional  blisters  to  the  larynx,  and  once  more  a  certain  amount  of  benefit  was  ob- 
tained. But  as  this  treatment,  combined  with  the  internal  administration  of  iodide 
of  potassium  and  bitter  infusions,  for  a  period  of  tour  weeks,  seemed  to  produce  no 
further  improvement,  she  was  dismissed  on  January  7th,  1852. 

Commentary. — Syphilitic  disease  of  the  laryn.x  is  one  of  the  most 
common  of  the  secondary  forms  of  the  disease,  a  fact  indicated  bv  the 
lioarse  and  broken  voices  so  frequently  noticed  among  women  of  aban- 
doned character.  The  topical  treatment  with  the  fiponge,  and  a  solution 
of  nitrate  of  silver,  does  not  seem  to  be  so  useful  as  in  simple  laryngitis ; 
but  even  here  its  eftects  on  the  mucous  membrane  are  evidently  bene- 
ficial. 

Case  CCXXIT.f — Syphilitic  Rupia.  foUoiced  by  Keloid  Growths  on  the  Cicatrices — 
Syphilitic  Psoriasis. 

History. — John  Young,  set.  24,  boiler-maker,  native  of  Xew-Monkland — admitted 

*  Reported  by  Mr.  C.  D.  F.  Phillips,  Clinical  Clerk, 
f  Reported  by  Dr.  T.  A.  Carter,  Clinical  Physician. 


SYPHILIS.  901 

Xor.  29,  1858.  The  patient  states  that,  until  eighteen  months  ago,  he  was  perfectly 
healthy,  but  at  that  time,  while  residing  at  Kilmarnock,  he  contracted  a  chancre  upon 
the  prepuce.  This  was  treated  by  the  external  application  of  black-wash  ;  and  he 
took  what  he  believes  to  have  been  mercurial  pills  internally.  The  sore  under  tills 
treatment  healed  in  a  week.  He  then  went  to  Leitli.  and  after  remaining  there  a 
fortnight,  discovered  that  an  ulcer  had  spontaneously  formed  exactly  where  the  pre- 
vious one  had  existed.  He  at  this  time  (July  31st,  1 857)  entered  the  surgical  wards 
of  the  Edinburgh  Infirmary,  and  there  took  pills  which  produced  soreness  of  the 
mouth  and  gums,  and  increased  salivation  lasting  for  about  three  weeks.  The 
ulceration  of  the  throat,  from  which  he  then  also  suft'ered,  was  frequently  cauterized, 
and  black-wash  was  applied  to  the  preputial  sore.  This  plan  of  treatment  was  fol- 
lowed by  a  course  of  iodide  of  potassium.  During  his  residence  in  hospital  an  erup- 
tion made  its  appearance,  which  was  evidently  rupia,  as  proved  by  the  numerous 
large  cicatrices  which  are  at  present  visible  all  over  the  surface  of  the  body.  He 
gradually  got  much  better,  and  was  dismissed  after  six  weeks'  residence.  At  the 
time  of  his  dismission,  however,  there  were,  according  to  his  own  account,  nimibers 
of  adherent  crusts  of  rup'ia  scattered  over  the  greater  part  of  his  body.  After 
leaving  the  Infirmary  he  went  to  ilotherwell,  where  his  throat  again  became  sore ; 
fresh  pustules  of  rupia  formed,  many  of  the  old  crusts  and  sores  enlarged,  and  deaf- 
ness supervened  which  continued  for  eight  or  ten  days.  He  applied  to  a  medical 
man,  who  syringed  his  ears  with  warm  milk  and  water,  and  gave  him  some  liquid 
to  take  internally,  which  he  says  benefited  him  while  he  continued  to  use  it  Fifteen 
weeks  after  this  time  he  went  to  Cumbernauld,  and  there  purchased  a  quack's  book 
containing  a  prescription  for  .sarsaparilla  and  iodide  of  potassium,  which  he  has  con- 
tinued to  take  from  lime  to  time  until  the  present  date.  The  medicine  did  not  cure 
the  disease,  but  kept  it,  he  believes,  from  "  turning  worse."'  Six  months  ago  patches 
of  psoriasis  commenced  to  appear  on  the  neck  and  shoulders,  which  were  soon  fol- 
lowed by  a  similar  eruption  over  other  parts  of  the  body.  Twelve  weeks  ago  a 
medical  man  made  three  attempts  to  inoculate  him  with  syphilitic  virus,  repeated  at 
intervals  of  eight  days,  but  without  success.  The  operation  was  performed  by 
scraping  some  of  the  matter  off  a  glass  upon  which  it  had  been  dried,  and  inserting 
it  under  the  skin  by  means  of  a  lancet. 

Stjiptoms  ox  Admissiox. — The  entire  surface  is  scattered  over  with  round  and 
oval  cicatrices  of  rupia,  which  are  closest  on  the  thighs,  are  not  so  common  on  the 
breast  and  abdomen,  but  pretty  general  on  the  back.  In  the  centre  of  some  of  the 
cicatrices  on  the  upper  extremities  and  back  are  a  few  flesh-coloured  solid  elevations, 
.some  occupying  only  a  portion,  others  the  entire  surface  of  these  cicatrices.  In  the 
latter  case  thej' constitute  nodular  swellings  or  tumours  of  a  flesh  or  pinkish  colour; 
smooth  on  the  surface  and  elevated  above  the  level  of  the  skin  from  one-eighth  to 
one  quarter  of  an  inch  ;  they  are  indurated  and  tough  to  the  feeL  oval  or  rovmd  in 
form,  and  vary  from  one-eighth  of  an  inch  to  one  inch  and  a  half  in  diameter.  The 
largest  of  them  is  situated  over  the  left  shoulder,  and  about  a  dozen  are  scattered 
over  the  neck,  back,  and  superior  extremities;  there  are  none  over  the  chest, 
abdomen,  or  lower  extremities.  In  addition  to  these  there  are  irregularly  shaj^ed 
patches  of  psoriasis  scattered  over  the  head,  neck,  abdomen,  arms,  legs,  and  back. 
On  two  of  the  largest  patches  irregular  ulcers  have  formed,  which  are  about  half  an 
inch  in  diameter,  and  are  at  the  present  time  covered  with  elevated  brown  crusts. 
There  are  numerous  small  pustules  resembling  those  of  acne  over  the  shoulders 
back,  breast,  and  face,  some  of  which  are  advancing  towards  suppuration.  Other 
systems  normal.  He  was  ordered  to  take  five  grains  of  the  Iodide  of  Potassium 
three  times  a  day,  and  to  apply  pitch-ointment  to  the  patches  of  psoriasis  morning 
and  night. 


902  DISEASES   OF  THE   BLOOD. 

Progress  of  the  Case. — The  treatment  just  stated  was  continued  for  two 
months.  The  patches  of  psoriasis  gradually  lost  their  scaly  character,  and  assumed 
the  appearance  of  copper-coloured  blotches,  and  the  intervening  portions  of  the 
skin,  owing  to  occasional  baths,  became  much  clearer  and  freed  from  the  acne. 
He  is  still  in  the  house  (March,  1859). 

Commentary. — This  case  offers  a  good  example  of  the  inutility  of 
mercury,  and  perhaps  even  of  the  evils  it  produces  on  the  economy,  for 
no  one  can  say  how  much  of  the  pustular  and  scaly  disease  niioht  not 
have  been  owing  to  the  effects  of  that  drug.  The  keloid  growths  were 
evidently  fibro-vascular  tumours,  occurring  in  the  cicatrices,  and  o-ave 
liim  no  inconvenience  whatever.  It  is  seldom  I  have  seen  the  skin  of  a 
young  man  so  disfigured,  presenting,  as  it  did,  circular  and  oval  marks 
of  the  former  rupia,  the  pink  swellings,  and  the  large  copper-coloured 
blotches  here  and  there. 

The  literature  of  syphilis  is  exceedingly  rich.  The  origin  of  the 
word,  the  source  of  the  disease,  the  time  of  its  appearance,  its  subse- 
quent course,  and  the  identity  of  its  different  forms  at  various  times, 
have  all  been  keenly  disputed.  Even  at  the  present  day,  its  exact 
nature  and  mode  of  treatment  excite  lively  discussion ;  for  such  are  the 
discordant  facts  reported,  and  such  are  the  prejudices  resulting  from 
education,  and  ex  parte  statements,  that  it  is  extremely  difficult  to  form 
an  unbiassed,  not  to  speak  of  a  correct  opinion.  All  then  that  I  shall 
venture  upon  here,  is  to  communicate  some  of  my  own  reflections  and 
observations  on  this  subject. 

The  venereal  disease  presents  a  great  variety  of  symptoms,  which  are 
generally  considered  as  primary  and  secondary.  They  may,  with  more 
propriety  pei-haps,  be  divided  into  primary,  secondary,  and  tertiary,  as 
follows : — 

Primary  symptoms — 

1.  Balanitis. 

2.  Gonorrhcea,-  ■!  ^^P^'  or  vlceratire. 

I  Acute  or  chrome. 

3.  Chancre. 

4.  Granular  disease  of  os  uteri. 


(  Testes,    Prostate,    Rectum, 
V  orofans, —  •< 


5.  Irritation  in  other  organs, —  )       Schneiderian  Menihrane, 

(       Conjunctiva,  etc. 
Secondary  syiiiptoms,  affecting  the — 

1.  Lymphatic  glands, — Bubo. 

2.  Mucous  membrane, —  Ulcerations. 

3.  Skin, —  Ulcerations  or  eruptions. 

4.  Eye, — Iritis,  etc. 

Tertiary  symptoms — 

5.  Disease  of  bone, — Exostosis,  Caries,  Necrosis. 

The  forms  of  syphilitic  disease  which  commonly  fall  under  our  notice, 
in  the  medical  clinical  wards,  are  such  as  affect  the  skin,  fiuices,  and 


SYPHILIS.  903 

larvnx.  Thev  all  require  the  same  constitutional  treatment,  Lut  the  two 
latter  cleniand  also  local  applications,  some  of  which  have  been  referred 
to  when  speaking  of  laryngitis. 

All  the  different  kinds  of  skin  disease  formerly  described  may  occur 
in  an  individual  affected  with  syphilis.  They  then  become  modified  in 
their  general  appearance,  course,  and  seats  of  predilection.  Thus  it  has 
been  observed  that  the  ordinary  red  colour  of  skin  diseases  assumes,  in 
those  affected  with  syphilis,  a  darker  or  copper}'  tint.  This  is  especially 
observed  in  the  scaly  eruptions,  the  patches  of  which  are  also  smaller, 
while  the  scales  are  thin,  and  of  a  gray  colour,  often  approaching  black. 
The  pustular  scabs  are  hard  and  thick,  of  a  dark  greenish  or  black 
colour,  furrowed  on  the  surface,  and  deep  in  the  skin.  The  ulcers  are 
deep,  circular,  with  hard  and  callous  edges.  The  cicatrices  are  unequal, 
round,  or  spiral,  white  and  depressed.  These  eruptions  may  occur  all 
over  the  surface,  but  are  most  common  on  the  forehead,  face,  nose,  back, 
and  shoulders.  In  children  they  generally  assume  the  form  of  maculse 
or  of  ulcerations;  in  adults,  of  tubercular  and  scaly  disorders,  altbough 
ulcers  are  also  very  frequent. 


Diagnosis  of  Syphilis. 

It  has  been  said  by  some  persons  that  they  can  readily  detect  a 
svpliilitic  from  all  other  skin  eruptions.  But  I  have  known  errors  made 
in  this  respect  by  the  most  experienced  and  eminent  dermatologists,  one 
of  which  I  may  relate. 

A  young  gentleman,  on  rising  one  morning,  found  himself  covered 
with  an  exanthematous  eruption.  He  had  dined  out  the  previous  day, 
and  indulged  in  eating  more  than  usual.  He  applied  to  an  English 
physician  practising  in  Paris,  who  pronounced  it  to  be  urticaria,  recom- 
mended a  dose  of  salts,  and  assured  him  that  it  would  disappear  in  a 
couple  of  days.  Some  friends,  however,  advised  him  to  consult  M.  Biett, 
at  that  time  chief  physician  to  the  Hopital  St.  Louis,  and  certainly  one 
of  the  most  experienced  dermatologists  in  Paris.  He  did  so,  and  the 
eruption  was  stated  at  once  to  be  syphilitic,  and  a  course  of  mercury 
recommended.  It  was  with  the  utmost  difficulty  that  his  English  medi- 
cal adviser  could  prevail  upon  him  to  wait  two  days  before  commencing 
the  mercurial  treatment,  when,  however,  he  had  the  pleasure  of  seeing 
his  diagnosis  justified,  by  the  disappearance  of  the  eruption.  Xow,  I 
need  not  say,  that  if  such  an  error  could  occur  to  one  so  experienced  as 
M.  Biett,  how  much  more  readily  may  it  happen  to  a  practitioner  com- 
paratively unacquainted  with  such  disorders. 

The  same  difficulty  occurs  with  primary  and  secondary  syphilitic 
ulcers.  The  question  here  is.  Is  there  anything  in  the  aspect  of  the 
sore  itself  which  will  enable  us  to  determine  its  nature?  Here,  also,  I 
have  seen  the  greatest  mistakes  made  by  the  most  experienced  surgeons. 
M.  Ricord  was  so  doubtful,  after  long  practice,  of  the  characters  of  a 
common  chancre,  that  he  commenced  a  series  of  inoculations  to  deter- 
mine which  was,  and  which  was  not,  a  true  venereal  sore.  I  am  satis- 
fied also,  that  individuals,  whose  systems  have  been  imjjregnated  with 
mercury,  frequently  have  ulcers,  which   are    constantly  mistaken  for 


901  DISEASES   OF   THE   BLOOD. 

venereal  ones,  although  really  the  results  of  a  poison  with  which  the 
body  is  impregnated.  The  following  case,  which  I  observed  twenty-two 
years  ago,  was  the  first  which  strongly  impi-essed  my  mind  with  this 
truth. 

A  girl,  seven  vears  of  age,  entered  the  surgical  hospital  in  1836.  She 
had  a  round  ulcer  over  the  tibia,  about  the  middle  of  the  left  leg.  It 
presented  all  the  characters  of  a  venereal  ulcer,  as  described  by  Hunter. 
On  inquiiy,  it  appeared  that  her  bowels  having  been  somewhat  deranged, 
the  mother  had  gone  to  a  drugsfist's  shop,  and  asked  for  some  opening 
powders.  She  received  twelve,  which  contained  a  white,  finely  powdered 
substance.  One  was  cjiven  morning  and  night.  In  four  days  profuse 
salivation  came  on.  The  whole  dozen  powders  were  given,  however,  and 
a  cachectic  state  was  induced.  Owing  to  some  accident,  she  received  a 
violent  blow  on  the  leg,  and  the  ulcer  mentioned  made  its  appearance. 
There  had  never  been  a  venereal  taint  in  the  family,  and  the  parents 
were  perfectly  healthy.  The  clinical  professor  declared  publicly,  that 
had  the  girl  been  seventeen  instead  of  seven  years  old,  no  asseverations 
on  her  part  could  have  persuaded  him  that  the  sore  was  not  syphilitic. 

Thus,  then,  it  is  only  when  the  symptoms  arise  in  a  certain  order,  that 
we  can  positively  declare  syphilis  to  be  present.  If  an  individual  has 
chancre,  which  is  followed  by  bubo,  or  ulcerated  throat ;  and  this  is 
accompanied  by,  or  precedes,  eruptions  on  the  skin,  then  we  may  feel 
pretty  confident.  Again,  when  deep-seated  pains  in  the  bones  follow 
the  previous  symptoms,  we  may  consider  them  to  be  syphilitic.  The 
circumstance  of  an  osseous  disease  more  frecjuently  affecting  the  shaft 
than  the  extremities  of  a  long  bone  will  serve  to  distinguish  syphilitic 
from  scrofulous  disease,  and  the  existence  of  caries  in  conjunction  with 
the  peculiar  ulcerations  formerly  alluded  to,  will  confirm  our  suspicions. 
You  should  remember,  however,  that  great  caution  is  always  required. 
The  common  idea  that  the  gonorrhoea  and  excoriations  in  men,  which 
often  follow  impure  connection,  are  a  proof  of  disease  in  the  female,  has 
led  to  great  error;  as  it  is  now  ascertained  that  they  may  occasionally 
arise  from  the  presence  of  the  menses,  some  unusually  acrid  discharge, 
or  other  non-venereal  cause.  A  hasty  opinion  given  to  the  effect  that 
this  or  that  eruption  is  syphilitic,  has  introduced  discord  into  families, 
and  produced  incalculable  mischief.  The  tertiary  syphilitic  symptoms 
also  have  frequently  been  confounded  with  the  deep-seated  pains  of 
rheumatism,  neuralgia,  malacosteon,  etc.  Moreover,  if  such  opinion  leads 
to  the  entering  upon  a  mercurial  course,  the  original  disorder  is  often 
replaced  by  an  artificial  one,  not  unfrequently  more  destructive  in  charac- 
ter, which  is  again  confounded  with  syphilis,  and  so  the  error  is  per- 
petuated. 

Propar/ation  of  Syphilid. 

Actual  contact  from  impure  connection  is  the  most  common  mode  bv 
which  syphilitic  sores  are  communicated.  A  gonorrhoeal  discharge  also 
applied  incautiously  to  the  conjunctiva  or  other  mucous  membranes,  will 
excite  inflammation  in  them.  The  secondary  forms  of  the  disease  are 
always  the  result  of  inoculation ;  but  this  may  arise,  not  only  from  the 
poison  being  absorbed  directly  from  a  primary  sore,  but  may  be  commu- 


SYPHILIS.  905 

nicated  by  the  mother  to  the  foetiis  in  utero, — by  the  infant  to  the  nurse, 
— and  again  by  the  nurse  to  the  infant.  The  following  case,  whicli  was 
most  carefully  investigated,  and  was  the  subject  of  legal  proceedings, 
illustrates  how  nurses  may  be  affected  by  syphilitic  infants. 

In  1842,  the  late  Dr.  W.  Campbell  brought  to  me  a  Avoman  -with  a 
child  ill  her  arms,  to  obtain  my  opinion,  whether  a  skin  eruption  on  the 
latter  was  or  was  not  syphilitic.  I  pronounced  that  it  was,  and  that  the 
woman  should  cease  to  nurse  it,  although  her  nipples  at  that  time  were 
in  no  way  aftected.  The  cbild  was  the  oftspring  of  respectable  pai'ents, 
and  had  been  sent  to  her  to  nurse.  In  consequence  of  my  opinion,  the 
infant  was  returned  to  the  friends,  whose  medical  attendant  maintained 
the  eruption  to  be  non-syphilitic.  The  woman  who  applied  to  ]ne  (nurse 
1)  was  received  as  a  wet-nurse  into  another  family,  and  the  child  was 
sent  to  another  nurse  (nurse  2).  In  a  week  the  child  died ;  and  a  few 
days  afterwards,  nurse  2  was  attacked  with  sore  nipples.  Nurse  1,  sliortly 
after  entering  her  new  situation,  also  perceived  sores  round  her  nipples ; 
and  the  medical  attendant  of  the  femily,  after  consultation  with  me, 
caused  her  to  be  discharged.  She,  in  consequence,  brought  an  action 
against  the  medical  man,  who  had  caused  the  syphilitic  infant  to  be  sent 
to  her,  and  had  mistaken  the  disease.  The  lawyer  she  employed  then 
took  me  to  visit  nui'se  2,  whose  whole  body  was  covered  with  a  syphilitic 
tubercular  eruption.  Both  nurses  ultimately  succeeded  in  obtaining 
compensation  from  the  medical  attendant. 


Pathology  of  Sy2)h.Uis. 

Syphilis  is  caused  by  a  poisonous  virus,  which,  mixing  with  the  blood, 
taints  the  constitution,  and  predisposes  it  to  those  forms  of  secondary  and 
tertiary  disorders  formerly  alluded  to.  The  nature  of  tliis  virus  is  involved 
in  the  same  mystery  as  that  of  other  animal  poisons.  All  that  we 
know  of  it  is  from  observation  of  its  effects.  Sir  A.  Crichton,  adopting 
Liebig's  view  of  a  catalytic  action  produced  in  the  blood,  pointed  out, 
in  1842,  that  this  catalytic  action  was  soon  desti'oyed  in  cases  of  scarla- 
tina, small-pox,  and  similar  acute  diseases.  Here  "the  fever,  which 
destroys  both  the  desire  for  food  and  the  process  of  chymilication,  and 
consequently  the  supply  of  new  elements  for  the  further  formation  of 
new  virus,  is  cut  otf.  But  in  syphilis  and  yaws,  which  do  not  affect  the 
brain  or  vital  functions  for  a  long  time,  the  patient,  by  daily  taking  food 
in  abundance,  supplies  every  day  new  elements  for  the  pi'od action  of 
fresli  quantities  of  poison,  and  consequently  the  disease  goes  on  and  is 
protracted  indefinitely."  This  theory  is  supported  by  the  comparatively 
mild  character  of  syphilis  in  warm  climates,  where  the  natives  live  chiefly 
on  vegetable  food,  and  is  abundantly  proved  by  the  ox»od  effects  of  a  low- 
diet  and  the  most  simple  means,  when  contrasted  with  the  effects  of  so- 
called  specifics. 

For  my  own  part,  I  believe  that  the  virus  of  syphilis,  if  left  to  itself* 
and  if  the  health  of  the  patient  be  attended  to,  will  generally  wear  itself 
out.  Unfortunately  we  are  only  commencing  to  observe  the  natural 
progress  of  syphilis,  and  consequently  we  are  unable  to  determine  how 
long,  under  ordinary  circumstances,  it  takes  to  accomplish  this.     So  far 


906  DISEASES   OF   THE   BLOOD. 

as  I  know,  we  have  no  specific  for  any  kind  of  animal  poison,  for  you 
will  remember  that  Jenner  was  of  opinion  (and  there  can  be  little  doubt 
that  he  was  correct),  that  in  giving  vaccination  to  man,  he  was  merely 
giving  him  small-pox  in  a  modified  form.  The  idea  that  mercury  is  a 
specific  for  the  svphilitic  poison,  and  the  incalculable  mischief  it  has 
occasioned,  will  constitute  a  curious  episode  in  the  history  of  medicine 
at  some  future  day.  It  is  now  well  known  that  the  poison  of  mercury 
produces  a  cachectic  disease  and  secondary  sores  in  the  bodv,  which  have 
been  to  a  great  extent  mistaken  for  those  of  syphilis.  It  consequently 
has  happened  that  mercury  given  to  cure  primary  sores,  has  produced  a 
constitutional  disorder  closely  resembling  that  of  syphilis;  more  mercury 
has  then  been  administered,  increasing  the  mischief,  and  so  the  disease 
has  been  perpetuated.  The  real  fact,  however,  is,  that  the  sypliilitic 
poison  is  no  exception  to  the  general  rule,  which  informs  us  that  all  con- 
tagious diseases  of  the  blood  run  a  certain  couree,  and  that  we  have  not 
yet  discovered  a  specific  cure  for  one  of  them.  The  great  proof  of  this 
is,  that  the  intensity  of  the  disease  in  modern  times  has  declined  exactly 
in  proportion  as  its  treatment  by  mercury  has  diminished,  and  the  disor- 
der been  left  to  follow  its  natural  course.  When  wc  treat  sy])hilis  on 
tlie  same  principles  that  we  do  scarlatiiui  and  small-pox,  it  will  prove 
intinitelv  less  fatal  than  those  disordei-s. 


Treatment  of  Syphilis. 

The  treatment  of  syphilis  may  be  said  to  be  of  two  kinds,  namely,  the 
simple  and  the  mercurial.  The  profession  are  rapidly  deciding  in  favour 
of  the  first,  although  some  of  its  members  still  give  mercurv  in  inveterate 
cases.  Many  of  the  cases  we  meet  with,  therefore,  have  taken  the  drug, 
and  we  have  to  eradicate  the  effects  of  the  mineral  poison  as  well  as  of 
the  original  disease. 

The  Simple  Trealinint  is  divided  into  internal  or  medical,  and  external 
or  surgical.  The  first  consists  in  the  observation  of  certain  hvgienic 
rules,  and  the  employment  of  general  therapeutic  means.  The  diet  must 
be  light  and  mild — meat  and  all  stimulating  viands  retarding  the  cure; 
even  with  the  lightest  diet,  the  hunfjer  should  never  he  (juite  appeased. 
The  regimen  must  be  the  more  diminished  and  rigid  in  proportion  to  the 
youth  and  vigour  of  the  patient.  Diluent  beverages,  decoctions  of  barley, 
liquorice,  and  linseed,  alone  or  mixed  with  milk,  should  be  taken  freely, 
to  the  amount  indeed  of  several  pints  a  day.  Perfect  repose  must  be 
secured  by  confinement  to  bed.  Constipation  must  be  obviated  by  the 
use  of  emollient  clysters  or  mild  laxatives.  The  air  should  be  maintained 
at  the  same  temperature — this  is  an  indispensable  precaution  in  chronic, 
consecutive,  and  mercurial  affections.  Exercise  is  only  useful  in  the 
convalescent  stage.  In  chronic  syphilis,  however,  it  may  often  be  carried 
to  fatigue  with  advantage.  Tepid  baths,  repeated  three  or  four  times  a 
day,  are  always  attended  with  advantage. 

In  the  external  or  surgical  treatment,  strict  attention  to  cleanliness, 
and  the  position  of  the  diseased  parts,  should  never  be  lost  sight  of 
Emollient  decoctions  or  fomentations,  or  dressings  of  simple  cerate,  are 
the  best  applications,  and  the  dressings  should  not  be  too  frequentl 


SYPHILIS.  907 

renewed.  The  greatest  benefit  is  derived  from  the  external  use  of  a  con- 
centrated solution  of  opium  (in  the  proportion  of  about  3  i j  to  |j  of 
water)  ;  it  soothes  excessive  irritability  in  all  cases.  When  the  suppuration 
is  moderated  and  the  surface  of  the  ulcer  cleansed,  stimulating  dressings, 
consi?tino-  of  solutions  of  the  sulphates  of  alum  and  copper,  the  nitrate 
of  silver,  and  sub-acetate  of  lead,  favour  cicatrization. 

In  inveterate  cases,  more  especially  those  labouring  under  tertiary 
symptoms,  the  iodide  of  potassium,  which  was  introduced  by  Dr.  AVal- 
lace  of  Dublin,  and  used  by  him  Avith  considerable  success,  may  be 
eraploved.  I  have  myself  given  it  in  numerous  cases  with  benefit,  in 
doses  of  5  gr.  three  times  a-day,  conjoined  with  emollient  applications  to 
the  affected  parts. 

The  Mercurial  Treatment  used  to  consist  in  keeping  up  slight  saliva- 
tion, by  means  of  the  internal  administration  of  blue  pills  or  some  other 
form  of  mercury,  sometimes  conjoined  with  mercurial  frictions  or  fumi- 
gations, at  least  for  the  space  of  a  month.  More  recently  much  smaller 
doses,  so  as  to  produce  scarcely  sensible  effects,  have  been  given  for  a 
longer  or  shorter  time.  The  physiological  action  of  the  drug  may  be 
produced  by  administering  any  of  its  preparations  continuously  in  small 
doses.  If  combined  with  opium,  they  act  less  on  the  bowels,  and  more 
on  the  system  generally. 

It  is  necessary  during  decided  salivation  that  the  patient  do  not  expose 
himself  to  cold.  A  certain  irritability  is  produced,  and  the  constant 
soreness  of  the  gums,  the  metallic  taste  in  the  mouth,  not  to  speak  of 
the  inconveniences  of  profuse  salivation,  wliicli  occasionally  occurs, 
render  this  species  of  treatment  anything  but  agreeable  to  the  patient. 

Both  kinds  of  treatment  have  now  been  extensively  tested.  In  the 
year  1822,  the  Royal  Council  of  Health  in  Sweden  having  been  charged 
by  the  king  to  conduct  a  series  of  experiments  upon  the  different  modes 
of  treating  venereal  diseases,  reports  from  all  the  civil  and  military  hos- 
pitals were  ordered  to  be  dra\yn  up  annually.  These  reports  establish 
the  inconveniences  of  the  mercurial  system,  and  the  superior  advantages 
of  the  simple  treatment.  In  the  yarious  hospitals  of  Sweden,  40,000 
cases  had  been  under  treatment,  one  half  bv  the  simple  method,  the 
remaining  half  by  mercury;  the  proportion  of  relapses  had  been,  in  the 
first  class,  seven  and  a  half,  in  the  second  thirteen  and  two-thirds,  in  one 
hundred.  Dr.  Fi'icke's  experiments  in  the  Hambui'g  general  hospital 
were  first  made  public  in  1828.  In  four  years,  out  of  16-49  patients  of 
both  sexes,  582  were  treate<;l  l)y  a  mild  mercurial  course,  and  1067  with- 
out mercury  ;  the  mean  duration  of  the  latter  method  was  51  days,  and 
that  by  mercury  85.  He  found  that  relapses  were  more  frequent,  and 
secondary  syphilis  more  severe,  when  mercury  had  been  given.  AVhen 
the  non-mercurial  treatment  was  followed,  they  rarely  occurred,  and  were 
more  simple  and  mild  when  met  with.  He  tells  us  that  he  has  treated 
more  than  5000  patients  without  mercury,  and  has  still  to  seek  cases  in 
which  that  remedy  may  be  advantageously  employed.  He  has  never 
observed  caries,  loss  of  the  hair,  or  pains  in  the  bones  follow  his  treat- 
ment, and  in  all  such  cases  which  have  come  under  his  care,  much  mer- 
cury had  been  given. 

In  1833,  the  French  Council  of  Health  published  the  reports  sent  in 


908  DISEASES   OF   THE   BLOOD. 

by  tlie  physicians  and  suro-eons  attached  to  regiments  and  military  hos- 
pitals in  various  parts  of  Fiance.  Some  of  the  reports  are  in  favour  of  a 
mild  mercurial  course,  others  in  favour  of  simple  treatment.  They  all 
agree  in  stating  the  cure  by  mercury  to  be  one-third  longer  than  by  the 
other  treatment.  At  Strasburg,  mercury  was  only  given  to  very  obsti- 
nate cases.  Between  1831  and  1834,  5271  patients  had  been  thus  treated, 
and  the  number  of  relapses  and  secondary  affections  calling  for  the 
employment  of  mercury  was  very  small.  No  case  of  caries,  and  only  one 
or  two  instances  of  exostosis,  had  been  observed.  Full  reliance  may  be 
placed  on  these  facts,  as  regiments  remain  in  garrison  at  Strasbui'g  for 
tive  or  six  years. 

In  the  various  reports  now  published,  more  than  80,000  cases  have 
been  submitted  to  experiment,  by  means  of  which  it  has  been  perfectly 
established  that  syphilis  is  cuied  in  a  shorter  time,  and  with  less  proba- 
bility of  inducing  secondary  syphilis,  by  the  simple  than  by  the  mercurial 
treatment. 

These  facts  are  now  very  generally  admitted,  and  malignant  syphilis 
is  gradually  disappearing.  Twenty  years  ago,  the  most  frightful  secon- 
dary and  tertiary  cases  were  met  with,  and  the  usual  treatment  was 
profuse  salivation.  At  present,  such  cases  ai'e  rare.  Abroad,  owing  to 
wise  police  regulations,  the  disease  is  intinitely  more  innocent  than  it  is 
even  at  present  in  Scotland  ;  and  under  the  salutary  inHuence  of  a  mild 
and  simple  treatment,  its  virulence  is  daily  abating. 

In  apprec^iating  the  value  of  this  important  revolution  in  practice  we 
should  not  forget  to  eulogise  those  who  had  first  the  boldness  to  introduce 
it.  The  credit  of  this  is  maiidy  due,  in  England,  to  Mr.  Fergusson,  and 
other  British  army  surgeons,  who  practised  it  during  the  Peninsular 
campaign  (Medico-Chir.  Trans.,  vol.  4) — and  to  Mi-.  Rose  of  the  Cold- 
stream Guards  (Ibid,  vol.  8).  In  Scotland,  the  writings  and  lectures  of 
the  late  Professor  John  Thomson  of  this  University  were  mainly  instru- 
mental in  convincing  Scotch  practitioners  of  the  evils  of  mercury  in 
venereal  diseases.  In  Englan(i,  the  Hunterean  theory  and  practice  have 
been  deeply  rooted,  and  in  Ireland  have  been  supported  by  the  writings 
of  Carmichael  and  Collis.  Mercury  in  consequence  is  still  very  generally 
employed  in  those  parts  of  the  kingdom.  The  gigantic  experiments 
made  abroad,  however,  ought  to  convince  the  most  sceptical — if  not,  let 
him  compare  what  syphilis  is  in  Scotland  with  what  it  was,  and  especially 
observe  that  we  never  see  an  instance  of  the  disease  such  as  those 
recorded  (Cases  CCXXII.  and  CCXXIV.),  unless  the  patient's  system 
has  been  contaminated  with  mercury. 

For  an  account  of  the  treatment  by  inoculations,  or  what  is  called 
"syphilization"  in  Italy  and  Norway,  which  was  apparently  commenced 
in  Case  CCXXIV.,  I  must  refer  you  to  papers  by  Drs.  Murchison  and 
Lindsay,  in  the  Edinburgh  Monthly  Journal  for  June  1852,  p.  575,  and 
November  1857,  p.  407.  See  also  the  Brit,  and  For.  Medico-Chir. 
Review,  Vol.  45,  p.  118. 


EHEUMATIS-AI    AND   GOUT.  909 

RHEUMATISM  AND  GOUT. 

General  Patholor/ij  and  Treatment. 

The  present  theory  with  regard  to  these  affections  is,  that  they  are 
both  connected  with  an  increase  of  lithic  acid  in  the  blood.  In  rheu- 
matism, this  is  dependent  on  excess  of  the  secondary,  and  in  gout  on 
excess  of  the  primary,  digestion.  In  rheumatism,  however,  there  is  con- 
siderable excretion  of  lactic  acid  by  the  skin  (Todd),  whilst  in  gout  there 
is  an  excess  of  soda,  which,  uniting  with  the  lithic  acid,  produces  a  com- 
pound of  lithate  of  soda,  that  may  be  detected  as  such  in  the  blood 
(Garrod),  while  sometimes  it  exudes  into  the  cellular  tissues  of  the  skin, 
constituting  tophaceous  deposits.  In  both  diseases  there  is  an  undue 
balance  between  the  excess  of  lithic  acid  and  the  power  of  excretion — in 
rheumatism  by  the  skin,  and  in  gout  by  the  kidney.  This  pathology 
serves  to  explain  the  similitudes  and  differences  existing  between  the  two 
af!ections.  In  both  there  is  a  certain  constitutional  state,  dependent  on 
deranged  digestion,  dui'ing  which  exciting  causes  occasion  local  effects. 
These  exciting  causes  in  rheumatism  are  bad  diet,  hard  work,  exposure 
to  cold  and  wet,  and  its  subjects  generally  are  the  poor  and  labouring- 
population.  In  gout  the  causes  are  good  diet,  indolence,  repletion,  indi- 
gestion, and  its  subjects  ai'e  for  the  most  part  the  rich  and  sedentary. 
The  local  manifestations  in  both  are  acute  wandering  pains,  with  pain 
and  swelling — in  rheumatism  of  the  large,  and  in  gout  of  the  small  joints, 
constituting  the  acute  attack  in  the  one,  and  the  so-called  regular  attack 
in  the  other.  These  are  combined  with  a  tendency  to  various  compli- 
cations of  the  internal  viscera,  which  are  more  or  less  dangerous  to  life. 

The  general  indications  of  treatment  are,  in  both  diseases,  (1st)  so  to 
regulate  the  nutritive  functions  as  to  ensure  a  due  balance  between  the 
amount  of  matters  entering  the  blood  as  the  result  of  digestion,  primary 
or  secondary,  and  the  amount  of  mattei's  discharged  from  the  economy 
by  the  excretory  organs.  (2d)  To  conduct  the  acute  attack  to  a  favour- 
able termination,  carefully  watching  the  internal  viscera,  and  being  pre- 
pared to  act  with  vigour  should  these  become  affected.  Hence  the 
treatment  of  these  diseases  resolves  itself  into  what  may  be  called  cura- 
tive and  preventive — the  first  having  reference  to  the  acute  attack,  the 
second  to  the  means  most  likely  to  hinder  its  return ;  the  one  must  be 
carried  out  by  remedies  which  act  upon  the  blood  and  excretory  organs, 
the  other  by  the  management  of  diet  and  exercise. 

Although  the  general  pathology  above  mentioned,  which  considers 
rheumatism  as  a  blood  disease,  may  be  considered,  on  the  wliole,  as  cor- 
rect, we  are  not  yet  enabled  to  explain  by  it  the  symptoms  of  an  acute 
attack  of  the  disease,  where  in  addition  to  the  constitutional  disorder,  we 
have  local  pain,  occasional  heat,  redness,  and  swelling,  with  febrile  symp- 
toms. Most  practical  men  have  attributed  these  phenomena  to  a  super- 
induced inflammation,  although  it  has  not  been  shown  that  exudation 
occurs,  or  that  it  is  followed  by  the  usual  results  of  that  condition.  Be- 
sides, its  erratic  character  is  opposed  to  what  we  know  of  the  process 
of  true  inflammation  and  calling  it  an  unhealthy  inflammation  in  no  way 


910  DISEASES   OF   THE   BLOOD. 

clears  up  the  mystery.  The  real  pathology  of  acute  rheumatism, 
therefore,  has  yet  to  be  determined,  and,  as  a  preliminary  step,  a  careful 
histological  examination  of  the.aftected  tissues  is  absolutely  necessary. 
So  far  as  I  am  aware,  this  has  never  yet  been  attempted,  if  we  except 
some  observations  by  IJasse  on  the  structure  of  tlie  bones  in  rheumatism 
(see  Monthly  Journal  of  Medical  Science  for  June  1847). 

Oiu'  treatment  of  this  disease,  therefore,  is  purely  empirical,  some- 
times directed  against  the  pain,  at  others  against  the  supposed  inflam- 
mation ;  now  attempting  to  combat  the  pathological  condition  of  the 
blood,  then  striving  to  remedy  its  ctfects  by  acting  on  the  excretions, 
and  not  unfrequently  giving  specifics,  in  the  hope  that  any  change  in 
the  constitution,  however  produced,  may  be  beneficial.  In  no  disorder, 
probably,  has  such  a  crowd  of  opposite  remedies  and  plans  of  treatment 
been  extolled,  and  yet  none  of  them  can  be  depended  on,  so  that  it  has 
been  hinted  that  six  weeks' rest  is  the  most  useful  prescription  (Warren). 
The  latest  author  on  rheumatism  endeavours  to  explain  the  fact  by 
observing,  that  this  need  not  be  wondered  at  by  "  those  who  consider 
the  true  nature  of  the  disorder,  and  the  variety  of  circumstances  under 
Avhich  the  physician  may  be  called  upon  to  minister  to  his  patient's  relief. 
The  bleeding,  which  in  the  young,  plethoric,  and  robust,  may  be  neces- 
saiy  to  allay  excessive  vascular  ae-tion  and  cause  free  secretion,  may  in 
the  weakly  induce  irritability  of  the  heait,  and  a  consequent  attack  of 
cardiac  inflammation.  The  opium,  whicii  in  one  person  mav  prove  of 
the  greatest  service  in  promoting  free  perspiration,  and  in  allaying  the 
general  irritabilitv*  of  the  system,  may  in  another  check  the  biliary  and 
other  secretions,  and  thus  prevent  the  elimination  of  the  rheumatic 
poison.  The  continued  use  of  calomel,  and  the  constant  purging,  which 
may  be  beneficial  to  one  patient  by  removing  large  quantities  of  unhealthy 
secretions,  may  unnecessarily  exhaust  the  strength  of  another,  and  tend 
very  greatly  to  impede  recovery.  And  so  in  regard  to  every  remedy 
which  has  been  proposed.  What  is  useful  at  one  time  proves  useless,  or 
positively  injurious,  at  another ;  and  the  conclusion  is  forced  upon  us, 
that  what  is  Avanted  '  is  far  less  the  discovery  of  untried  methods  of 
treating  disease  than  of  discriminative  canons  for  the  proper  use  of 
those  we  possess ;' — far  less  the  discovery  of  any  new  medicines,  than 
the  adaptation  of  our  present  remedies  to  the  exigencies  of  each  case." 
(Fuller  on  Rheumatism,  p.  73.)  These  judicious  observations  may  serve 
to  explain  the  cause  of  our  failure  ;  but  until  we  obtain  more  exact  infor- 
mation regarding  the  special  pathology  of  rheumatism,  it  is  in  vain  to 
hope  for  a  rational  treatment. 

Occasionally  I  have  tried  the  effects  of  special  remedies  in  this  dis- 
ease, and  watched  a  series  of  cases,  all  which  were  treated  in  the  same 
manner.  Thus  I  have  tried  aconite,  and  believe  that  alone  it  is  of  little 
service ;  colchicum  also  I  have  given  frequently,  and  am  of  opinion 
that  in  pure  rheumatism  it  is  of  no  advantage,  although  in  gout  it  is 
invaluable. 


Treatment  of  Acute  Rheumatism  hy  Xiirate  of  Potash. 
During  the  session  1851-2,  I  made  another  trial  of  this  kind  witli  the 


RHEUMATISM   AND   GOUT.  911 

nitrate  of  potash,  a  remedy  fonuerly  rccoininended  by  Dr.  Brocklesby, 
and  which  had  been  given  with  good  etiect  l>y  M.  (iendrin,  in  the  wards 
of  La  I'itie  in  I'aris,  as  recorded  by  Dr.  Henry  l>ennet  (Lancet,  1844, 
vol.  i.  p.  374).  It  has  more  lately  been  {)ressed  on  our  attention  by  Dr. 
Basham  (Medico-Chir.  Trans.,  vol.  xxxii.),  who  tells  us  that  from  one  to 
three  ounces  of  tlie  salt,  if  freely  diluted  in  watei-,  may  be  taken  by  the 
patient  in  the  course  of  twenty-four  hours,  without  any  injurious  results, 
but  with  the  effect  of  relieving  in  a  marked  manner  the  swelling,  heat, 
and  pain  in  the  joints.  Li  the  following  cases  the  remedy  was  tried  in 
much  smaller  doses,  and  it  appears  to  me  with  more  than  average  suc- 
cess. 

Case  CCXXV.* — Mrs.  Anderson,  set.  48,  sick  nurse — admitted  December  30, 
1851.  States  that  previous  to  the  present  attack  she  had  always  enjoyed  pretty  good 
health,  with  the  exception  of  a  liability  to  a  slight  cough ;  had  been  lately  subjected 
to  much  fatigue  in  her  occupation  as  a  sick  nurse,  and  had  been  exposed  to  cold  from 
sitting  up  for  several  nights  in  succession  in  a  large  room,  heated  by  a  fire,  and 
ventilated  by  keeping  the  windows  open.  Having  no  adequate  protection  from  the 
cold  draught  thus  caused,  she  became  affected  with  sore  throat,  and  had  pain  in  the 
chest.  This  occurred  in  the  latter  part  of  October  last,  and  from  that  time  up  to 
November  20th  she  suffered  from  slight  sliivering  and  uneasiness;  transient  pain  in 
different  parts  of  the  body ;  nausea  and  vomiting.  About  a  fortnight  before  admis- 
sion, she  had  a  distinct  rigor,  followed  by  heat  of  skin  and  other  febrile  symptoms, 
witli  very  severe  pain  in  the  joints  especially,  much  increased  by  any  attempt  at 
motion.  The  vomiting  also  continued ;  and  last  week  she  suffered  from  pain  and 
palpitation  in  the  cardiac  region,  and  at  the  same  time  an  aggravation  of  her  former 
symptoms.  At  present  she  cannot  move  without  suffering  excruciating  agony,  having 
severe  pain  apparently  in  every  joint  of  the  body.  Heart's  sounds,  impulse,  rhythm, 
and  position  normal;  pulse  about  100,  weak.  Irregular  fits  of  copious  clammy  per- 
spiration, of  acid  smell ;  no  oedema  of  the  joints.  Urine  scanty,  dark-coloured, 
deposits  crystals  of  the  triple  phosphates,  with  some  mucus.  Tongue  loaded ; 
anorexia;  thirst;  occasional  vomiting;  no  tenderness  on  pressing  tlie  epigastrium  ; 
bowels  confined;  pulmonary  functions  normal.  5  MuriaUs  Mo'iyMce  semigranum ; 
Pulveris  Aromatici  grana  quinque.  If.  Ft.  pulv.  Mittanf,ur  tales  sex.  One  to  be  taken 
every  half  hour.  Dec.  Ath. — She  took  three  of  the  powders  last  night,  after  Avhieh 
she  fell  asleep ;  and  this  morning  feels  somewhat  better ;  she  has  also  had  the 
bowels  emptied  by  an  enema,  and  is  now  using  a  diuretic  mixture.  Dec.  5th. — 
Pains  in  limbs  much  the  same ;  gets  no  sleep  ;  perspiration  still  copious ;  urine  not 
increased  in  quantity ;  vomiting  continues ;  has  been  taking  diuretics  and  Dover's 
powder.  Dec.  &Ji. — Had  an  exacerbation  last  night,  the  pain  in  the  joints  and 
limbs  being  excruciating.  IJ  Poiassce  Nitratis  semiunciam ;  Aquce  uncias  sex.  Misce 
et  signetur — a  iaUespoonful  every  four  hows.  Dec.  lih. — Has  taken  three  doses  of 
the  medicine ;  she  perspired  a  good  deal  during  the  night ;  urine  not  increased  in 
quantity ;  pain  is  less  severe.  Dec.  8th. — Still  sweats  a  good  deal ;  pains  much  the 
same  as  yesterday.  Adde  misturce  Nitratis  Potass.,  3j.  Dec.  9th. — Pains  better; 
copious  perspiration ;  urine  increased  in  quantity ;  increase  of  the  nausea  and 
vomiting  and  of  the  thirst.  Dec.  lOth. — Pains  nearly  gone;  sickness  continues; 
refuses  to  use  her  medicine;  pulse  80,  weak;  much  general  debility.  After  this 
date  the  pain  ceased  entirely,  and  she  was  shortly  afterwards  discharged  cured. 

Commentary . — This  was  a  severe  case  of  both  general  muscular  and 
*  Reported  by  Mr.  William  Broadbent,  Clinical  Clerk. 


912  DISEASES   OF   THE   BLOOD. 

articular  rlieumatism,  of  a  fortnight's  standing,  when  she  entered  the 
house.  There  was  still,  however,  great  pain  on  the  slightest  movement, 
which,  during  two  days,  in  no  way  yielded  to  morphia,  diaphoretics,  and 
diuretics.  On  the  exhibition  of  the  nitrate  of  potash,  profuse  diapho- 
resis came  on,  which  was  apparently  kept  up  by  the  medicine,  with 
marked  amendment  to  the  rheumatic  pains,  followed  by  i-apid  recovery. 
The  improvement  conld  not  be  attributed  to  the  occurrence  of  any  criti- 
cal day  in  this  case;  and  the  night  previous  to  the  exhibition  of  the 
remedy,  there  had  been  a  marked  exacerbation.  Every  one  who  saw 
this  case  felt  persuaded  that  the  good  effects  were  attributable  to  the 
nitrate  of  potash. 

Case  CCXXVI.*— Jane  Irvine,  fet.  17,  servant — admitted  19tb  December  1851. 
States  that  seven  days  ago,  whilst  engaged  at  her  usual  occupation,  she  was  suddenly- 
seized  with  severe  febrile  symptoms,  and  constant  pain  in  the  left  ankle,  which  was 
increased  by  pressure  and  motion ;  it  was  red  and  tumefied.  On  the  following  day 
the  right  ankle  became  similarly  affected,  and  then  in  succession  the  knees,  shoulders, 
wrists,  and  fingers ;  the  pain  stUl  continuing,  but  modified  in  severity  in  the  parts 
first  attacked.  She  has  been  undergoing  treatment  by  diaphoretics,  without,  how- 
ever, having  experienced  any  relief  from  them.  On  admission  the  pulse  is  100. 
full  and  soft.  A  soft  bellows  murmur,  synchronous  with  the  radial  pulse,  accom- 
panies the  first  sound,  heard  loudest  at  the  base,  and  is  propagated  along  the  course 
of  the  large  arteries.  Cannot  sleep  from  the  pain,  which  is  general,  and  is  causing 
intense  suffering.  Tongue  moist,  preternaturally  red  at  the  tip  and  margin ;  no 
appetite;  thirst,  nausea,  and  vomiting;  the  bowels  are  costive;  some  tenderness 
on  pressure  in  the  epigastrium.  Urine  high  coloured,  deposits  a  slight  sediment 
of  lithates.  Skin  moist,  from  copious  perspiration ;  knees  and  ankles  are  swollen 
and  painful  on  the  least  pres.sure.  The  right  wrist,  especially  near  the  metacarpal 
bone  of  the  thumb,  is  at  present  the  seat  of  greatest  suffering,  and  is  red,  painful, 
and  swollen.  Ordered  to  be  hied  to  §  xvj.  and  to  have  a  imrgative  enema.  December 
20(h. — Is  much  worse  lo-day ;  the  pains  in  the  wrist  and  hands  are  especially 
aggravated.  Copious  perspiration  still  continues.  1^  Potass.  Nitratis,  §  ss ;  Aqiue 
§  vj.  A  iablespoonf id  every  four  hours.  Dec.  2\st. — Slept  during  the  night.  The 
sweating  is  still  profuse.  Urine  in  moderate  quantity,  sp.  gr.  1016,  deposits  lithates. 
Pulse  90,  weak ;  cardiac  murmur  very  indistinct.  The  pain  is  considerably  relieved, 
except  in  the  left  lower  extremity.  Dec.  22d. — Still  continues  taking  the  Potass. 
Xit. ;  the  improvement  more  marked,  and  she  can  allow  the  Imibs  to  be  moved 
about  to-day.  Dec.  23d. — She  presents  quite  a  cheerful  appearance  to-day,  and  is 
entirely  relieved  from  pain ;  all  the  joints  can  be  moved  quite  freeh-,  without  exciting 
uneasiness.  Pulse  68;  skin  cool;  tongue  clean ;  appetite  returning;  bowels  regu- 
lar; urine  natural — some  sediment.  Cardiac  murmur  is  more  distinct  to-day.  Con- 
valescence proceeded  satisfactorily  from  this  date  till  January  5th,  when  she  was 
attacked  by  typhus  fever,  from  which,  however,  she  ultimately  recovered,  and  was 
dismissed  well. 

Commentary. — This  was  also  a  very  severe  case  of  general  rheuma- 
tism, which  was  in  no  degree  benefited  by  diaphoretics,  and  a  large 
bleeding  on  the  seventh  day.  On  the  eighth  day  she  was  if  anything 
worse,  and  then  nitrate  of  potash  was  given,  producing  marked"  relief 
on  the  following  day.     On  the  eleventh  day  of  the  disease,  and  third 

*  Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


RHEUMATISM   AND   GOUT.  913 

from  the  exhibition  of  the  salt,  tlie  disease  was  subdued,  and  she  became 
convalescent.  Here,  again,  tlie  period  of  improvement  cannot  be  con- 
founded with  critical  days,  and  strictly  corresponds  to  the  administration 
of  the  remedy.  The  bleeding  may  have  assisted  its  effects,  but  certainly 
was  not  followed,  as  is  usually  the  case,  by  an  evident  amelioration. 
This  girl  had  an  endocardial  murmur  on  admission,  which  continued 
during  the  progress  of  the  case,  and  I  asceitained  from  the  medical 
practitioner  who  sent  her  into  the  house  that  she  had  laboured  under 
tliis  before  the  attack  of  rheumatism  came  on.  Was  this,  therefore,  an 
anemic  murmur  independent  of  the  general  disease,  or  produced  by  it  ? 
We  may  ask  another  question,  viz.,  Are  all  the  endocardial  murmnrs 
occurring  in  conjunction  with  rheumatism  caused  by  endocarditis,  and 
attributable  to  the  rheumatic  diathesis?  These  questions  demand  more 
careful  attention  to  these  murmurs  in  young  women  than  has,  I  think, 
hitherto  been  paid  to  them.  For  my  own  part  I  am  satisfied  that  these 
anemic  murmurs  in  young  girls  are  very  common,  and  that  they  have 
frequently  been  mistaken  for  sounds  dependent  on  endocarditis.  As 
the  patient  becomes  more  robust  these  murmurs  disappear,  and  hence, 
probably,  has  arisen  the  idea  of  the  good  effects  of  mercury  when  given 
in  such  cases. 

Case  CCXXVIL* — Janet  Wright.  This  woman  had  been  admitted  October  22d, 
1851,  labouring  under  the  usual  symptoms  of  acute  rlieumatism,  and  had  been  under- 
going treatment  by  Dover's  powder,  diuretics,  leeching,  etc.,  up  to  the  6th  December, 
without  any  benefit  whatever,  when  on  that  day  she  was  ordered  !^  Potass. 
Nitratis,  3iij:  Aq.  §  vj.  Misce.  A  iable-spoo7ifid  every  three  hours.  Dec.  ^th. — 
Has  taken  four  doses  of  the  medicine,  but  without  any  good  effect.  Took  a  dose  of 
Dover's  powder  last  night,  and  slept  well ;  pain  in  the  shoulders  very  severe,  and 
also  in  the  knees.  Dec.  8th. — Pain  still  continues.  Adde  onistune  Potass.  Nitraiis,  3  j- 
Dec.  10th — Has  been  using  the  medicine  regularly ;  she  says  it  makes  her  very  weak, 
sleepy,  and  stupid.  She  sweats  a  good  deal  at  night,  and  the  urine  is  increased  in 
quantity ;  is  very  thirsty,  and  complains  of  bad  taste  in  her  mouth;  pains  gone  from 
knees.  Dec.  13th. — Still  continues  the  medicine.  No  return  of  pain  in  the  knees ; 
greatly  relieved  in  shoulders,  etc. ;  the  increased  secretion  from  the  skin  and  kidneys 
continues.  The  improvement  continued  up  to  the  ICth,  when  she  was  dismissed  for 
disorderly  conduct. 

Commentary. — In  this  case  the  nitrate  of  potasli,  after  being  taken  for 
three  days,  had  caused  much  diaphoresis  and  diuresis,  followed  by  dimi- 
nution in  the  rheumatic  pains  and  rapid  improvement,  at  the  time  she 
was  dismissed. 

Case  CCXXVIII.f— James  Rough,  s&t  26,  blacksmith,  admitted  December  29, 
1851.  States  that  he  has  suffered  on  two  former  occasions  from  attacks  of  rheuma- 
tism. During  his  last  attack,  tliree  years  ago,  he  was  treated  in  this  hospital,  and 
it  lasted  five  weeks.  The  present  attack  came  on  nine  days  ago  with  great  severity, 
having  been  preceded  by  febrile  symptoms,  which  appeared  to  have  followed 
exposure  to  cold ;  the  pain  was  very  severe  in  all  the  joints,  but  especially  so  in  the 
wrists  and  knees.     He  has  noticed  within  the  last  year  or  two  that  considerable 

*  Reported  by  Mr.  William  Broadbent,  Clinical  Clerk. 
f  Reported  by  Mr.  William  Calder,  Clinical  Clerk. 
58 


914  DISEASES   OF   THE   BLOOD. 

palpitation  of  the  heart  ensues  after  much  exertion,  or  indulgence  in  ardent  spirits ; 
but  in  his  ordinary  condition  he  is  not  troubled  with  it.  At  present  the  pain  in  the 
joints  is  not  severe,  unless  on  attempting  motion ;  pressure  on  the  right  shoulder 
and  ankle  causes  considerable  tenderness.  The  cardiac  dulness  measures  a  feAv 
lines  more  than  two  inches  across;  the  apex  strikes  the  thoracic  parietes  in  the  normal 
position.  A  very  distinct  bellows  murmur  accompanies  the  first  sound,  is  heard 
loudest  at  the  apex,  and  is  not  prolonged  along  the  course  of  the  great  vessels ;  the 
second  sound  is  more  sharp  and  abrupt  than  natural.  The  radial  pulse  is  not 
synchronous  with  the  impulse  of  the  heart,  but  follows  it  after  a  very  appreciable 
interval.  A  few  sibilant  rales  can  be  heard  here  and  there  over  the  chest.  Tongue 
is  slightly  furred ;  appetite  is  impaired ;  thirst  not  excessive.  There  is  slight 
diarrlioea.  The  urine  is  normal.  Skin  is  moist,  but  no  excessive  perspiration. 
5  Potass.  Nitratis,  §ss;  Aq.,  3  vj.  M.  A  tahle-spoonful  to  he  taken,  diluted  with 
much  ivater,  three  times  a  day.  Dec.  Slst. — Pains  much  easier  to-day.  The  bellows 
murmur  is  much  softer  also.  Urine  deposits  some  lithates.  Is  sweating  a  little 
to-day.  Pulse  86,  soft  and  regular.  Jan.  2d,  1852  (thirteentli  day). — Has  no  pain 
to  day.  Continues  to  perspire  a  good  deal ;  and  the  urine  deposits  a  copious  precipi- 
tate of  the  lithate  of  ammonia.  Pulse  68,  soft  and  regular.  Complains  much  of 
weakness.  After  this  date,  the  amendment  continued  uninterruptedly,  although  only 
one  bottle  of  the  Nit.  of  Potash  mixture  had  been  used,  and  he  was  dismissed  cured 
on  the  12th  January. 

Commentary. — The  employmerit  of  the  nitrate  of  potasli  was  followed 
by  apparently  marked  effects  in  tliis  case,  producing  diaphoresis  and 
evident  benefit  on  the  twelfth  day,  and  removal  of  pain  on  the  thirteenth 
day  of  the  disease.  As  the  attack  commenced  nine  days  before  admis- 
sion, we  cannot  suppose  that  the  recovery  was  owing  to  the  occui'rence 
of  a  critical  day.  Besides  the  good  eff"ects  were  apparent  the  day  after 
the  exhibition  of  the  salt,  and  on  the  following  day  the  pains  had  dis- 
appeared. The  valvular  murnmr  with  the  first  sound  at  the  apex,  and 
the  character  of  the  pulse,  could  leave  little  doubt  as  to  the  miti'al 
incompetency ;  and,  as  he  had  been  previously  subject  to  rheumatism, 
there  is  every  probability  that  the  cardiac  lesion  was  the  result  of  previous 
attacks  of  the  disease. 

In  a  large  number  of  cases  which  I  have  subsequently  treated  with 
niti'ate  of  potash,  I  have  satisfied  myself  that  the  disease  is  more  readily 
subdued  by  this  treatment  than  by  any  other. 


Treatment  of  Rheumatism  by  Ziemon-juice. 

Case  CCXXIX.*— Abigail  Eankin,  a  servant,  aH  39 — admitted  15th  December 
1852.  Had  rigors  on  the  7th,  followed  by  febrile  symptoms  and  acute  pain  in  all 
the  joints.  On  admission,  jiulse  100,  full  and  strong ;  heart  sounds  normal ;  con- 
siderable febrile  .symptoms ;  acute  pains  and  swelling  in  all  the  joints  increased  on 
motion ;  much  sweating  at  night.  Other  functions  healthy.  Habeat  Succ.  Limonum 
1  ij  ter  indies.  On  tlie  17th,  she  was  ordered  9j  of  Dover's  powder.  Dec.  20th. — 
The  pains  have  continued  as  acute  as  ever  till  to-day,  although  she  has  taken  §  vj  of 
lemon-juice  every  twenty-four  hours.  At  present  she  experiences  somewhat  less 
suffering  on  moving  the  joints.     Habeat  Succ.  Limomim  §  iij  ter  indies.     Dec.  22d. — 

*  Reported  by  Mr.  F.  M.  Russell,  Clinical  Clerk. 


RHEUMATISM   AND    GOUT.  915 

There  was  great  sweating  last  night,  and  to-day  slie  is  much  better.  Ilabeat  Succ. 
Lhnonum  3  i  ter  indies.  Some  swelhng  of  the  left  wrist  joint  remained  until  the 
23d,  on  which  all  pain  had  left  lier.     Dismissed  well  January  Glh,  1853. 

Case  CCXXX.* — Catherine  Rookc,  set.  21,  married — admitted  December  23d, 
1852.  Had  rigors  on  the  14th,  followed  by  febrile  symptoms,  and  excessive  pain, 
at  first,  in  the  knees  and  ankles,  but  subsequently  in  everj-  joint  of  the  body.  On 
admission,  pulse  84,  of  moderate  strength;  heart's  sounds  and  impulse  normal; 
the  joints  are  more  or  less  swollen,  painful  on  pressure  and  on  motion ;  skin  bathed 
with  perspiration ;  febrile  symptoms,  with  the  exception  of  increased  pulse,  well 
marked ;  a  considerable  deposit  of  lithates  in  the  urine.  Other  symptoms  normal. 
]J  Pulv.  Doveri,  gr.  x  statim  sumend.  5  Sol.  Mur.  Morph.  3  ss ;  Fotassce  Bilart. 
§  ss ;  Sp.  jEOier.  Kit.  §  j ;  Aqua,  3  j ;  Ft.  haust.  hord  somni  sumendus.  On  the 
25th,  purgatives  of  calomel  and  jalap  were  ordered.  Dec.  2(}th. — The  pain  and 
swelling  of  the  joints  have  somewhat  diminislied,  but  are  still  very  acute.  Haheat 
Succ.  Limon.  ^j  ter  indies.  Jan.  2,  1853. — The  pains  have  slowly  subsided  since 
last  report,  but  there  is  still  considerable  soreness  and  stiffness  of  the  knees.  The 
arthritic  swellings  have  everj'where  disappeared.  Jan.  4th. — Acute  pain  has 
returned  in  the  right  arm,  which  she  cannot  move.  Jan.  5th. — Acute  pain  has 
extended  to  the  right  arm  and  back.  Omiitatur  Succ.  Limmium.  ^  Poiassce 
Nitratis  §  ss ;  Aquce  §  iv.  M.  Sumat  ^i  ex  aqua,  §  iv.  ter  indies.  Jan.  Gih. — The 
pains  have  now  disappeared ;  marked  improvement.  No  critical  discharge.  Dis- 
missed well  January  7  th. 

Case  CCXXXL* — Thomas  Aitken,  fet.  30,  blacksmith — admitted  December 
25th,  1852.  Fourteen  days  ago,  after  exposure  to  cold,  he  was  attacked  by  rigors, 
followed  by  febrile  symptoms  and  pain  in  his  joints,  which  have  continued  up  to 
this  date.  On  admission,  pulse  74,  rather  weak.  A  blowing  murmur  with  the  first 
sound  loudest  at  the  apex,  which  it  seems  resulted  from  a  previous  attack  twelve 
months  ago.  Slight  swelling  only  in  his  right  hand  and  wrist,  but  tliere  is  pain  in 
all  the  joints,  more  or  less  of  an  erratic  character.  Febrile  symiDtoms  very  slight. 
Slight  bronchitis.  Ilabeat  Succ.  Limonum,  §  ss.  ter  indies.  On  the  28th,  the  dose 
of  lemon-juice  was  increased  to  ^j.  On  Jan.  2d,  he  was  much  better;  but  on 
the  4th  the  pains  returned,  but  not  so  violently.  On  the  12th,  he  was  free  from 
paiii,  having  had  some  diarrhoea,  and  taken  a  two-scruple  dose  of  Dover's  powder. 
On  the  22d  the  pains  returned,  but  again  subsiding  on  the  24th,  he  was  dismissed. 

Case  CCXXXIL* — James  Ohason,  a;t.  20,  clerk — admitted  January  4th,  1853, 
with  organic  disease  of  the  heart  of  long  standing,  and  chronic  rheumatism  of  an 
erratic  cliaracter,  sometimes  violently  attacking  one  joint  and  sometimes  another, 
accompanied  with  swelling  and  tenderness.  Lemon-juice  in  |j  doses  was  tried 
three  times  a  day,  for  four  days ;  but,  being  evidently  of  little  benefit,  was  then 
abandoned  for  opiates  and  sedatives. 

Commentary. — In  no  one  of  these  four  cases  in  wliicli  lemon-juice 
was  given,  although  in  two  six  ounces  and  in  one  nine  ounces  were 
taken  daii}',  did  it  appear  to  me  that  the  disease  was  in  any  way  con- 
trolled or  alleviated  by  the  remedy.  In  Case  CCXXIX.  six  ounces 
were  taken  daily  without  any  effect,  and  then  the  quantity  was  increased 
to  nine  ounces  daily,  until  the  21st  day  of  the  disease,  when  sweating 
and    resolution  of  the  symptoms   followed,  more  from    natural   crisis, 

*  Reported  by  Mr.  Alexander  J.  Macarthur,  Clinical  Clerk. 


916  DISEASES   OF   THE   BLOOD. 

perhaps,  than  from  the  effects  of  the  juice.  In  Case  CCXXX.  the 
remedy  was  continued  for  ten  days,  and  until  the  21st  day  of  the  dis- 
oider  was  fairly  passed.  The  nitrate  of  potash  was  given  with  tlie 
immediate  effect  of  relieving  the  symptoms — although  liere  also  it  is 
not  improbable  that  a  natuial  crisis  of  the  disease  was  then  established. 
In  any  case  the  inefficacy  of  the  lemon-juice  appeared  manifest. 
Cases  CCXXXI.  and  CCXXXII.  were  cases  of  sub-acute  and  erratic 
rheumatism,  which  also  resisted  the  lemon-juice;  the  first  for  a  month, 
the  second  for  four  days.  On  the  whole,  this  trial  of  the  remedy  was 
in  no  way  favourable,  and  is  strongly  contrasted  with  the  good  effects 
of  nitrate  of  potash,  which  I  formerly  biought  beibre  you. 

Case  CCXXXIII.* — Diaphragmatic  Rheumatism, 

History. — John  Robinson,  a  bookbinder,  ret.  24 — admitted  February  5th,  1858. 
He  says  that  on  Sunday  last,  January  31st,  he  caught  cold  when  at  a  funeral,  and 
experienced  some  pain  across  the  back  and  chest,  especially  on  the  right  side.  He 
felt  extremely  weak,  and  experienced  great  difiBculty  in  breathing.  On  the  follow- 
ing day  he  noticed  an  eruption  on  the  extensor  surfaces  of  both  legs.  Beyond  a 
blister  which  was  applied  to  the  painful  side,  he  has  been  subjected  to  no  treat- 
ment. 

SviiPTOMS  ON  Admission. — Pain  on  inspiration  over  right  side,  laterally  and 
l^osteriorly.  Slight  cough  with  scanty  expectoration.  Percussion  good  and  equal 
on  both  sides.  On  auscultation  .slight  harshness  of  inspiratory  murmur ;  pulmonary 
sounds  otherwise  normal.  Pulse  110,  soft. — Tongue  furred,  but  moist;  bowels 
open ;  skin  hot ;  perspires  abundantly.  The  extensor  surfaces  of  both  legs  are 
covered  with  urticaria.  Other  systems  normal.  To  have  scruple  doses  of  nitrate  of 
potash  in  half  a  tumblerful  of  water  three  times  a  day. 

Progress  of  the  Case. — Feb.  8th. — Perspired  profusely  yesterday,  and  to-day 
there  is  a  copious  sediment  of  urates  in  the  urine.  The  pain  is  greatly  relieved. 
The  urticaria  is  nearly  gone,  but  there  is  an  erythematous  spot  over  each  patella. 
Feb.  15th. — Has  now  no  pain,  and  complains  of  weakness  only.  5  Quince  Sulph. 
gr.  i. ;  Acid.  Mtric.  m.  x.;  Aqu^  5j. ;  M.  Ft.  haustus  ter  in  die  sumendus.  Dis- 
missed well,  March  10th. 

Commentary. — Deep-seated  rheumatic  pains  in  the  cbest  are  very  apt 
to  be  mistaken  for  pleural  or  pulmonaiy  diseases.  In  the  present  case 
I  found  most  of  the  clinical  clerks  disposed  to  consider  the  disease  a 
pleuro-pneumonia,  and  they  had  framed  a  report  which  gave  consider- 
able colour  to  their  opinion.  A  careful  examination  of  the  chest,  how- 
ever, convinced  me  that  the  lungs  were  sound,  whilst  the  febrile  symptoms, 
the  pain  on  inspiration  and  its  seat,  satisfied  me  we  had  to  do  with 
diaphragmatic  I'heumatism.  The  treatment,  therefore,  was  governed  by 
this  view  of  the  case,  and  we  saw  the  usual  phenomena  of  critical  dis- 
charge by  urine  and  skin  on  the  seventh  day  of  the  disorder.  He  was 
of  weak  constitution,  however,  and  lingered  in  the  bouse  some  time 
longer.  In  the  same  manner  intercostal  rheumatism  is  very  likely  to 
be  mistaken  by  inexperienced  persons  for  pleurisy,  especially  if  they  are 
not  sure  of  the  non-existence  of  friction  or  other  physical  sign  in  the 
chest,  which  their  pre-conceptions  liave  suggested  to  them  exists  there. 

*  Eeported  by  Mr.   Adolphe  Baraud,   Clinical   Clerk. 


RHEUMATISM   AND    GOUT.  917 

But  if  they  carefully  compress  and  rub  the  muscles  between  the  ribs, 
while  the  chest  is  at  rest,  pain  will  be  elicited,  even  to  a  greater  extent 
than  occurs  during-  inspiration;  a  symptom  which  is  diagnostic.  Such 
cases  formerly  must  have  frequently  been  mistaken  for  pleurisy,  and 
bled  of  course  with  the  etiect  of  ultimately  causing  a  cure.  In  agricul- 
tural districts,  slight  intercostal  or  diajihragmatic  rheumatism  is  most 
common  at  certain  seasons  of  the  year  among  labourers,  who  used  con- 
sequently to  be  bled  on  a  Saturday  afternoon,  rest  all  Sunday,  and  return 
to  their  work  quite  well  on  the  following  Monday.  In  such  persons  the 
venesection  was  supposed  by  both  practitioner  and  patient  to  have  cut 
short  an  incipient  pleurisy. 


Case  CCXXXIV.* — Rheumatic  Iritis,  folhvring  Acute  Rheumatism — Recovery. 

History. — John  DuQy,  jet.  '25,  Ordnance  surveyor — admitted  April  6th,  1857. 
Three  weeks  before  admission,  when  in  the  pursuit  of  his  occupation,  he  got  wet, 
and  a  day  or  two  afterwards  was  seized  with  rigors  followed  by  febrile  symptoms, 
pains  in  all  his  joints,  and  swelling  of  both  knees,  and  of  the  left  elbow.  After 
being  in  bed  a  fortnight  and  treated  medically,  he  entered  the  Infirmary,  where  he 
took  Pulv.  Doveri  and  Tr.  Colchici  internally,  and  had  Tr.  lodini  applied  locally. 
On  taking  charge  of  the  case  in  May  I  first  administered  Xitrate  of  Potash ;  subse- 
quentlv  he  was  ordered  warm  baths,  and  then  quinine  with  wuie  and  generous  diet, 
under  which  treatment  he  became  much  better.  Chronic  pains,  however,  still 
continuing  to  linger  about  the  joints,  and  especially  the  knees,  cod-liver  oil  was 
ordered  on  the  2.5th  of  May,  both  internally  and  externally,  and  the  quinine  was  dis- 
continued. 

OccuRREycE  OF  Iritis  AXD  Progress  of  the  Case. — Junelth. — For  three  days 
has  had  slight  redness  of  the  conjunctivae,  with  watering  of  both  eyes,  for  which  he 
was  ordered  a  zinc  lotion.  June  9th. — Conjunctivitis  on  the  right  side  increased,  and 
a  small  blister  was  applied  over  the  right  temple.  June  10th. — Frontal  headache. 
The  conjunctiva,  uumediately  around  the  cornea,  is  surrounded  by  a  zone  of  straight 
vessels,  radiating  outwards.  Inferior  half  of  conjunctiva  of  uniform  red  colour.  To 
be  cupped  over  riglit  temple,  and  §  v  of  blood  extracted.  Extract  of  belladonna 
to  be  applied  externally  round  the  eye.  June  llth. — The  whole  of  right  conjunctiva 
of  a  deep  uniform  vermilion,  and  zone  of  vessels  round  the  cornea  of  a  darker  shade. 
Atropine  to  be  dropped  into  the  eye  to  ensure  dilatation  of  the  pupil.  To  wear  a 
large  shade.  June  I'dth. — Yesterday  a  weak  lotion  of  Alum  (gr.  iij  to  |  j  of  water) 
was  applied,  but  has  caused  much  irritation.  Inner  margin  of  iris  thickened  and 
irregular,  pupil  dilated.  Discontinue  lotion,  apply  belladonna  externally,  and  a 
warm  poultice  over  the  e3"e  at  night.  June  l-ith. — To-day  iritis  and  conjunctivitis 
have  appeared  in  the  left  eye.  Much  pain  in  head,  and  restlessness  during  the  night. 
Appetite  bad;  tongue  coated;  pulse  76,  moderate  strength.  To  have  Quince  Sulph. 
gr.  iij  three  times  a-day.  To  go  into  the  side-room,  and  the  window  to  be  obscured. 
June  nth. — Left  conjunctiva  now  of  as  uniform  redness  as  the  right,  and  iritis  well 
developed ;  pupil,  however,  more  dilated.  Belladonna  has  been  applied  round  both 
eyes.  Last  night  had  3  j  .of  Castor  oil,  which  not  having  operated,  was  ordered 
to-day,  01.  Croton.  gutt.  unam  et  Ext.  Colocynth.  Co.  gr.  x.  June  20ih. — Both  irides, 
which  naturally  are  of  a  light-blue  colour,  present  a  dark,  dirty  green  colour.  The 
pupillary  margins  are  thick,  and  that  of  the  right  side  irregular,  especially  at  one 

*  Reported  by  Mr.  Stewart  Lockie,  Chnical  Clerk. 


918  DISEASES   OF   THE   BLOOD. 

place  where  an  adhesion  has  formed.  Both  conjunctivae  are  of  a  uniform  dense  ver- 
milion colour.  There  is  considerable  pain  in  tlie  head ;  photophobia  and  lacryma- 
tion.  Discontinue  quinine.  5  Pulv.  Cinchon.  Ruhr,  et  Pulv.  Soda  Bicarh.  aa  gr.  v. 
Ft.  pulv.,  to  he  taken  three  times  a  day.  July  1th. — To  day  the  right  eye  is  much 
improved,  redness  of  conjunctivae  diminished,  adhesion  of  pupillary  margin  disaj)- 
peared,  and  vision  perfect.  Left  eye  the  same  as  before,  but  an  adhesion  has  formed, 
which  has  rendered  the  pupil  irregular  for  some  da^-s.  Cephalalgia  has  been  some- 
times better,  sometimes  worse.  Belladonna  has  been  constant!}'  applied.  Applicent. 
hirudines  iij  tempor.  sinist.  July  l-ith. — The  right  eye  is  now  quite  well.  Left  eye 
appears  if  anything  worse.  The  pupil  is  dim,  greatly  contracted,  and  its  margin 
much  thickened.  Yision  also  is  nearlj^  gone ;  he  sees  as  if  tlirough  a  thick  cloud. 
Applicent.  hirudines  ij  tempor.  sinist.  July  22d. — The  leeches,  he  says,  relieve  the 
frontal  pain,  and  they  were  again  applied  yesterday.  To-day  conjunctivitis  less,  and 
evident  improvement ;  pupil  larger ;  vision  clearer.  July  28th. — Since  last  report 
the  morbid  appearances  in  the  eye  have  gradually  disappeared.  Two  leeches  have 
again  been  applied,  and  a  blister  to  the  neck.  General  health  much  improved, 
although  still  weak.  August  lOth. — Has  been  quite  well  for  some  days;  vision  in 
left  eye  is  still  slightl}-  dim.  but  is  getting  clearer  daily.     Dismissed. 

Covimentary. — This  case  of  double  rheumatic  iriti.«,  with  conjunc- 
tivitis, was  of  the  most  severe  description.  So  much,  liowever,  lias  been 
said  about  the  danger  of  allowing-  such  cases  to  run  their  natural  course, 
and  of  the  necessity  of  treating  them  with  sj)ecifics,  more  especially  with 
colchicum  and  mercury,  that  1  resolved  to  treat  this  case  without  them. 
It  was  watched  on  this  account  with  great  interest  by  the  clinical  class, 
especially  as  it  was  seen  from  time  to  time  by  my  friend,  the  ophthalmic 
surgeon  to  tlie  Infirmary,  who  predicted  the  worst  consequences.  Yet 
notwithstanding  the  weakened  condition  of  the  patient  when  iritis  came 
on,  the  severity  of  the  disease  in  both  eyes,  and  the  apparent  closure 
which  was  about  to  take  place  in  one  pupil,  1  persevered,  and  the  ix'sult 
in  perfect  recovery  justified  my  expectations.  It  may  be  argued,  how- 
ever, that  the  case  would  have  got  well  much  sooner  if  mercurials  had 
been  given.  It  is  very  difficult  to  determine  this  point,  because  few 
oculists  have  informed  us  what  is  the  ordinary  course  of  a  severe  rheu- 
matic iritis  with  conjunctivitis.  According  to  Wharton  Jones,*  if  taken 
in  time  before  much  exudation  has  occurred,  and  properly  treated,  it 
may  be  cured  in  three  or  four  weeks.  AVhat  are  called  active  remedies 
were  not  applicable  in  this  case,  even  according  to  the  principles  of 
those  who  use  them,  and  the  amount  of  exudation  was  considerable. 
The  complete  recovery  of  the  right  eye,  therefore,  in  five  weeks,  and  of 
the  left  eye  in  six  weeks,  seems  to  me  to  have  been  on  the  whole  a  short 
period,  considering  all  the  circumstances,  although,  on  this  point,  further 
observations  are  required.  In  the  meantime,  the  case  demonsti'ates  that 
the  most  severe  attacks  of  rheumatic  iritis  may  get  well,  altogether  inde- 
pendent of  mercurials  and  active  antijihloixistics.  A  similar  conclusion 
had  been  previously  arrived  at  by  Dr.  Williams  of  Boston,  TJ.  S.,  from 
a  pretty  extensive  field  for  observation.     (See  p.  277.) 

*  Ophthalmic  Medicine  and  Surgery,  p.  150. 


RHEUMATISM   AXD   GOUT.  919 


Case  CCXXXV.* — Chronic  Gout  vjith  Toiihaceous  Deposits  in  all  the  Joints. 

History. — Thomas  Burns,  a  tobacco-pipe  maker — admitted  Xovember  4tli,  1857. 
Says  he  first  became  ill  in  Glasgow  about  ten  years  and  a  half  ago,  with  pain  and 
swelling  in  both  his  big  toes.  Soon  afterwards  the  ankles  and  knees  became  affected. 
He  was  confined  for  a  month,  being  unable  to  walk,  or  even  to  put  on  his  shoes. 
Since  then  he  has  had  on  an  average  three  such  attacks  every  year,  spring  and 
autumn  being  the  worst  seasons ;  but  he  has  rarely  been  confined  by  them  more 
than  a  week.  Tlie  attacks  have  generally  commenced  with  rigors,  followed  by  more 
or  less  fever  and  swelling  in  one  or  other  of  the  joints.  Almost  every  joint  in  his 
body  has  suffered  in  this  way  at  one  time  or  another.  At  the  first  attack,  he  says, 
chalk  stones  formed  in  his  toes,  and  since  then  they  have  appeared  in  his  feet,  knees, 
elbows,  and  hands.  The  right  hand  especially  has  been  much  deformed  by  them. 
He  is  in  the  habit  of  cutting  down  upon,  and  extracting  them,  whenever  they 
approach  the  surface  and  are  unusually  painful.  He  has  been  twice  in  the  In- 
firmary, and  on  both  occasions  dismissed  relieved.  The  present  illness  commenced 
suddenly  six  weeks  ago,  and  has  more  especially  affected  the  ankles.  He  has 
undergone  a  great  amount  of  treatment,  having  been  bled  and  cupped,  and  having 
taken  much  medicine.  He  had  been  accustomed  to  drink  a  good  deal  of  porter,  as 
weU  as  of  spirits,  until  three  weeks  before  his  first  admission,  in  June  1856,  since 
which  time  he  has  been  more  temperate. 

Symptoms  ox  Admission'. — He  complains  of  pain  in  the  left  wrist  and  both  ankle 
joints,  which  latter  are  swollen,  and  pit  on  pressure.  The  joints  of  the  fingers  are 
nodulated  and  crooked,  especially  those  of  the  right  hand,  hard  to  the  feel,  with 
numerous  tophaceous  deposits  visible  through  the  shining  and  stretclied  integument, 
about  the  size  of  millet  seeds.  The  elbow  and  knee  joints  are  similarly  affected, 
with  several  deposits  over  the  olecranon  and  patella  of  each  Imib.  The  toes  are  not 
so  distorted  as  the  hands.  There  is  pain  on  pressure  over  the  right  lumbar  region, 
with  a  slight  trace  of  albumen  in  the  urine.  Other  functions  normal.  ]J  Potassce 
Acet.  3iiss;  Sp.  ^iher.  ML   3ss;    T>:   Colchici  3j;  Mist.   Camph.  ad  ^xuy     M. 

^j  to  be  taken  three  times  a  day. 

Progress  of  the  Case. — Xovember  25th. — Small  abscesses  have  appeared  over 
the  patella  and  heel,  to  which  poultices  have  been  applied.  The  mixture  has  been 
apparently  of  no  service,  and  is  to  be  discontinued.  Dec.  ISih. — Last  night  was 
seized  with  severe  lumbar  pain,  and  general  febrile  symptoms,  and  on  examining 
the  urine  it  was  found  to  be  highl}-  albuminous.  Tlie  sediment  contained  numerous 
epithelial  cells  from  the  kidney,  with  granular  and  desquamative  casts  of  the  tubes. 

5  V  of  bbod  to  be  extracted  from  the  loins  by  cupping,  and  to  have  at  night  Pulv. 
Doveri  gr.  x.  Dec.  2lst. — Is  much  better.  Albumen  in  the  urine  diminished.  5 
Ammon.  Fhosphat.  Zy,  Tr.  Gent.  Co.  ^j;  Inf.  Gent.  Co.  ^v.  M.  A  fourth  part 
to  be  taken  in  half  a  tumblerful  of  water  three  times  a  day.  Jan  6th,  1858. — Since 
last  report  has  been  comparatively  free  of  pain  and  doing  well,  but  last  night  was 
again  seized  with  severe  febrile  symptoms,  accompanied  by  painful  sensations 
throughout  his  body.  To-day  the  joints  of  the  extremities,  especially  those  of  the 
hands,  are  very  painful.  The  hands  to  be  poulticed.  To  have  Sol.  Acet.  Ammon.  3  j 
every  hour.  Jan.  Sih — He  has  been  perspiring  much,  and  is  better,  although  pains 
in  joints  are  stOl  very  severe.  The  poultices  have  brought  away  several  fragments 
of  the  tophi  near  the  surface.  They  are  of  a  pale  yellow  colour,  friable,  and  when 
examined  under  the  microscope  present  a  mass  of  needle-shaped  crystals  of  urate  of 
soda.      5  Ammon.   Phosphatis,    3ss;   Tr.    Colchici  3j;  Aquie    3  vj.     M.     A  third 

*  Reported  by  Mr.  WUkes,  Clinical  Clerk. 


920  DISEASES   OF   THE   BLOOD. 

part  to  he  taken  three  times  a  day.     Jan.  22d. — The  paius  in  the  joints  have  now  been 
absent  for  ten  days,  and  he  was  dismissed. 

Commentary. — The  above  is  only  the  second  case  of  gout  I  have 
seen  in  the  wards  of  the  Royal  Intirmary,  and  it  is  a  niatter  of  general 
observation  that  the  disease  is  one  from  which  the  people  of  Scotland 
are  remarkably  free.  Tliis  has  generally  been  attributed  to  tlieir  frugal 
habits,  but  more  especially  to  the  drinking  of  whisky,  instead  of  malt 
liquors  and  wines.  Dr.  William  Budd  has  described  gout  to  be  common 
among  a  class  of  workmen  on  the  Thames,  whose  occupation  it  is  to 
raise  ballast  from  the  bottom  of  the  river.  "Those  men,"  he  says, 
"  drink  from  two  to  three  gallons  of  porter  daily,  and  generally  a  con- 
siderable quantity  of  spirits  besides."*  Now,  it  is  curious  that  this  is 
what  the  man,  whose  case  is  before  us,  seems  to  have  done,  and  to  this 
habit,  therefore,  we  may  fairly  ascribe  the  occurrence  of  the  disease. 
He  admitted  that  for  some  years  he  was  accustomed  to  drink  upwards 
of  half  a  gallon  of  porter,  besides  from  four  to  eight  ounces  of  whisky 
daily.  There  was  no  hereditary  tendency.  The  numerous  local 
attacks  frequently  gave  rise  to  excretion  of  the  moi'bid  products  by  tlie 
kidneys,  with  all  the  symptoms  of  Bright's  disease,  including  albuminous 
iirine,  and  desquamation  of  cells  with  casts  of  the  tubuli.  In  a  week 
or  so,  however,  they  disappeared,  and  he  enjoyed  a  temporary  immunity 
from  uneasiness.  As  to  treatment,  nothing  seems  to  have  been  of 
permanent  benefit,  the  tophaceous  deposits  apparently  keeping  up 
more  or  less  irritation  and  tendency  to  local  attacks,  which  in  their 
turn  excited  constitutional  ones,  more  especially  the  fever  and  urinary 
symptoms. 


SCORBUTUS. 

Case  CCXXXYI.f — James  Dermot,  a^t.  21,  railway  labourer — admitted  May 
27th,  1847.  Has  been  working  on  the  Caledonian  line  of  railway  for  nine  months, 
and  enjoj^ed  good  health  till  three  months  ago,  when  he  received  a  blow  on  the 
right  tibia.  This  produced  a  sore,  and  an  ulcer  formed.  His  diet  consisted  of  bread, 
coffee,  ham,  butter,  and  sugar;  but  no  milk  or  fresh  vegetables.  On  admission, 
an  elliptical-shaped  ulcer,  about  two  inches  in  length,  is  seated  over  the  middle 
of  the  tibia,  covered  with  irregular  livid  granulations,  and  surrounded  by  a  raised 
purple  edge.  Another  ulcer,  the  size  of  a  shilling,  is  seated  below  this,  and  a 
third  similar  one  on  the  outside  of  the  leg.  Eighteen  months  ago  his  left  leg  was 
burnt,  and  over  the  seat  of  the  old  cicatrix  a  number  of  ulcers,  similar  to  those  on 
the  opposite  leg,  exist.  One  of  these,  towards  the  lower  part  of  the  leg,  is  the  size 
of  half-a-crown,  and  more  livid  than  the  others,  which  are  smaller.  The  gums 
are  swollen  and  fleshy,  but  not  livid.  Pulse  74,  soft.  Bowels  constipated.  To 
have  fidl  diet.  ^.  Aluminis  3  j ;  Aquce  §  viij.  Solve.  Ft  Gargarisma.  3  Sued 
limonis  §iij;  Sacchari  §iss;  Aquce  §  iss.  M.  Sumat  pro  potu  ex  aqua,  indies. 
June  2d. — Ulcers  looking  more  healthy.  Their  surface  to  be  touched  with  nitrate  of 
silver.     July  27th. — Has  slowly  got  well  since  last  report,  and  is  now  discharged. 

*  Library  of  Medicine,  vol.  v.,  p.  219. 

f  Reported  by  Mr.  J.  Robertson,  Clinical  Clerk. 


SCORBUTUS.  921 

Case  CCXXXVII.*— John  M'Kenzie,  vet  26,  railway  labourer — admitted  July 
7th,  1847.  During  the  last  two  months  his  diet  has  consisted  chiefly  of  coS'ee  or  tea, 
with  bread,  butter,  and  sugar,  but  no  milk.  Two  weeks  ago  pain  and  swelling  came 
on  in  his  left  leg.  Soon  afterwards  the  right  leg  was  also  affected,  and  both  became 
discoloured.  Epistaxis  now  occurred,  and  has  continued  at  intervals  ever  since,  and 
has  been  so  severe  during  the  last  two  days,  that  his  nostrils  have  been  plugged. 
On  admission,  the  left  leg  is  much  swollen,  and  of  a  purple  colour  chiefly  on  its 
anterior  and  inner  aspect.  The  right  leg  is  similarly  affected,  but  to  a  less  degree. 
He  complains  of  pain  and  stiffness  in  both  limbs,  especially  about  the  ankles.  The 
gums  are  slightly  swollen,  and  livid  at  the  edges,  but  do  not  bleed  on  masticating 
food.  Pulse  80,  soft.  Tongue  clean.  Bowels  regular.  To  have  full  diet.  Juhj 
20th. — Since  admission  the  symptoms  have  gradually  disappeared,  and  to-day  he  was 
dismissed  cured. 

Covimcntcn-y. — During  the  year  from  October  1846  to  October  1847, 
no  less  than  231  cases  of  Scorbutus  entered  tlie  Royal  Iniii'niary,  of 
whom  30  also  laboured  under  continued  fever.  Of  the  entire  number 
nine  were  females,  and  seven  died.  In  the  previous  year  only  one  case 
entered  the  Infirmary,  and  in  the  following  one  only  six.  I  myself 
treated  between  seventy  and  eighty  of  these  patients,  having  succeeded 
Dr.  Christison  in  the  charge  of  a  long  shed  which  contained  a  large 
number  of  them,  besides  seeing  others  who  came  into  my  other  Avards. 
At  the  same  period  there  existed  a  most  extensive  epidemic  of  typhoid 
or  tvphus  fever.  Yet  it  is  singular  that  the  causes  which  produced 
scurvy,  mostly  in  the  able-bodied  population,  and  especially  among  the 
class  of  labourers  or  "navvies"  then  working  on  our  railways,  were  of  a 
kind  distinctly  different  from  those  usually  giving  rise  to  continued 
fever.  The  potato  crop  had  failed  for  two  successive  seasons,  and  caused 
among  the  poorer  population  the  consumption  of  a  diet  not  only  deficient 
in  vegetables,  but  of  milk  and  fresh  meat  also.  Among  the  railway 
labourers,  the  truck  system,  and  establishment  of  local  stores,  where 
provisions  of  inferior  quality  were  given  on  a  ruinous  svstem  of  credit  or 
exchange,  greatly  assisted  the  absence  of  vegetables  in  causing  the  dis- 
ease. The  previous  winter  had  been  severe  and  protracted,  so  that 
whilst  food  of  all  kinds  was  high  priced,  the  work  and  exposure  of  the 
labouring  population  were  unusually  severe.  But  scanty  and  improper 
diet,  and  especially  such  a  kind  as  was  deficient  in  fresh  meat,  milk,  or 
vegetables,  could  in  almost  every  case  be  ascertained  to  be  the  cause  of 
its  occurrence.  Accordingly,  in  a  large  proportion  of  the  cases,  it  was 
found  sufficient  to  give  the  full  diet  of  the  house  (Case  CCXXVL),  lo 
which,  in  unusually  severe  cases,  two  or  three  ounces  of  lemon-juice  with 
■wine  were  added  (Case  CCXXVIL).  This,  if  the  individual  was  not 
too  prostrated  before  admission,  always  produced  a  cure  in  a  period 
varying,  according  to  the  intensity  of  the  disease,  from  thi-ee  to  six 
weeks.  The  vast  majority  of  cases  entered  the  house  between  the 
months  of  January  and  August. 

Dr.  Christison,  who  has  given  a  most  able  history  of  the  epidemic 
as  it  was  observed  in  Edinbui'gh  and  in  the  Perth  Penitentiary,!  con- 

*  Reported  by  Mr.  J.  Robertson,  Clinical  Clerk. 

•)•  Monthly  Journal  of  Medical  Science,  June  and  July,  1847.  See  also  Dr.  Ritchie 
on  Scorbutics,  as  it  appeared  in  Glasgow  at  the  same  time,  July  and  August,  1847. 


922 


DISEASES   OF   THE    BLOOD. 


clasively  shows  that  to  tlie  absence  of  milk,  or  its  equivalent  nitrogenous 
constituents,  much  of  the  disease  was  owing.  In  the  Perth  Penitentiary 
treacle-water  had  been  given  instead  of  it,  and  on  restoring  the  milk  no 
fresh  cases  occurred.  I)r.  Lonsdale  again  showed,  that  in  the  agricul- 
tural valleys  of  Cumberland,  milk  was  abundant,*  and  that  the  absence 
of  potatoes  and  fresh  vegetables  was  the  evident  cause.  The  probably 
correct  conclusion  is,  that  health  demands  a  varied  diet,  and  that  a  too 
rigid  abstinence  from  milk  and  fresh  meat,  as  well  as  from  vegetables, 
may  occasion  the  disorder.  The  observations  of  Dr.  Christison  unques- 
tionably prove  the  anti-scorbutic  properties  of  milk  and  of  the  full  diet 
of  the  Edinburgh  lutirniary,  as  these  very  frequently  constituted  the  only 
treatment  of  individuals  who  recovered  rapidly. 

The  following  table,  drawn  up  bv  Dr.  Christison,  shows  the  nutritive 
proximate  principles  in  various  dietaries,  healthy,  convalescent,  and 
scorbutic.     The  numbers  represent  ounces  avoirdupois. 


I.  HEALTHY. 

I.  Scott.  Prison  standard. 
•2.  Glasgow  Prison,  3d  rate 

3.  Edinburi'h  Prison,  do. 

4.  Millbank  Prison,  1521. 

5.  Do.    Convicts,  1S40.. 

6.  Dublin  Bridewell,  1S47 

II.  CONVALESCENT. 

7.  Edin.  Inf.  full  diet.... 
S.  Fever  conval.  diet 

TIL  SCOPvBUTIC. 

9.  General  Prison,  1846. . 
10.  Millbank  Prison,  ly23. 

II.  Do.     Soldiers,  lSlO-1. 
12.  Do.  do.  Improved,  1S41 

Tolal. 

IfOJJ-NlTEOGEXOnS.  1                                    NlTROGESOUS. 

1 

Slarch.    Sug.ir. 

F.U.     .Gluten. 

I.egum.  AHmm.  i  Casein 

Mas.  fib,  Total. 

25-2 
25  0 
24-3 
25-0 
231 
19-5 

19  4 
201 

24-2 
20-9 
lS-9 
19-2 

17-8 
18-2 
17S 
19-4 
17-9 
13-4 

11-6 
11-1 

17-S 
16-6 
1.5-3 
150 

1-32 
0-82 
1-56 

o-os 

1-10 
1-50 

1-56 

Oil 
016 
013 
0.55 
0-57 
0-60 

1-26 
S-S3 

111 
0-20 
0-3S 
038 

396 
407 
3 -89 
3  01 
3  06 
2  93 

2-36 
1-82 

396 
3-80 
2-97 
304 

0-13 
013 
0-26 
0-47 

013 

0-23 
0-21 

0-113 
004 
0-04 
0-3G 
0-23 
.. 

0  01 
0-49 

003 
00-4 

1-36 
1-36 
0-38 

0-40 
1-57 

1-50 
0-03 

0-or 

0-55 
0-23 
023 
121 
0-99 
0-94 

1-65 
2-16 

0-55 
0-30 
0-78 
0-64 

6-08 
5-83 
4-79 
5  05 
4-74 
5-49 

5-52 
4-40 

4-74 
39S 
3-78 
3-S9 

Note. — 1,  2.  3.  The  standard  third-rate  diet  of  the  Scotch  prisons,  as  used  in  the  General 
Prison  at  Perth,  in  healthy  years.     4.  Diet  of  Millbank  Penitentiary.  London,  before  being 
changed  to  No.  10.    5.  Millbank  diet  of  civil  convicts,  who  remained  free  of  scurvy,  while 
the  military  prisoners  were  attacked  under  the  diet.  No.  11.     The  data  given  by  Dr.  Baly, 
physician  tl)  the  prison.     6   The  present  diet  of  the  DubliD  i)rison.  where  male  convicts  are 
kept  for  long  terms.     7.  Edinburgh  Koyal  Infirniary  full  diet,  under  which  scorbutics  promptly 
recovered.    8.  Coflvalescent  diet  of  a  fever  patient  of  the  wealthy  ranks,  rapidly  recovering 
flesh  and  strength.    9.  Diet  of  the  General  Prison  before  the  scurvy  broke  out.     10.  Ditto 
before  the  Millbank  epidemic  at  London  in  1^23.    11.  Ditto  before  the  military  prisoners 
in  Millbank  Penitentiary  were  attacked  with  scurvy  in  1840-41.    12.  Improved  diet  on  that 
occasion,  but  found  ineffectual. 

The  individuals  subjected  to  the  dietaries  in  the  I.  and  III.  Divisions  were  all  in  conflne- 
ment  for  long  terms. 

Dr.  Garrod.f  from  an  examination  of  the  composition  of  food,  under 
the  use  of  which  scurvy  was  capable  of  occurring,  as  well  as  of  such  sub- 
stances as  had  been  proved  beyond  doubt  to  be  anti-scorbutic,  was  led 
to  the  conclusion  that  the  absence  of  potash  was  the  cause  of  scurvy.     In 


*  Op.  Citat.,  August,  1S47. 

f  Monthly  Journal  of  Medical  Science,  January,  1S48. 


POLYDIPSIA.  923 

this  way  lie  sliows,  1st,  That  potash  is  deficient  in  scorbutic  diet;  2d, 
That  all  bodies  proved  to  be  anti-scorbutic,  including  fresh  meat  and 
veo-etablcs,  milk,  lemon-juice,  etc.,  contain  a  large  amount  of  potash ; 
3d,  That  in  scurv\'  the  blood  is  deficient  in  potash,  and  the  amount  of 
that  substance  thrown  out  by  the  kidneys  is  less  than  what  takes  place 
in  health ;  4th,  That  scorbutic  patients,  when  kept  under  a  diet  which 
gave  I'ise  to  the  disease,  recover  when  a  few  grains  of  potash  are  added 
to  their  food.  The  salts  of  potash,  such  as  tlie  nitrate,  oxalate,  and 
bitartrate,  are  -svell-known  anti-scorbutics,  but  the  eflicacy  has  always 
been  ascribed  to  the  acid  rather  than  to  the  alkali ;  5th,  That  deficiency 
of  potash  in  the  system  seems  capable  of  explaining  some  of  its  symptoms, 
especially  muscular  weakness,  as  potash  is  a  necessary  constituent  of  the 
muscular  system.  These  yiews  undoubtedly  merit  attention,  and  it  is 
much  to  be  regretted  that  they  were  not  made  known  until  the  epidemic 
which  had  called  thein  forth  had  disappeared. 


POLYDIPSIA. 

Case  CCXXXYUI.*— Sudden  Polydqma— Incurable. 

HiST0R\' — Margaret  Shearer,  a  French  pohslier,  ait.  34 — admitted  May  31st, 
1854.  States  that  a  year  and  a  half  ago  she  went  to  work  at  six  o'clock,  a.m., 
in  her  usual  state  of  good  health,  and  at  eight  o'clock,  two  hours  afterwards,  was 
suddeulj'  f-eized  with  great  thirst,  which  has  continued  ever  since,  accompanied  by 
excessive  discharge  of  uriue.  About  three  months  afterwards,  she  was  obliged  to 
give  up  work  on  account  of  a  pain  in  the  loins.  At  various  times  she  has  expe- 
rienced loss  of  appetite,  nausea,  fulness  of  the  abdomen,  palpitations,  constipation, 
or  diarrhoea.  Thinking  that  her  strength  had  diminished  of  late,  she  entered  the 
Intirmaiy. 

Symptoms  ox  Admission. — On  admission,  the  amount  of  urine  passed  in  twenty- 
four  hours  was  424  ounces — pale  in  colour — of  sp.  gr.  1005,  not  coagulable  by  heat 
or  nitric  acid,  and  containing  no  sugar,  as  determined  by  Trommer's  test.  She  is 
a  stout  able-bodied  woman,  and  speaks  of  occasional  slight  complaints.  She  has  a 
pale  countenance,  furred  tongue,  and  dry  skin ;  but  in  every  other  respect  is  quite 
healthy.  Dr.  Ahson,  who  first  treated  her,  ordered  warm  baths  and  astringents, 
and  afterwards  galvanic  shocks  to  be  passed  through  the  epigastric  region.  On 
taking  charge  of  the  case  in  the  middle  of  June,  I  ordered  bitter  tonics,  and  the  diet 
was  carefully  arranged,  and  the  amount  of  water  drunk  limited,  and  mixed  with 
milk  and  a  little  magnesia.  No  change,  however,  occurred,  and  she  confessed  that 
she  could  not  admit  of  restraint  with  regard  to  the  amount  of  drink.  During  the 
w^hole  month  of  Julj-,  she  was  weighed  daily,  and  the  amount  of  water  drunk  and 
emitted  from  the  kidneys  carefullj'  measured.  Her  average  weight  was  eight  stone, 
which  underwent  little  variation.  The  amount  of  water  drunk  varied  from  370  to 
520  ounces,  the  average  being  440  ounces.  The  amount  passed  varied  from  350  to 
500  ounces;  and  it  was  observable  that  it  was  always  from  20  to  50  ounces  less 
than  the  quantit)^  drank.  The  sp.  gr.  varied  from  1001  to  1005,  and  was  frequently 
tested  for  sugar,  with  the  uniform  result  of  its  never  being  detected.  The  bowels 
were  generally  open  every  other  da}-,  and  the  stool  was  of  normal  consistence  and 
healthy  appearance. 

*  Reported  by  Mr.  James  Thorburn,  Clinical  Clerk. 


/ 


92-i  DISEASES   OF   THE   BLOOD. 

Progress  of  the  Case.— From  the  9th  to  the  14th  of  July,  I  tried  the  influence 
of  narcotics,  and  she  took  three  grains  of  opium  daily,  with  3  iss  and  then  3  ij  of 
solution  of  morphia.  Under  this  treatment  she  frequently  appeared  drowsy  and 
stupid,  but  sound  sleep  was  never  prolonged,  and  no  diminution  of  the  thirst  and 
diuresis  was  perceptible.  She  then  took  large  doses  of  gallic  acid,  and  subsequently, 
at  her  own  request,  cod-liver  oil,  under  the  use  of  which  she  became  stouter,  stronger, 
and  the  appetite  improved.  August  22nd. — All  other  treatment  was  suspended,  and 
she  was  ordered  to  take  ten  minims  of  the  liq.  iodini  comp.,  which  was  continued  to 
the  14th  of  September  without  any  efiect.  On  the  16th  she  was  ordered  5  Mass. 
pil.  aloet.  et  myrrhce  3j;  Ferri  sulph.  9ij;  Ext.  hyoscyam.  9ij.  Ft.  massa  in  pil. 
xij  dividenda.  Turn  pills  to  he  taken  twice  daily.  On  the  26th  there  was  diarrhoea 
when  the  pills  were  discontinued,  and  an  astringent  mixture  ordered.  The  report 
on  the  1st  of  October  was — "general  health  good,"  and  from  an  observation  made 
for  the  first  seven  days  of  this  month,  it  appears  that  the  thirst  and  diuresis  had 
somewhat  diminished,  tlie  amount  of  urine  varying  from  280  to  350  ounces.  There 
was  no  further  change  up  to  October  10,  when  she  left  the  house. 

Commentari/. — I  prefer  calling  this  case  polydipsia  to  diabetes  insi- 
pidus, as  frequent  careful  inquiry  established  the  fact  that  it  commenced 
with  thirst,  and  tliat  the  increased  How  of  nrine  was  a  simple  result  of 
the  quantity  of  water  drunk.  In  the  present  state  of  science,  no  reason- 
able theory  can  be  conceived,  e.vplanatory  of  the  fact,  that  a  woman, 
apparently  in  good  health,  is  suddenly  seized  with  great  thii-st,  and 
thereupon  drinks  two  or  three  gallons  of  water  daily,  passes  a  correspond- 
ing quantity  of  urine,  and  that  this  continues  for  nearly  two  years  with- 
out any  marked  change  in  her  health.  Where  there  is  no  scientific 
indication,  the  treatment  is  wholly  empirical,  and  even  the  results  of 
experience  are  wholly  negative  and  useless.  Astringents,  diaphoretics, 
galvanic  shocks,  narcotism  by  means  of  opium,  cod-liver  oil,  iodine,  and 
purgatives,  all  failed.  The  latter,  by  increasing  the  alvine  discharges, 
diminished  somewhat  tlie  excretion  of  urine,  but  we  could  not  flatter 
ourselves  that  she  was  in  any  way  benefited  by  her  four  months'  treat- 
ment in  the  Infirmary. 

Case  CCXXXIX.* — Polydipsia — Ejxessive  Amount  of  Albuminous  Urine — Phthisis 
Pulmonalis —  Waxy  Liver,  Kidneys,  and  Spleen. 

History. — Thomas  Kegan,  set.  40— admitted  December  13th,  1848.  Patient 
states  that  he  was  in  the  enjoyment  of  good  health  till  last  May,  when  he  first  expe- 
rienced intense  thirst,  and  began  to  drink  large  quantities  of  water.  At  the  same 
time  he  observed  that  his  urine  became  very  much  increased  in  quantity,  and  he 
required  to  get  up  three  or  four  times  in  the  course  of  the  night  to  micturate.  He 
had  no  pain  in  the  region  of  the  kidneys  or  on  making  water.  This  polydipsia  and 
excessive  micturition  continued  undiminished  till  five  months  ago,  when  he  expe- 
rienced a  dull  aching  pain  in  the  small  of  the  back.  This  pain  in  the  loins  after- 
wards degenerated  into  a  feeling  of  weakness,  which  has  continued  ever  since.  On 
the  29th  October  he  went  into  the  Glasgow  Infirmary,  complaining  of  loss  of  appe- 
tite, great  thirst,  weakness,  and  loss  of  flesh.  He  remained  in  this  Institution  for 
six  weeks,  and  took  several  remedies  without  any  benefit.  During  the  last  fortnight 
his  appetite  has  returned,  and  he  has  been  much  better. 

*  Reported  by  Mr.  George  Shearer,  Clinical  Clerk. 


POLYDIPSIA.  925 

Symptoms  ox  Admissiox. — There  was  dulness  on  percussion  and  cracked-pot 
sound  over  the  upper  third  of  left  lung  in  front.  Over  this  part  there  were  heard 
tubular  breathing  and  loud  raucous  rales  ;  over  the  right  apex  prolonged  expiration. 
Posteriori}'  percussion  equal  on  both  sides.  Crepitation  and  sibilant  rales  on  left 
side.  There  is  frequent  cough,  with  copious  niuco-purulent  expectoration.  Tongue 
dry,  clean,  red,  and  tremulous.  Appetite  good,  but  thirst  excessive.  Drinks,  as 
nearly  as  can  be  ascertained,  a  gallon  of  water  daily.  Bowels  regular.  He  is  much 
emaciated ;  skin  dry.  He  has  not  jjerspired  any  for  several  weeks.  No  oedema  or 
ascites.  The  urine  acid,  unusuallj'  transparent,  sp.  gr.  1010,  shows  a  considerable 
quantity  of  albumen,  chlorides  abundant,  no  sugar.  Large  waxy  tube  casts  were 
detected  in  the  urine,  under  the  microscope.  There  is  slight  tenderness  on  press- 
ing tirmly  over  the  region  of  the  kidneys. 

Progress  of  the  Case. — December  I5ih. — He  passes  from  100  to  130  oz.  of 
urine  dailj'.  He  has  expectorated  a  considerable  quantity  of  muco-purulent  matter. 
His  mouth  and  fauces  were  so  dry  this  morning  that  blood  flowed  on  dragging  the 
tongue  from  the  palate,  to  which  it  adhered  by  clammy  glutinous  secretion.  There 
was  a  slight  discharge  of  blood  after  blowing  his  nose  also.  December  18th. — Passed 
176  oz.  of  urine  on  the  16th,  128  oz.  on  the  17th,  to-day  82  oz.,  and  drinks  large 
quantities  of  water.  Ordered  to  be  dry  cupped  over  the  kidneys.  To  drink  soda- 
ivater,  and  milk  and  water  instead  of  simph  ivaier.  December  20th. — Urine  112  oz. 
Ordered  a  tablespoonful  of  Oleum  Morrhucb  three  times  a-day,  and  the  folloiving  mix- 
ture:—  5  Spt.  jEtheris  Nitrici  31;  Sol.  Mur.  Morph.  3ss;  Mist.  CamphorcB  §  ij. 
M.  Half  the  mixture  at  bed-time.,  and  the  other  half  in  three  hours  if  the  cough  is 
trouhhsome.  December  2\st. — Had  a  good  sleep  after  the  mixture,  but  felt  drowsy 
and  sick  all  daj-.  Pupils  contracted  at  morning  visit.  Passed  112  oz.  of  urine 
22d — Feels  very  well  to-day.  Passed  a  good  night.  Urine  64  oz.  December  25th. 
— Has  still  a  feeling  of  weakness  and  heaviness  in  the  loins,  and  breathes  heavily 
and  with  some  difficulty.  Expectoration  purulent  and  considerable  in  quantity. 
Slight  oedema  of  left  foot  observed  this  morning.  Urine  diminished  to  54  oz.  in  the 
twenty-four  hours.  December  26th. — Passed  48  oz.  of  urine  since  j^esterday.  Has 
had  no  stool  during  last  twenty-four  hours.  Complains  of  great  sickness  to-day, 
and  vomited  his  dinner.  Ordered  XajMhoi  Medicin.  §ss:  Tr.  Card.  Co.  §i;  M.  A 
teaspoonful  occasionally  in  a  glass  of  water.  IJ  Fulv.  Jalapce  Co.  3  ss ;  7nitie  tales 
xij ;  07ie  three  times  a  day.  Oi'dered  also  4  oz.  of  gin  daily.  December  21th. — 
Passed  a  very  uncomfortable  night,  with  frequent  moaning  and  stertorous  breathing. 
At  1  P.M.,  his  respirations  became  very  slow  and  laboured,  a  mucous  rattle  was 
heard  in  his  throat,  and  at  45  minutes  past  one,  he  expired. 

Sectio  Cadaveris. — Forty -eight  hours  after  death. 

Bod\'  a  good  deal  emaciated. 

Thorax. — Very  dense  adhesions  at  the  apices  of  both  lungs.  The  upper  lobe  of 
each  lung  felt  firm  and  dense.  In  the  upper  lobe  of  the  left  lung  there  was  a  cavity 
of  tolerably  regular  oval  form,  and  nearly  the  size  of  a  hen's  egg.  The  lower  extre- 
mity communicated  with  a  smaller  one  of  an  irregular  form.  These  cavities  were 
lined  by  a  well  organized  lining  membrane,  having  a  cheesy-looking  matter  adherent 
to  it  at  many  places,  and  here  and  there  the  cavities  were  crossed  by  bands  of 
condensed  fibrous  tissue.  The  pulmonary  tissue  around  them  was  greatly  condensed. 
There  was  much  yellow  tubercle  scattered  through  the  remainder  of  the  lung,  and 
several  vomica.  One  or  two  small  cavities  and  a  good  deal  of  tubercle  were  found 
scattered  through  the  upper  lobe  of  the  right  lung.  About  two  inches  below  the 
apex,  and  nearly  in  the  centre  of  the  organ,  was  a  cretaceous  concretion,  about  the 
size  of  a  pea,  enclosed  in  a  capsule  of  dense  fibrous  tissue.     About  an  inch  below 


/ 


926  DISEASES   OF   THE   BLOOD. 

this,  there  was  a  second  concretion.  The  middle  and  lower  lobes  contained  little 
tubercle.  Bronchial  glands  enlarged,  indurated,  and  loaded  with  black  pigment. 
Heart  healthy. 

Abuomex. — The  liver  was  much  enlarged,  and  was  of  unusual  firmness  and 
density.  On  section  it  presented  the  waxy  degeneration,  well-marked,  the  surface 
of  section  being  dry,  of  a  somewhat  mottled  yellowish-red  colour,  with  a  peculiar 
translucent  appearance;  lobular  structure  very  indistinct.  The  organ  weighed 
6  lbs.  6  oz.  The  spleen  was  enlarged  S^  oz.,  and  felt  somewhat  dense.  On  section 
it  was  found  to  be  pretty  abundantly  studded  with  clear  Malpighian  bodies,  resem- 
bling grains  of  boiled  sago.  The  kidneys  were  enlarged,  weighing  15^  oz.  On 
stripping  off  the  capsule,  the  surface  of  the  gland  was  found  quite  smooth,  very  pale, 
of  a  whitish-yellow  colour,  and  of  unusual  density.  The  surface  was  somewhat 
mottled,  owing  to  some  patches  of  vascularity,  contrasting  strongly  with  the  generally 
ansemic  condition.  On  section  the  cortical  substance  was  found  hypertrophied,  and 
had  a  pale,  translucent  appearance.  The  medullary  portion  was  moderately  con- 
gested. Almost  all  the  branches  of  the  renal  arter\'  in  each  kidney  contained  whitish 
clots ;  some  of  them  were  firm,  others  partially  softened.  Some  chronic  tubercular 
ulcers  were  found  in  the  lower  part  of  the  small  intestine,  and  in  the  upper  part  of 
the  large  intestines. 

Microscopic  Ex-a^mixatiox — On  examining  microscopically  a  little  of  the  softened 
portion  of  the  clots  in  the  renal  arteries,  it  was  seen  to  consist  chiefly  of  granular 
matter  with  a  comparatively  small  number  of  cells,  having  the  character  of  pus 
globules.  When  a  section  of  the  kidney  was  examined,  the  minute  arteries  were 
found  to  be  much  thickened.  The  cells  and  otlier  structures  of  the  kidney  presented 
the  usual  characters  of  waxy  degeneration. 

Commentary. — Tlie  polydipsia  seemed  to  arise  spontaneouslv  in  this 
as  in  tlie  last  case,  but  there  came  on  subsequently  pain  in  the  lumbar 
region  and  other  symptoms  probably  indicating  the  commencement  of 
the  renal  lesion.  After  admission  the  persistent  albuminnria  and  the 
waxy  casts  detected  iu  the  nrine  left  \is  in  little  doubt  as  to  the  existence 
of  Bright's  disease  of  the  kidney,  although  there  was  no  dropsv  in  con- 
sequence of  the  large  quantity  of  water  which  was  freely  passed  from 
the  system.  The  complication  of  excessive  thirst,  great  diuresis,  and 
Bright' s  disease,  mnst  be  one  of  excessive  rarity,  if  indeed  it  has  ever 
been  previously  noticed.  After  death  both  kidneys  exhibited  a  chronic 
state  of  waxy  degeneration,  a  ccmdition  which  in  this  case  was  proved 
to  be  quite  compatible  with  the  excretion  of  large  quantities  of  urine. 
Death  was  occasioned  by  exhaustion  from  the  pulmonary  disease,  vomit- 
ing, and  impeded  nutrition. 


POLYSARCIA   OR   OBESITY. 

Case  CCXL.* — Great  Obesity — Fatty  Degeneration  of  Heart  and  Muscular  System 
generally — of  Liver  and  Kidneys — Hypertrophy  and  Dilatation  of  Heart. 

History. — Anne  Gilchrist,  set.  42,  a  cook— admitted  June  ITth,  1857.     With  the 
exception  of  an  attack  of  rheumatism  when  13  years  of  age,  she  baa  enjoyed  good 

*  Reported  by  Dr.  John  Glen,  Resident  Physician. 


POLYSARCIA   OR   OBESITY.  927 

health  until  three  _vears  ago,  when  she  ruptured  a  blood-vessel  in  the  lung  from  over- 
exertion. Last  March  she  caught  a  cold,  and  shortly  afterwards  observed  a  swelling 
of  the  feet,  gradually'  extending  up  the  extremities.  Since  then  she  has  suffered 
much  from  dyspnoea.  She  has  been  of  a  full  habit  of  body  since  the  age  of  thirteen  ; 
has  indulged  largely  in  eating  and  drinking ;  besides  spirits,  having  drunk  at  least  a 
bottle  of  porter  daily.  She  has  always  been  exposed  to  large  fires  in  the  kitchen, 
and,  in  consequence  of  corpulence,  has  taken  little  exercise. 

Symptoms  on  Admission. — The  woman  is  of  an  unwieldy  size  from  corpulence. 
The  circumference  of  the  body  at  the  umbilicus  is  61  inches,  of  the  calf  of  the  leg  20 
inches?,  ami  of  the  ankle  13  inches.  She  can  lie  on  either  side,  but  is  very  uneasy  on 
the  back.  Slight  exertion  produces  dj-spnoea.  The  sounds  of  the  lungs  and  heart 
are  normal.  Percussion  of  the  latter  organ  is  unsatisfactory,  in  consequence  of  the 
uncommon  size  of  the  left  mamma,  and  accumulation  of  fat.  Pulse  82,  regular  and 
of  good  strength.  Tongue  covered  with  a  thick  fur.  Appetite  good.  Urine  scanty 
and  turbid,  sp.  gr.  1015,  albuminous  on  being  heated.  The  skin  over  the  abdomen 
and  lower  extremities  was  indurated  and  coarse.  The  scales  of  the  house  would  only 
weigh  25  stone,  and  she  was  much  heavier  than  this.  To  have  a  scruple  dose  of 
Bitartrate  of  Potash  three  times  a-day.     Full  diet  and  4  vz.  of  wine  daily. 

Progress  of  the  Case. — June  2\si. — Since  admission,  pulse  better,  and  passes 
more  urine — yesterday  voided  30  oz.  July'  9th. — Has  passed  from  20  to  30  oz.  of 
urine  daily,  and  the  legs  have  ceased  to  be  oedematous.  Complains  of  loss  of  appe- 
tite. Pulse  80,  weak.  To  have  ^v}  of  wine  daily.  Jidy  lOth. — Urine  again  scanty, 
onlj'^  passed  10  oz.  yesterday.  To  have  a  squill  and  digitalis  x)ill  three  times  daily,  in 
addition  to  the  powders.  JulylMh. — At  the  visit  to-day  was  found  lying  on  the  right 
side,  too  weak  to  raise  her  head,  and  breathing  with  difBcultj^,  the  respirations  being 
short  and  laboured.  The  urine  w^as  again  deficient  in  quantity,  and  there  was  con- 
stipation. A  drachm  of  the  compound  Jalap  poivder  tuas  ordered  to  be  taken  immedi- 
ately. In  the  afternoon,  before  the  powder  had  operated,  she  suddenly  grew  livid  in 
the  face,  a  tracheal  rattle  was  heard,  and  in  two  minutes  she  expired. 

Sectio  Cadaveris — Forty-four  hours  after  death. 

External  Appearances. — Bod}'  of  enormous  size,  owing  to  excessive  develop- 
ment of  adipose  tissue.  The  head  appeared  to  emerge  ^^'ithout  any  neck  from  the 
trunk.  Mamma;  enlarged,  each  above  the  size  of  an  adult's  head.  The  following 
measurements  were  taken: — 

Height     ..... 
Circumference  of  chest  below  nipples 
Breadth  from  shoulder  to  shoulder 
Circumference  of  abdomen 

„  mamm;e  at  base 

„  upper  arm 

„  lower  arm 

,,  thigh   . 

„  leg  below  the  knee 

„  ankle  . 

Thickness  of  integument  over  sternum   . 
„  „  abdomen 

Thorax. — Heart  much  enlarged;  it  weighed  22  oz.  All  the  cavities  were  dilated, 
the  walls  retaining  their  normal  thickness.     The  valves  were  healthy.     The  muscular 


G5^ 

inches 

54 

36 

69 

36 

19 

16 

28 

20| 

13 

2 

5 

928  DISEASES   OF   THE   BLOOD. 

tissue  of  the  heart  was  pale  and  soft.  The  lungs  were  healthy.  The  osseous  walls 
of  the  thorax  were  not  larger  than  usual,  the  breadth  internally  being  11^  inches. 

Abdomen^. — There  were  two  ounces  of  serum  in  the  peritoneal  cavity.  The  liver 
was  much  enlarged,  weighed  7  lb.  10  oz.,  and  was  of  a  pale  fawn  colour  The  two 
kidneys  weighed  13^  oz.  They  were  of  soft  consistence,  and  pale  colour.  The 
spleen  weighed  13^  oz. ;  it  was  softer  than  natural.  The  intestines  were  healthy, 
and,  with  the  exception  of  a  few  cysts  in  each  ovary,  the  other  viscera  were  normal. 

Microscopic  Ex.\iiiN'ATiox. — The  muscular  tissue  of  the  heart  was  seen  to  be  in 
an  advanced  stage  of  fatty  degeneration.  The  cells  of  the  liver  were  crowded  with 
large  drops  of  oil,  and  the  nuclei  of  many  of  them  were  absent.  The  cells  of  the 
kidney  were  also  very  fatty. 

Commentari/. — The  circumstances  in  which  this  poor  woman  was 
placed  were  exactly  those  most  favourable  to  the  production  of  obesity. 
As  cook  in  several  noblemen's  families,  there  had  been  no  necessity  for 
her  undertaking  much  personal  exertion,  and  having  a  good  appetite 
and  sound  dio-estive  oro-ans,  she  indulged  laro;elvin  eating  and  drinkinor, 
whilst  always  more  or  less  in  a  heated  atmosphere.  It  is  much  to  be 
regretted  that  her  e.vact  weight  was  not  ascertained.  When  standing 
on  the  Infirmar}'  scale,  which  only  allowed  us  to  weigh  to  the  extent  of 
25  stone,  it  seemed  as  if  she  was  at  least  5  stone  more.  In  a  table  of 
obese  persons  given  by  Dr.  T.  K.  Chamber.*,*  one  man  is  said  to  have 
weighed  30  stone,  but  he  was  6  feet  1  inch  high  ;  two  others,  a  man  and 
a  woman,  weighed  28,  and  another  woman  26  stone.  In  the  case  before 
us,  the  increase  of  fat  had  certainly  arrived  at  an  extent  seldom  wit- 
nessed in  the  human  subject,  and  with  the  result  of  gradually  causing 
fatty  degeneration  of  internal  organs  essential  to  life.  Latteily,  from 
fatty  degeneration  of  the  kidneys  albuminuria  made  its  appearance,  with 
oedematous  limbs.  From  this,  however,  she  might  have  recovered,  had 
not  the  ailvanced  fatty  degeneration  of  the  heart  and  liver  so  enfeebled 
the  circulation  as  to  render  fatal  syncope  at  no  distant  period  certain. 
It  is  probable  that  the  change  of  diet  and  absence  of  her  accustomed 
stimuli  contributed  to  the  result,  although  every  care  was  taken  to 
counteract  such  causes  of  exhaustion  as  much  as  possible. 

*  On  Corpulence.     1850.     P.  139. 


COXCLUSION* 

The  Ethics  of  Medicine. 

Gen-tlemen — After  a  lengthened  period  of  study,  and  a  series  of 
examinations,  intended  to  test  the  amount  of  your  knowledge,  you  have 
received  the  degree  of  Doctor  in  Medicine,  the  highest  academic  honour 
it  is  in  the  power  of  any  University  to  confer.  The  direct  connection 
which  has  hitherto  existed  between  you  and  your  teachers  here  termi- 
nates, and  all  those  restraints,  which  public  opinion  and  legal  forms  have 
imposed  upon  the  uneducated,  are  removed.  The  energies,  which  you 
have  hitherto  employed  in  acquiring  the  necessary  preparatory  informa- 
tion, you  may  now  dedicate  to  the  practical  affairs  of  life.  In  short, 
gentlemen,  you  this  day  obtain  a  high  status  in  society,  and  without,  I 
hope,  ceasing  to  be  students,  you  -become  members  of  a  liberal  and 
highly  honourable  profession.  Such  an  event  constitutes  an  important 
epocli  in  the  life  of  every  man,  and  is  well  calculated  to  excite  not  only 
deep  feelings  of  reflection  in  yourselves,  but  those  of  lively  emotion  in 
all  who  are  concerned  (and  who  is  not  \)  in  the  progress  of  that  art 
which  is  directed  to  the  prolongation  of  life  and  the  cure  of  diseases. 
It  will  not,  then,  be  considered  superfluous  if,  in  obedience  to  established 
usage  before  you  leave  this  institution,  a  member  of  the  medical  faculty 
seizes  the  opportunity  of  offering  to  you  a  few  words  of  advice,  of  point- 
ing out  the  importance  of  your  future  profession,  and  describing  to  you 
the  spirit  in  which  it  ought  to  be  practised. 

I.  The  first  piece  of  advice  that  I  shall  take  the  liberty  of  oflering  is, 
always  to  cherish  a  feeling  of  deep  respoiisibility.  A  medical  man  is  the 
earthly  arbiter  of  life  and  death.  He  is  the  guardian  of  our  race  through 
the  dangers  of  birth,  and  the  perils  of  infancy.  He  is  called  upon  to 
treat  the  diflFerent  maladies  which  can  afflict  the  human  frame,  nnder 
every  circumstance  of  climate,  age,  sex,  or  condition  ;  and  lastly,  when 
all  means  fail  to  prolong  life,  it  is  his  duty,  if  possible,  to  alleviate  those 
pangs,  and  diminish  those  sufferings  which  accompany  the  separation  of 
the  soul  from  its  present  dwelling-place.  If,  then,  we  regard  him  as  the 
soother  alike  of  the  entrance  and  the  exit  of  this  life,  as  the  first  and  the 
last  friend  of  frail  humanity,  and  if  we  further  consider  him,  in  the  social 
scale,  5is  the  superintendent  of  all  public  and  private  institutions  for  the 

*  An  Address  delivered  as  Promo  tor  of  the  iledical  Faculty  to  the  graduates  in 
medicine.     August  1,  1849. 

59 


930  CONCLUSION. 

sick  and  the  insane,  as  the  adviser  of  legal  tribunals  in  tlie  administra- 
tion of  justice,  and  as  the  regulator  of  the  sanitary  conditions  of  armies, 
fleets,  and,  indeed,  of  nations,  it  is  scarcely  possible  to  conceive  a  vocation 
in  which  every  feeling  of  duty  and  honour  ought  more  to  incite  to  activity 
and  usefulness ;  to  the  cultivation  of  his  intellectual  powers  and  resources; 
to  a  life  of  beneficence  and  integrity,  and,  above  all,  to  a  sense  of  the 
deepest  responsibility.  This  feeling  is  one  which  the  most  experienced 
and  able  practitioner  can  scarcely  shake  off,  and  Avhich  ought  to  press, 
with  enormous  force,  upon  those  who  are  newly  called  upon  to  decide 
concerning  the  awful  aft'airs  of  life  and  death.  A  fellow-creature  having 
received  some  violent  accident,  or  being  attacked  by  acute  disease,  calls 
upon  you  for  assistance.  There  may  be  no  more  experienced  practi- 
tioner near ;  these  is  none  to  consult  with  ;  the  danger  is  imminent,  and 
you  feel  conscious  that  not  only  something  must  be  done  immediately, 
but  that  what  is  done  may  save  or  destroy.  Then  there  rushes  upon 
your  mind  a  peculiar  feeling  of  dread  and  anxiety,  rendered  more  embar- 
rassing, perhaps,  by  the  conviction  that  your  future  prospects  may  be 
influenced  by  the  manner  in  which  you  conduct  the  case  before  you. 
Such  a  circumstance,  as  I  have  supposed,  may  happen  to  any  of  you  at 
the  commencement  of  your  career,  and  it  is  then,  you  Avill  perceive,  that 
the  only  true  support  to  be  depended  on,  is  a  consciousness  that  you  are 
enabled  to  put  in  practice  all  those  means  which  the  present  condition 
of  the  science  and  the  art  of  medicine  has  recognised  as  being  correct. 
At  such  moments  there  will  be  impressed  upon  you  the  convicrtion  that 
the  good  of  your  patients,  and  your  own  mental  tranquillity,  are  inti- 
mately united  ;  you  will  see  the  advantage  of  having  studied  your  profes- 
sion, not  merely  as  an  object  of  gain,  but  from  a  love  of  its  intrinsic 
excellence — not  because  it  brings  you  consideration  and  respect,  but 
because  it  enables  you  to  do  good  and  to  relieve  suftering — not  with  a 
vain  effort  at  exhibiting  your  superior  knowledge,  but  with  that  humilitv 
which  is  the  necessary  result  of  true  wisdom. 

The  object  of  medicine  is  to  preserve  health,  prolong  life,  cure  diseases, 
and  thereby  to  forward  the  happiness  of  mankind;  and  it  is  evidently 
the  duty  of  those  who  practise  it,  to  lose  no  opportunity,  and  to  adopt 
every  means  of  prosecuting  that  object  to  its  fullest  extent  and  in  its 
widest  signification.  With  this  view,  gentlemen,  vour  past  studies  have 
been  directed  to  the  acquirement  of  various  kinds  of  knowledge,  the  pur- 
pose of  which  has  been  not  merely  the  obtaining  of  professional  rules, 
but  enlarging  the  mind,  and  cultivating  the  reasoning  powers.  The 
time  has  now  arrived  when  you  must  concentiate  the  miscellaneous 
information  you  have  gathered  together,  in  order  better  to  carry  out 
that  particular  kind  of  practice  which  you  in  future  intend  to  pursue. 
Any  of  the  so-called  accessory  sciences  may  (should  your  tastes  allow) 
be  still  further  prosecuted,  but  not  to  the  exclusion  of  more  important 
matters.  Your  duty  is  to  cure  the  sick  and  relieve  suffering,  and  not  to 
be  distinguished  as  a  chemist,  a  botanist,  or  a  naturalist.  Neither  is  it 
expected  that  you  should  have  all  the  knowledge  which  each  of  your 
teachers  possesses  in  his  especial  department,  but  that  irom  the  whole 
yovi  should  have  obtained  such  a  sum  of  learning,  and  such  an  available 
kind  of  information,  that  you  may  undertake  the  serious  duties  of  a 
medical  practitioner  with  credit  to  yourselves  and  advantage  to  the  pub- 


THE   ETHICS   OF   MEDICINE.  931 

lie.  Such  an  amount  of  knowledge  is  within  the  reach  of  all ;  and 
should  there  have  been  any  deficiencies  or  omissions  in  your  past  career, 
you  are  imperatively  called  upon  to  remedy  them  at  once.  Perhaps  it 
is  unnecessary  for  me  to  say  your  education  is  not  comj)Iete ;  indeed,  in 
one  sense,  it  may  he  said  to  be  only  beginning.  Hitherto,  you  have 
depended  on  others,  now  you  must  advance  by  yourselves — the  informa- 
tion of  collegiate  life  must  be  perfected  and  elaboi'ated,  in  order  to  meet 
the  exigencies  of  cvery-day  aftairs.  You  must  prune  away  those  imagin- 
ings in  which  the  student  loves  to  indulge,  and  direct  your  thoughts  to 
the  stern  realities  before  you.  For  this  purpose,  you  should  seize  the 
interval  which  may  elapse  between  your  retirement  from  the  schools 
and  the  commencement  of  actual  practice,  in  arranging  your  past  acquire- 
ments for  ready  use,  and  in  extending,  by  every  possible  means,  your 
experience  in  the  observation  and  treatment  of  disease.  By  so  doing,  I 
consider  you  will  be  best  qualified  to  meet  the  serious  responsibility  you 
have  to  undertake,  and  will  thereby  attain  that  comfort  of  mind  and 
true  respectability  which  the  proper  and  enlightened  exercise  of  our 
noble  profession  can  alone  secure. 

II.  This  leads  me,  in  the  second  place,  to  impress  upon  you  the  import- 
ance of  2>'>'(''Ctising  the  art  and  cultivating  the  science  of  medicine,  in  a 
sjnrit  of  sincerity  and  of  truth. — It  is  a  well-known  fact,  that  whilst  the 
public  can  judge  with  tolerable  correctness  of  merit  in  any  other  profes- 
sion, it  is  wholly  incapable  of  forming  an  estimate  of  ability  in  medicine. 
The  structure  of  the  human  body,  the  functions  it  performs,  the  laws 
which  regulate  it,  and  the  derangements  which  aft'ect  it,  are  to  mankind 
in  general  completely  unknown.  All  that  your  patients  will  concern 
themselves  with,  are  results — but  so  ignorant  are  they  of  the  means  by 
which  results  are  obtained,  so  little  do  they  know  of  the  operations  of 
nature  as  distinguished  from  those  of  art,  that  they  are  especially  liable 
to  be  led  into  erroneous  conclusions.  In  consequence,  unprincipled  per- 
sons, from  time  immemorial,  have  successfully  practised  on  public 
credulity,  and  some  specious  but  shallow  theor}^,  some  vaunted  nostrum, 
some  pecuHar  accomplishment,  or  some  singularity  of  manner,  has 
each  in  turn  been  made  the  means  of  imposition.  It  is  expected  of  you, 
gentlemen,  that  you  are  so  well  grounded  in  the  facts  and  principles  of 
medicine,  as  to  be  enabled,  on  all  proper  occasions,  to  put  down  ignorant 
presumption,  refute  false  doctrines,  and  expose  artful  knavery.  You  will 
remember  that  medicine  is  a  progressive  science,  and  that  whilst  the 
wise  and  learned  who  have  cultivated  it  have  done  much,  more  remains 
to  be  accomplished.  You  will  therefore  readily  acknowledge  its  imper- 
fections where  such  truly  exist,  and  prefer  a  frank  avowal  of  ignorance 
to  a  false  assumption  of  knowledge. 

There  is  one  great  ditficulty  you  will  have  to  encounter,  viz.,  that  the 
rules  and  principles,  which  guide  the  profession,  in  the  coui'se  of  time 
undergo  a  considerable  variation.  The  arts  and  luxuries  of  life,  the 
physical  changes  of  the  globe,  and  the  differences  of  education  and  civili- 
zation to  a  certain  extent,  modify  the  constitution  of  man  and  the  diseases 
to  which  he  is  subject.  Maladies  described  as  existing  in  former  times 
are  now  unknown,  whilst  others  are  altogether  of  modern  origin.  It  is 
of  the  utmost  consequence,  therefore,  that  the  medical  practitioner  should 


932  coxcLusiox. 

be  alive  to  the  importance  of  following  the  progress  of  his  art,  and  not 
imagine  that  at  any  time  he  has  learnt  all  that  is  useful,  or  that  he  can 
ever  reach  that  point  where  improvement  is  not  to  be  gained.  At  the 
same  time,  he  must  learn,  amidst  the  multitude  of  suggestions,  the  num- 
ber of  theories,  and  the  opposing  statements  which  will  perplex  him,  to 
reject  what  is  worthless,  and  only  adopt  what  is  truly  useful.  In  all 
such  cases,  the  best  rule  is  to  be  on  your  guard  against  loose  and  confi- 
dent plausibilities,  especially  where  such  are  advanced  not  in  their  true 
character  as  hypotheses,  but  as  established  laws  which  are  to  regulate 
your  practice  at  the  bed-side.  It  is  sometimes  allowable  to  give^  cer- 
tain rein  to  the  imagination,  and  cultivate  that  power  of  generalization 
w-hich  has  led  to  the  most  important  and  brilliant  results  in  scince  ;  but 
it  this  be  not  controlled  within  its  proper  limits,  nothing  can  be  more 
mischievous,  especially  w  hen  the  errors  may  affect  the  lives  of  mankind. 
Strive,  then,  so  to  improve  your  intellectual  resources  and  observing 
powers,  that  you  may  be  enabled  to  shun  error  and  admit  truth,  especially 
avoiding  all  those  easy  and  fallacious  paths  to  knowledge,  into  which  the 
interested  endeavour  to  entrap  the  unwary. 

A  desire  to  practise  your  profession  in  sincerity  and  truth,  will  also 
lead  you,  in  cases  which  you  have  not  particularly  studied,  or  which 
demand  special  kiuds  of  treatment,  to  require  the"^  assistance  of  some 
brother  practitioner.  Xo  two  persons  prosecute  their  studies  in  exactly 
the  same  direction  ;  and  the  subject  of  medicine  is  so  extensive,  so 
complicated,  and  requires  so  much  application,  that  it  is  almost  impossi- 
ble for  a  single  individual  to  become  master  of  the  whole.  Vanitv  and 
self-conceit,  it  is  true,  have  led  some  men  to  maintain  the  contraiy';  but 
where  is  the  individual  who  is  at  the  same  time  a  good  physician,  a  good 
surgeon,  and  a  good  obstetrician  ?  There  are  "many,  doubtless,  who 
practise  very  usefully  in  all  these  branches,  and  you  may  be  so  circum- 
stanced hereafter  as  to  do  the  same.  If  so,  you  will  necessarily  be  often 
consulted  in  cases  where  you  must  fee!  internally  convinced  "that  you 
cannot  do  full  justice  to  your  patient,  and  then  it  will  be  right  to  bear 
in  mind  that,  if  you  possess  a  gi-eater  share  of  infoi'mation  in  some 
respects  than  others,  they  in  certain  particulars  know  more  than  you. 
Do  not,  then,  be  deterred  by  a  false  feeling  of  shame,  or  a  desire*  for 
gain,  from  consulting  your  medical  brethren  ;  reciprocal  services  beo-et 
mutual  kindness,  and  it  is  at  all  times  better  to  resign  the  treatment  of 
a  case  you  do  not  understand,  than  subject  yourselves,  bv  undertaking  it, 
to  a  perpetual  series  of  mortifications  and  disai>pointment's.  By  exercising 
your  profession,  then,  in  a  spirit  of  sincei'ity  and  truth,  you  will  be  ani- 
mated by  a  proud  desire  to  advance  its  claim  to  public  confidence,  rather 
than  your  own  immediate  interests  ;  you  will  despise  the  miserable  vanity 
of  announcing  what  is  new,  without  a  scrupulous  regard  to  its  being  cor- 
rect. You  will,  while  retaining  the  right  of  thinking  boldly  for  ''your- 
selves, not  forget  that  observation  is"  diflicult,  theon-  imperfect,  and 
experience  frequently  fallacious.  You  will  not,  therefore^  rashly  substitute 
your  own  authority  for  that  of  those  whose  knowledge  is  more  extensive, 
or  commit  yourselves  to  the  ephemeral  doctrines  of  the  day,  by  which  a 
few  otherwise  respectable  men  have  lost  their  professional  reputation. 
You  will  remember  that  the  conclusions  of  youth  are  almost  always 
modified  by  the  experience  of  age  ;   and  that  the  wisest  and  most  emi- 


THE   ETHICS   OF   MEDICINE.  933 

nent  men  of  science  have  given  the  best  proofs  of  a  solid  understanding, 
by  the  readiness  with  which  thev  have  acknowledojed  their  own  io-no- 


III.  The  third  and  last  point  to  which  I  shall  direct  your  attention  is, 
that  you  oxujlit  to  be  strouf/ly  imbued  with  a  sense  of  duty  and  of  moral 
obligation.  Xo  profession  demands  that  its  members  should  be  governed 
in  their  practice  by  purer  principles  of  honour  than  our  own.  The 
medical  man  is  received  into  the  bosom  of  private  families,  where  he  is 
intrusted  with  mattei-s  of  such  a  nature,  that,  if  they  were  disclosed, 
they  would  be  attended  with  the  greatest  distress,  and  would  plunge 
parents  or  children  into  the  most  bitter  and  poignant  agony.  It  is  your 
office  not  only  to  regulate  the  corporeal,  but,  in  many  cases,  the  mental 
derangements  and  irritability  of  your  patients ;  but  who  can  govern  the 
minds  of  others,  if  he  is  incapable  of  commanding  his  own  .-  Prudence, 
sobriety,  kindness,  and  delicacy  of  feeling,  are  therefore  especially 
enjoined  upon  those  who  treat  the  sick.  It  is  true,  you  will  labour 
among  scenes  of  woe,  and  have  to  watch  incurable  diseases,  and  loath- 
some maladies ;  but  he  whose  sensibility  is  thereby  blunted,  and  who 
can  look  with  indifference  on  the  agonies  of  a  fellow-creature,  will  sel- 
dom feel  that  anxiety,  or  experience  that  watchfulness,  which  is  so 
necessary  for  detectmg  the  true  condition  of  his  patient.  Self-interest  is 
the  worst  of  all  models  for  a  medical  practitioner,  and  is  a  vice  which 
our  profession  may  proudly  claim  exemption  from.  You,  I  trust,  will 
never  experience  it,  but  rather  those  pleasurable  emotions  which  result 
from  lessening  human  suffering,  without  thought  of  profit,  and  from 
exercising  friendly  offices  with  that  politeness  and  delicacv  of  sentiment 
which  distinguish  every  man  of  a  gentlemanly  and  refined  mind.  Mixed, 
as  you  occasionally  will  be,  with  every  branch  of  society,  you  must 
expect  sometimes  to  meet  with  ingratitude,  and  be  ignorantly  unde- 
servedly charged  with  committing  errors.  All  men  are  liable  to  misre- 
presentation ;  and  although  I  do  not,  at  such  periods,  advise  you 
quietly  to  submit  to  insult,  I  strongly  recommend  great  circumspection 
in  manifesting  resentment.  "Unjust  suspicions  may  attach  to  an  inno- 
cent man ;  the  general  consistency  and  integrity  of  his  life  will  wipe 
them  away ;  the  imprudences  of  }"outh  may  be  repaired  by  the  circum- 
spection of  middle  age ;  but  if  you  once  lose  your  reputation  for 
professional  prudence  and  honour,  you  wnll  find,  whatever  be  your 
attainments,  that  your  influence  is  gone,  and  that  you  are,  in  all  respects, 
lost  and  ruined  men." 

In  addition  to  the  duties  which  you  discharge  to  the  public  at  laro-e, 
there  are  others  of  no  less  importance  which  you  owe  to  yourselves. 
Opportunities  will  frequently  occur,  where  you  may,  bv  looks  or  words, 
seriously  injure  the  reputation  of  some  brother  practitioner,  when  in 
reality  he  does  not  deserve  it.  The  period  of  the  disease,  or  the  circum- 
stances which  have  occurred,  may  enable  you  to  do  what  your  predecessor 
could  not.  Every  good  feeling  demands,  that  under  such  circumstances 
you  should  explain  the  cause  of  yonr  success  to  the  patient,  and  not 
allow  him  to  suppose  his  previous  attendant  was  in  fault.  Besides,  the 
most  scientific  and  experienced  physician  may  sometimes  err  unavoida- 
bly, and  you  must  never  attempt  to  aggravate  the  consequences  of  his 


934  COXCLUSIOX. 

failure,  by  adding  to  the  patient's  dissatisfaction.  Conduct  of  tliis  kind 
Avill  cause  the  offender  to  be  shunned,  and  sooner  or  later  to  feel  that  no 
success,  and  no  wealth,  can  compensate  for  the  absence  of  self-esteem, 
or  the  good  opinion  of  the  enlightened  and  honourable  men  of  his  own 
profession. 

Gentlemen,  habitually  engaged  as  you  will  be  at  the  bedside  of  the 
sick  and  the  dying,  you  will  have  abundant  opportunities  of  rio;htly  esti- 
mating the  insufficiency  of  mere  worldly  considerations.  I  think  vou 
will  tind,  notwithstanding  what  is  said  to  the  contrary,  that  there  is  no 
class  of  society  in  which  the  true  spirit  of  religion  is  more  extensively 
diffused  than  among  members  of  the  medical  profession.  True,  they 
shrink  from  an  officious  and  public  manifestation  of  it,  and  their  habits 
of  thought  teach  them  to  distinguish  between  trifling  forms  and  essential 
truths  ;  but  I  know  of  no  calling  more  practically  engaged  in  acts  of 
charity,  in  an  abnegation  of  self,  a  desire  to  do  to  others  what  we  wish 
others  should  do  to  us,  and  an  endeavour,  if  occasion  require  it,  to  afford 
all  those  consolations  which  a  pure  Christianity  can  alone  impart.  This 
has  ever  been  the  conduct  by  which  all  the  brightest  and  most  eminent 
characters  in  our  profession  have  been  distinguished,  and  I  earnestly 
pray  that  such  may  be  yours. 

And  now.  gentlemen,  I  and  my  colleagues  bid  you  farewell,  trusting 
that  whatever  part  you  are  destined  to  fulfil  in  the  affairs  of  life  as  medical 
practitioners,  you  will  ever  labour  under  a  deep  sense  of  res{)onsibilitT,  that 
you  will  always  act  in  sincerity  and  truth,  and  ever  be  governed  by  a  high 
feeling  of  duty  and  of  moral  obligation.  Let  us  hope  that  you  Avill  regard 
your  past  teachers  as  your  future  friends,  and  that  in  whatever  part  of 
the  world,  however  distant,  your  lot  may  be  cast,  we  shall  still  be  united 
by  a  chain  of  good  feeling  and  mutual  esteem,  which,  however  it  may 
be  lengthened,  can  never  be  cut  across.  We  desire  that  you  will  con- 
sider the  reputation  of  this  University  as  in  some  degree  identified  with 
your  own,  and,  whilst  on  the  one  hand  you  take  care  never  to  sully  the 
degree  she  has  this  day  conferred,  on  the  other  you  will,  by  constant 
good  conduct,  and  by  well-directed  endeavour,  add  fresh  lustre  to  the 
reputation  she  holds  among  the  academic  institutions  of  this  great 
country. 


TABLE    OF    CASES. 


DISEASES   OF  THE  NERVOUS   SYSTEM. 

Case  Page 

I. — Acute  Hydrocephalus — Recovery 312 

II. — Acute  Hydrocephalus  in  a  scrofulous  child — Recovery     .         .         .         312 
III. — Acute  Hydrocephalus — Phthisis  pulmoualis — Death — Eflusion  into 
the  lateral  ventricles — Non-inflammatory  softening  of  the  central 
parts  of  tho  brain — Meningitis  at  the  base  of  cranium — General 

tuberculosis 314 

TV. — General  Acute  Meningitis  supervening  on  pleuro-pneumonia    .         .         319 
Y. — Acute  meningitis  at  the  base  of  brain — Serous  effusion  into  the  ven- 
tricles, with  white  softening  of  cerebral  substance — Phthisis         .         320 
VI. — Acute  Meningitis  at  the  base  of  the  brain — Etiusiou  of  serum  into 
the  lateral  ventricles — Eflete   tubercle, in  the   pons  varolii  and 

lungs 322 

YII. — Chronic  Meningitis — Serous  effusion  into  the  ventricles — Tubercular 
mass  in  left  lobe  of  the  cerebellum — Cretaceous  tubercle  in  the 
lungs,  with  fibrous  cicatrix  ........         325 

YIIL — Chronic  Cerebral  Meningitis ;  induration  surrounded  by  softenuig  of  a 

portion  of  the  left  cerebral  hemisphere  .         .         .         .         .         327 

IX. — Acute  Cerebritis — Abscesses  in  the  brain — Old  Tubercle  in  vai'ious 

Organs — Chronic  Peritonitis 329 

X. — Acute  Cerebritis — Abscesses  in  the  brain — Pulmonary  tubercle — 

Abscess  in  kidney        .         .         .         .         .         .         .         .         .         331 

XI. — Chronic   Cerebritis — Epileptiform   convulsions — Hemiplegia  of  tlie 
right   side — Loss   of  smell — Blindness  of  the  left  eye;  amyloid 
bodies  in  the  brain       .........         333 

XII. — Chronic   Meningo-Cerebritis — Sudden   convulsions — Hemiplegia   of 
left  side — Softening  of  anterior  lobe  of  right  cerebral  hemisphere 
— Adhesions  of  arachnoid    ........         336 

XIII.-  Clu-onic  Cerebritis  of  the  right  hemisphere — Cancerous  ulcer  of  the 

oesophagus  and  neighbouring  glands — Patty  heart        .         .         .         338 
XIY. — Paralysis  of  the  abducens  oculi  and  auditory  nerves — Exophthahnia 

— Tumour  at  the  base  of  the  cranium — Partial  Recovery     .         .         342 
XY. — Paralysis  rapidly  becoming  general — Old  apoplectic  cyst  in  riglit 
corpus    striatum — Softening   of   pons    varolii — Clot    obstructing 
basilar  artcrj' — Pneumonia  of  left  lung.         .....         345 

XYI. —  Apoplexy — Hemiplegia  of  left  side — Convulsive  attacks — Cardiac 
and  renal  disease — Old  clot  in  the  right  cerebral  hemisphere,  with 
surrounding  softening 348 


A 


936  TABLE    OF   CASES. 

Case  Page 

XVII. — Two  sudden  attacks  of  Apoplexy — Hemiplegia — Cardiac  dis- 
ease— Persistent     albuminuria — Enlarged     and     diseased 
spleen — Cerebral  softening — Anasarca — Atheroma  of  arte- 
ries— Obstruction  of  left  middle  cerebral  artery  .         .         351 
XVIII. — Apoplexy,  followed  by  Hemiplegia  of  left  side — Recovery     .         356 
XIX. — Apoplexy  followed  by  Hemiplegia  of  the  right  side — Recovery         357 
XX. — Palsy — Hemiplegia  of  left  side — Recovery     ....         358 

XXI. — Sudden  Paralysis  of  face  and  left  arm — Pneumonia — Bright's 

disease — Recovery    ........         359 

XXII. — Apoplexy — Extravasation  of  blood  into  the  left  corpus  stria- 
tum— Pneumonia — Arrested  tubercle  of  lung     .         .         .         3G0 
XXIII. — Apoplexy — Hemiplegia  of  left  side — Hemorrhage  into  right 

cerebral  hemisphere — Diseased  heart — Pneumonia     .         .         3G2 
XXIV. — Apoplexy — Hemorrhage  at  the  base  of  the  brain  in  a  boy 

aged  14  years 363 

XXV. — Apoplexy,  followed  by  delirium,  and  proving  fatal  in  eight 

hours — Hemorrhages  into  the  meninges  of  the  brain  .         365 

XXVI. — Hemorrhage  into  the  right  crus  cerebri — Meningitis  at  the 
base  of  the  encephalon — Serous  effusion  into  the  lateral 
ventricles — Chronic  phthisis — Vertigo — Paralysis — Spasms 

of  the  jaw — Delirium  and  coma 366 

XXVII. — Apoplexy — Hemorrhage  into  right  optic  thalamus,  causing 
hemiplegia  on  left  side — Progressive  recovery — Two  months 
afterwards,  hemorrhage  into  pons  varolii  and  membranes 
on  right  side — Death  in  seven  hours  ....         370 

XXVIII. — Five  years  before  admission,  hemiplegia,  followed  by  recovery 
— Four  months  before  admission,  apoplexy,  with  convul- 
sions and  partial  recoverj^ — Pulmonary  disease — Death  by 
asphyxia — Chronic  softening  of  right  corpus  striatum — 
More  recent  hemorrhage  into  the  pons  varolii — Cardiac 
hypertrophy,  with  mitral  constriction — Hemorrhage  into 

the  lungs 371 

XXIX. — Cancer  of  the  brain,  spinal  cord,  liver,  and  bones  .         .         378 

XXX. — Chronic  hydrocephalus — Paracentesis  Capitis — Xo  benefit     .         381 
XXXI. — Acute  myelitis  in  the  cervical  portion  of  the  cord — General 
pains,  resembling  those  of  rheumatism — Fugitive  paralysis 
in  the  arms  and  legs — Engorgement  of  the  lungs — Death  .         385 

XXXII. — Slight  paraplegia — Recovery 388 

XXXIII.— Paraplegia— Partial  Recovery 388 

XXXIV. — Paraplegia — Incurable 389 

XXXV.— Paraplegia — Chronic  myelitis— Death 390 

XXXVI. — Paraplegia — Tubercular  caries  of  dorsal  vertebrte — Myelitis — 

Pulmonary  Tubercle 392 

XXXVII. — Paraplegia — Cancer  of  vertebral  bones — Softening  of  the  cord 
from  pressure — Cancer  of  lung,  liver,  and  lumbar  glands — 
Ulceration  of  urinary  bladder    ......         395 

XXXVin. — Partial  amaurosis — Spectral  illusions — Perversions  of  hearing, 

smell,  and  touch — Spinal  Irritation 399 

XXXIX. — Delirium  tremens— Recovery 410 

XL. — Delirium  tremens  with  ocular  spectra — Recovery  .         .         .         410 
XLI. — Dehrium  tremens  with  con-vulsions  and  coma — Recovery       .        411 


Case 


TABLE   OF    CASES.  937 

Page 
XLIL— Coma  and  death  from  excessive  drinking— Opacity  of  arach- 
noid—Sub-arachnoid  eflfusion— Fluid  blood         .         .         .         411 

XLIII. — Poisoning  by  opium — Recovery 413 

XLIV. — Poisoning  by  Hemlock— Death 413 

XL  v.— Poisoning  with  lead— Painter's  colic— Lead  paralysis— Partial 
recovery    ...••••••• 


418 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

XLYI.— Tonsillitis 421 

XLYIL— Follicular  Pharyngitis 422 

XLTIII.— Stricture  of  the  CEsophagus  from  Epithelioma         .         .         .         423 
XLTX.— Epitheliomatous  Ulceration  of  the  (Esophagus,  communicating 

with  the  Lung— Pneumonia  terminating  in  Gangrene         .         424 
L. — Carcmomatous  Stricture  of  (Esophagus — Cancer  of  the  Liver 

—Pulmonary  Emphysema  and  Tubercle — Pneumonia         .         426 

LI. — Dyspepsia ^^^ 

LIL — Dyspepsia — Oxaluria 430 

LIU. — Dyspepsia — Hypochondriasis — Oxaluria         ....         430 

LIT. — Dyspepsia^ — Vomiting  of  fermented  matter  containing  Sarcinge.         435 

LY. — Dyspepsia — ^Yomiting  of  fermented  matter  containing  Sarcinte.         438 

LYI. — Chronic  Ulcer  of  the  Stomach — Recovery      ....         438 

LYIL— Chronic  Ulcer  of  the  Stomach— Cure 439 

LYIII. — Chronic  ulceration  and  perforation  of  the  stomach — Peritonitis 
— Limited  pneumonia  with  gangrene — Abdominal  abscess 

— simulating  pleurisy — Death 440 

LIX. — Chronic  ulceration  in  the  stomach — Perforation  occasioned  by 

a  faU  (?)— Recovery 445 

LX. — Cancer  of  stomach,  pancreas,  and  mesenteric  glands— Cystic 

atrophy  of  right  kidney 448 

LXI.— Colloid  cancer,  with  perforating  ulcer  of  stomach — Peritonitis.         449 
LXII. — Acute  congestion  of  the  liver — Hepatitis? — Recovery    .         .         454 
LXIII. — Acute  jaundice — Albuminuria — Recovery      ....         4.54 
LXIY. — Impaction  of  a  gall-stone  in  the  common  bde-duct — Jaundice 

—Death 456 

LXY. — Jaundice — Compression  of  the  ductus  communis  choledochus 
from  a  cancerous  tumour,  composed  of  epigastric  and  lum- 
bar glands — Occlusion  of  cystic  duct — Enlargement  of  gall- 
bladder—Cancer of  the  pancreas — Biliary  congestion  of  the 
liver — Cancerous  exudation  into  various  organs — Shght 
leucocythemia  .....-••.  458 
LXYI. — Jaundice— Cancerous  tumour  of  the  pancreas,  comprising  the 
ductus  communis  choledochus— DUatation  of  the  gall-bladder, 
and  passage  of  gall-stones  into  the  gall-bladder — Cancer  of 

the  liver  and  kidneys 461 

LXYII. — Enlargement  of  the  liver — Ascites — Albuminuria — Recovers'.         463 

LXYIIL— Fatty  Enlargement  of  the  Liver 464 

LXIX. — Cirrhosis  with  Atrophy  of  the  Liver — Ascites         .         .         .         467 
LXX. — Cirrhosis  with  Enlargement  of  Liver— Hyj^ertrophy  of  Spleen 
— Slight  leucocythemia — Jaundice — Constriction   of   arch 
and  descending  Aorta 468 


938  TABLE   OF   CASES. 

Case  Page 

LXXI. — Cancerous  Exudation  into  the  Liver — Cancerous  Ulceration 
of  oesopliagus — Simple  stricture  of  the  pylorus — Profuse 
hematemesis — Aneurism  of  thoracic  aorta,  bursting  into  the 
left  pleura  .  ■       .         .         .         .         .         .         •         .         472 

LXXIL — Diarrhoea — Eecoverj-- 476 

LXXIII.— Diarrhoea— Recovery 477 

LXXIV. — Acute  Dysentery — Recovery 479 

LXXV.— Sub- Acute  Dysentery — Recovery 479 

LXXVL — Chronic  Dysentery — Ascites  and  oedema  of  the  legs  — Leu- 

cocythemia — Cirrhosis  of  the  liver — Cancer  of  the  lung         .         480 
LXXVn. — Obstruction  of  tlie  large  intestine — Cancer  of  stomach,  liver, 

peritoneum  generally,  and  mesenteric  glands      .         .         .         486 
LXXVIII. — Strangulation  of  the  small  intestine  from  Inguinal  Hernia — 
Gangrene,  ulceration,  and    perforation  of  the  intestine — 
Peritonitis  .........         488 

LXXIX.— Tape-worm  treated  by  the  ^Ethereal  Extract  of  the  Male 

Shield  Fern 495 

LXXX. — Tape-worm  expelled  by  the  yEthcreal  Extract  of  the  Male 

Shield  Fern 496 

LXXXI. — Tape-worm  expelled  by  the  same  remedy    ....        497 

LXXXII. — Tape-worm  expelled  by  Kamala 498 

LXXXin. — Acute  Peritonitis  from  bursting  of  Graafian  Yesicles  into  the 

Peritoneum — Pleurisy — Inter-lobular  Pneumonia       .         .         499 
LXXXIV. — Tubercular  Peritonitis  with  great  Deposit  in  Parietal  Layer 
— Tubercle  and  Hepatisation  of  Lungs — Pleuritis — Adhe- 
rent   Pericardium —Commencing    Fatty   Degeneration    of 
Heart — Biliary  Congestion  and  Fatty  Degeneration  of  Liver 

— Slight  Leucocythemia 501 

LXXXV. — Cancer  of  various  Abdominal  Organs  and  of  the  Lungs,  pro- 
ducing S^'mptonis  of  Peritonitis  .....         504 
LXXXVI. — Cancerous    Peritonitis — Ascites    and    H^vdrothorax — Para- 
centesis Abdominis — Arrested  Phthisis  Pulmonalis     .         .         508 

DISEASES  OF  THE  CIRCULATORY  SYSTEM, 

LXXXYII. — Acute  Pericarditis — Recovery 514 

LXXXVIII. — Pericarditis  and  Endocarditis — Hydropericardium  .         .         515 

LXXXIX. — Acute  Pericarditis  followed  by  Acute  Double  Pneumonia — 
Recovery— Aortic  Incompetence — Subsequent  Articular 
Rheumatism — Sudden  Death — Adherent  Pericardium — 
Fatty  Enlarged  Heart — Thickening  of  Aortic  Valves  .         516 

XC. — Acute  Pericarditis  supervening  on  Phthisis  .         .         .         620 

XCI. — Ascites — Anasarca — Adherent  Pericardium  with  Fatty  Atro- 
phied  Heart — Congested  Liver         .....         523 

XCII. — Rheumatic  Pericarditis 525 

XCIII. — Incompetency  of  Aortic  Yalves — Dilated  Hypertrophy  of  Left 
Ventricle — Dilatation  of  Ascending  Portion  of  Aortic  Arch 
— Chronic  Arteritis  with  Aneurismal  Pouches  .  .  .  533 
XCIV. — Incompetency  of  Aortic  Valves — Hypertrophy  of  Left  Ven- 
tricle and  Auricle — Obstruction  and  Incompetency  of  Mitral 
Valve — Pneumonia  ........         534 


536 


TABLE   OF   CASES.  939 

Cask  ^5^ 

XCV.— lucoaipetency  of  Mitral  Valve 536 

XCVI.— Incompetency    of  Mitral  Valve— Pulmonary  Hemorrhage— 

Hydrotliorax 

XCVI  [.—Mitral  Incompetency— Hypertrophy  of  left  Ventricle— At- 
tack of  Acute  Kheumatism,  followed  by  Aortic  Incompe- 
tency        . ■5^'' 

XCVIII.— Mitral      Incompetency— Hypertrophy    of    left    Ventricle- 
Aortic  Incompetency  and  Obstruction — Angina  .         .         539 
XCIX.— Incompetency  of  the  Aortic  Valves  with  Musical  Murmur- 
Hypertrophy  with  Dilatation  of  left  Ventricle — Pneumonia 

— Pulmonary  Hemorrhage 540 

C— Mitral  Incompetency— Hypertrophy  of  left  Ventricle  — Dila- 
tation and  Disease  of  Arch  of  Aorta— Aortic  Incompetency         542 
CI.— Constriction  of  Mitral  and  Tricuspid  Orifices— Aortic  Incom- 
petence— Anasarca— Hydi-othorax-Collapse  of  left  Lung 

— Bright's  disease  of  Kidney 543 

CIL— Constriction  of    Mitral    and   Tricuspid    Orifices— (Edema- 
Hemorrhage  into  the  Lungs 544 

CIIL — Soft  Adherent  Polypus,  causing  incompetency  of  the  Mitral 

Orifice — Anasarca 546 

CIV.— Enlarged  Foramen  Ovale — Phthisis -     548 

CV. Aneurism  of  the  Ascending  Arch  of  the  Aorta— Incompetency 

of  Aortic  Valves — Hypertrophy  of  left  Ventricle      .         .         557 

CVI Aneurism  of  Ascending  Aorta,  immediately  above  the  Aortic 

Valves— Incompetency  of  Aortic  and  Mitral  Valves— Hyper- 
trophy   of   left    Ventricle— T^axy   Kidneys— Pulmonary 

Hemorrhage— Anasarca  558 

CVII. Aneurism  of  Ascending  Arch  of  Aorta— Chronic  Pericarditis 

—Disease  of  Aortic  Valves— Great  H^-pertrophy  of  Heart 
— Anasarca  .....••••  560 
CYIII.— Large  Aneurism  of  the  Ascending  Arch  of  the  Aorta,  causing 
Absorption  of  a  portion  of  the  third  Rib,  and  bursting  into 
the  Pericardium — Chronic  Pericarditis — Incompetency  of 
Aortic  Valves — Hypertrophy  of  left  Ventricle  .         .         562 

CIX. Varicose  Aneurism  of  the  Ascending  Aorta  communicating 

with  the  Poilmonary  Artery— Jaundice  and  Xutmeg  Liver         564 

ex. — Aneurism  of  the  arteria  innominata 568 

CXL Aneurism  of  transverse  aortic  arch— Chronic  pericarditis  with 

effusion — Tubercular  lungs — Anasarca — Former  popliteal 

aneurism  cured  by  compression 572 

CXII. — Aneurism  of  lower  portion  of  the  thoracic  aorta,  pressing  on 
the  thoracic  diict — Aneurism  of  abdominal  aorta  —Chronic 
ulcer  of  stomach — Chronic  tubercular  abscesses  of  liver  and 
right  kidne}^ — Liver  and  left  kidney  waxy — Leucocythemia  575 
CXIIL — Aneurism  of  the  superior  mesenteric  artery  and  aorta — 
Obscure  aneurism  of  descending  thoracic  aorta — Treatment 
by  the  method  of  Valsalva — Pleuritis — Caries  of  the  verte- 
brae, softening  of  the  spinal  cord  and  Paraplegia — Sudden 
death  by  poisoning  with  tincture  of  aconite        .        .        .        577 


940  TABLE   OF   CASES. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Case  Page 
CXIV. — Acute  Laryngitis — Treated  by  topical  applications— Recovery         593 
CXV.— Chronic  Laryngitis — Topical  applications — Recovery      .         .         594 
CXVI. — Acute  oedema  of  the  glottis — Chronic  pharyngitis  and  laryn- 
gitis— Sudden  death 598 

CXYII. — Chronic  lar^-ngitis  and  pharyngitis — Tracheotomy— Recovery         599 

CXYIII. — Acute  bronchitis — Recovery 602 

CXIX.— Acute  bronchitis 603 

CXX. — Chronic  bronchitis — Acute  peritonitis — Collapse  of  the  lung         605 
CXXI. — Chronic  bronchitis— Emphysema — Acute  laryngitis       .         .         606 
CXXIL — Chronic  bronchitis— Emphysema— Injection   of   the  bronchi 

with  a  solution  of  the  nitrate  of  silver         ....         600 

CXXIII. — Acute  pleurisy — Recovery  613 

GXXIY. — Acute  pleurisy  without  functional  symptoms — Rapid  recovery         614 
CXXV. — Chronic  pleurisy  on  both  sides — Bronchitis  .         .         .         616 

CXXVL — Empyema,  witli  fistulous  openings  between  the  lung  and  pleu- 
ral cavity,  and  between  the  pleural  cavity  and  external 
surface  .........         621 

CXXVII. — Chronic  pleuritis  and  pneumo-thorax,  without  symptoms — 

Articular  rheumatism — Pericarditis — Recovery  .         .         623 

CXXVIIL — Empyema,  following  chronic  phthisis — Paracentesis  thoracis 
— Pneumo-thorax — Singular  mode  of  death  from  enormous 
distension  of  tlie  stomach  and  emphysema  of  its  coats — 
Tubercular  pleuritis — Adherent  pericardium — Waxy  spleen 

— Tubercle  in  the  kidneys 625 

CXXIX. — Pneumonia  on  right  side  and  slight  pleuritis — Recovery         .         630 

CXXX. — Double  pneumonia — Recovery  631 

CXXXL — Pneumonia  on  the  right  side — Early  bleeding — Slow  recovery         632 
CXXXIL — Erysipelas  of  the  face  followed  by  pneumonia  of  the  right 

.    side — Recovery 634 

CXXXIII. — Double  pneumonia — Treatment  by  mercury,  which  caused 

profuse  salivation  before  admission — Prolonged  recovery  635 
CXXXIY. — Pneumonia  of  right  side — Critical  diarrhoea  on  the  twenty- 
first  day — Recovery 637 

CXXXY. — Pneumonia  of  left  side — Critical  diarrhoea  on  the  fourteeutli 

day — Recovery 638 

CXXXYL — Double  pneumonia — Critical  diarrhoea  on  the  twenty-first  day 

— Recovery 638 

CXXXYIL — Pneumonia  ushered  in  by  violent  vomiting  and  gastric  pain — 

Recovery  in  five  days 639 

CXXXVIIL — Double  pneumonia,  with  urgent  symptoms,  and  fuU,  strong 

pulse — Pleuritis  on  left  side — Recovery  in  nine  days  .         641 

CXXXIX. — Bronchitis  and  pulmonary  congestion,  from  morbus  cordis, 
resembling  pneumonia,  but  no  absence  of  chlorides  in  the 
urine  ..........         645 

CXL. — Chronic  pneumonia  of  upper  tliird  of  right  lung — Gangrenous 

abscess — Recovery  648 

GXLI. — Chronic  pneumonia  of  both  lungs,  with  rdceration — Death — 
Great  condensation,  with  cavities  and  pigmentary  deposits 
in  the  lungs — Chronic  tubercle  in  various  organs — Disease 
of  both  supra-renal  capsules,  without  bronzing  of  the  skin         649 


65i 


672 


672 


TABLE   OF    CASES.  941 

Case  ^''f 

CXLII.— Gangrene  of  the  luugs— Dysentery 651 

CXLIII.— Gangrenous  abscess  of  the  right  lung,  caused  by  the  swallow- 
ing of  a  piece  of  chicken  bone  four  and  a  half  years  pre- 
viously     ...•■••••• 
CXLIV.— Phthisis  pulmonalis  in  its  last  stage,  with  incompetency  of  the 
aortic  valves— Cod-hver  oil— and  nutrients— Complete  re- 

covery • 

CXLV.— Phthisis  pulmonaUs— Amendment  from  treatment  and  disap- 
pearance of  symptoms— Their  subsequent  return— Death  .         662 
CXLVL— Plithisis   pulmonalis— Large  vomica  on  left  side— Caries  of 

left  wrist  joint— Febricula— Variola— Scrofulous  nephritis         665 
CXLVII.— Phthisis    pulmonahs— Vomica    on   right   side— Death   from 

haemoptysis °"° 

CXLVIIL— Phthisis  pulmonalis— Two  vomicaa  on  right  side— Small  cavi- 
ties on  left  side— Death  from  exhaustion  .         •         .         670 
CXLIX.— Phthisis  pulmonalis— Large  vomica  with  pneumo-thorax  (?) 
on   left   side— Softened  tubercle   on   right   side— Bright's 
disease      ....•••••• 

CL.— Chronic  phthisis— Enlarged  liver— AJbuminuria— Large  ex- 
cavation in  left  lung— Cicatrices  and  mduration  of  right 
lung— Waxy  liver  and  kidneys— Tubercular  ulceration  of 
intestines  ....-•••■ 

CLI.— Advanced  phthisis— Restoration  to  health— Death  many  years 
afterwards  from  delirium  tremens — On  dissection,  a  cicatrix, 
three  inches  long,  in  apex  of  right  lung,  and  cretaceous  con- 
cretions, with  puckering  at  the  summit  of  left  lung  .         682 
CLIL— Cancer  of  the  lung,  thyroid  body,  and  lymphatic  glands  of  the 

neck — Bronchitis — Leucocythemia  ....         696 

CLIIL— Carbonaceous  lungs  with  black  expectoration       ...         699 
CLIV.— Carbonaceous  luugs  with  black  expectoration  in  a  female      .         700 

DISEASES  OF  THE  GEXITO-URIXARY  SYSTEM. 

CLV. — Ovarian  dropsy— Frequent  paracentesis — Excision  of  both 
ovaries— Strangulation  of  the  intestine— Phlebitis— Death 
from  ileus  the  seventieth  day  after  the  operation        .         .         706 

CLVI. — Ovarian  dropsy — Spontaneous  ulcerative  opening  of  the  cyst 

into  the  bladder,  and  evacuation  of  its  contents— Recovery  716 
CLVIL— Ovarian    dropsy   which   gradually    emptied  itself  spontane- 
ously by  openings  through  the  fallopian   tube — Singular 
attempt  at  imposition  of  pig's  bladders,  for  cystic  forma- 
tions in  the  uterus              '^^ 

CLVIII. — Acute  nephro-pyelitis — Recovery "^26 

CLIX. — Subacute  nephritis,  with  great  anasarca — Recovery — Acute 

nephritis  of  left  kidney — Recovery             .         .         •         •         728 
CLX. — Acute   Desquamative  Nephritis,   proving  rapidly   fatal  from 
diminished  flow  of  Urine,  general  Anasarca,  and  (Edema 
of  the  Lungs  '^^^ 

CLXL— Acute  Desquamative  and  Hemorrhagic  Nephritis— Hydro- 
thorax— Collapse  of  the  right  lung— Pulmonary  (Edema 
and  Bronchitis,  with  symptoms  of  Pneumonia  .         .         ""SS 


9-12  TABLE   OF   CASES. 

Cask  P^e 

CLXIL — Acute  Xephritis — Clinniic  Pneumonia — (Edema  of  the  Long 
and  Anasarca  p«)Fing  fatal — ^Perfwating  Ulcer  of  the 

Duodenum,  without  symptonig 735 

rr.TTTT — ^Xephritis  followed  bj  toe  Cinnation  of  a  large  Ahecess  in 
the  right  Kidnev,  opening  into  the  lumbar  cellular  tissue — 
Ulceration  of  Ureter  and  Bladder — ^l^ickening  of  Mitral 
and  Trictx?pid  Valves — Partial  Atrophy  of  Ltings,  with 
and  without  Induration — Partial  (Edema.  .  .  .  T37 
CLXIT. — Scrofulous  Xephritis  and  Ab«:esses  in  the  Kidneys — Exten- 

siTe  deposition  of  Tubercle  in  the  Longs  and  Latestines  740 

CL5T. — Calemloos  Nephritis  and  Gangrenous  Abscess  of  right  Kid- 
ney— Waxy  Liver — Rectovesical  Fatuia        .        .        .        742 
CLXTX — Chronic  Pyelitis,  and  Cvstic  Kidneys — DilatatioD  of  Ureters 

— ^Fungoid  Ulceration  of  Urinary  Bladder       .        .        .        745 
CLXTIL — ^Albuminuria — General  Anasarca — (Edema  of  Long — ^Re- 
covery   749 

CLXTin. — ^Albuminuria — (Edema  of  both  feet  and  legSj  left  arm  and 

hand — Recovery 750 

CLXIX- — Albuminuria — (Edema — Ascites  and  General  Anasarca — 

Coma  and  Convulsions — Recovery  .        .        .        .         752 

CLXX — ^Tbird  Attack  of   General   Anasarca  with    Albuminuria — 
Enormous  Dropsical  Distension  of  the  Abdomen.  Scrotum, 
and  Inferior  Extremities — Complete  Recovery  under  the 
Action  of  Sapertartrate  of  Potash  ....         7-53 

CLXXI. — Second  Auack  of  Albuminuria  with  Anasarca — ^Dismissed 

relieved 756 

CLXXII. — Second  Attack  of  Albuminuria  after  an  interval  of  twenty- 
nine  years,  with  Anasarca^Bronchitis — ^THsmissed  re- 
lieved      757 

CliXXHL — ^Third  Attack  of  Albuminuria  with  Anasarca — ^Dismised 

relieved 758 

CLXXTY. — Albuminuria,  with  General  Anasarca,  terminating  fataUy — 
Waxy  Kidneys,  Spleen  and  Liver,  with  Extensive  Depo- 
sition of  Tubercle T60 

CLXXY. — ^Albuminuria  coming  on  during  the  pnogress  of  Phthisis 
Pnlmonalis,  terminating  fatally — ^Extensive  Deposition  of 
Tuberde — ^Waxy  Kidney.  Liver,  and  Spleen  .        .        761 

CLXXYI. — Albuminuria,  with  Phthisis  Pulmonalis.  terminating  fataUy — 
Extensive  Deposition  of  Tubercle  and  Colliquative  Diar- 
rhoea— ^Atrophied  Fatty  Kidney — ^Ulcerated  Intestines  763 

IHSEA.SES  OF  THE  DTTEGUMENTAKT  SYSTEM. 

CLXXYII. — Favus  of  the  Scalp  in  an  Adult — Incurable        .        .        .  7&4 
CLXXTIII. — Favus  of  the  Scalp  of  three  years'  standing — (Jured   .        .  795 
CLXXIX. — Favus  caught  in  the  Ward  from  Case  CLXXVII— Cured    .  795 
CLXXX. — ^Favus  of  the  Scalp  o?  fijur  years'  standing,  cured  by  a  Sul- 
phuric Acid  Lotion 796 

CLXXXX — ^limited  Favus  of  the  Cheek,  cured  by  Cauterization  with 

Xitrate  of  Silver     ........  796 

CLXXXIL — Parasitic  Pitvriasis — ^Incurable 797 


TABLE   OF    CASES 


943 


-En- 


the 


iffht 


DISEASES  OF  THE  BLOOD. 

CLXXXUI— LeuoocTthemia  discovered  after  deatli— HTpertropbr  of  the 
Spleen,  Liver,  and  Lrmpliatic  Gland^-Absenee  of  Phle- 
bitis and  of  Piiralent  Collections  in  any  part  of  the  body 
CLXXXIT.— Leneocythemia  detected  daring  Life— Hypertrophy  of  the 

Spleen — Ascites      ..-•■• 
CLXXXY.— Commencing  Leuoocythemia  deterauned  daring  Lii" 

larg^d  Spleen  and  Liver — Ascites 
CLXXXTL — Chlorosis  and  Anaemia — Cored  ... 

CLXXXTIL — AOTte  Ariicalar  Eheamatism — Multiple  Absce^c-s  in 
Joints,  in  the  Musdes,  within  the  Cranium,  etc 

CLXXXTHL — Diabetes  Mellitas 

CLXXXIX.— Diabetes  Mellitas— Phthisis  Polmonalis— Tomiea  on 

Side — Death 

CXC. — ^Febricula,  convalescent  on  the  axth  day    . 
CXCL — Febricnla,  convalescent  on  the  eighth  day 
CXCIL — Febricola,  convalescent  on  the  seventh  day 
CXCIIL — ^Febrieula.  convalescent  on  the  fourth  day 

CXCIV. — Relapang  Fever 

CXCV. Typhoid  Fever,  convalescence  on  the  forty-second  day 

CXCVL — ^Typhoid  Fever,  fatal  on  the  twenty-fifth  day 
CXCVIL— Typhoid  Fever,  fatal  from  perforating  aloer  of  the  intestine 
CXCVIII  — Typhus  Fever,  with  cerebral  complication 

CXCLX Typhus  Fever,  terminating  on  the  fourteenth  day 

CC. Typhus  Fever,  terminating  on  the  twenty-third  day 

CCL— Typhus  Fever,  with  petechijc — Convalescent  sixteenth  day 

CCIL ^Typhus  Fever,  convalescent  the  twenty-fourth  day 

CCELL Typhus  Fever,  convalescent  the  fourteentli  day 

CCIV. ^Typhus  Fever,  convalescent  the  fourteenth  day 

CCV. Typhus  Fever,  complicated  with  bronchitis  and  collapsed 

lung — ^Fatal  on  the  twelfth  day 

CCYL ^Typhus  Fever,  convalescent  on  the  twelffli  day 

CCVIL ^Typhus  Fever,  convalescent  on  the  twenty-first  day 

(XVIIL— Tvphus  Fever,  convalescent  on  the  twenty-second  day 
CCIX. — Remittent  Fever,  resembling  Acute  Hydrocephalus 

CCX. ^Tertian,  Litermittent,  cured  by  Quinine 

CCXL — Scarlatina,  with  Angina 
CCXIL — Scarlatina,  with  violent  delirium 

CCXnL ^Scarlatina,  with  diminished  Urine  and  Coma 

CCXIY. Scarlatina,  with  Angina  and  delirium 

CCXV. — Scarlatina,  with  Purpura  and  delirium 
CCXVL — Scarlatina,  with  delirium  and  c^oma  . 
CCXTIL — Erysipelas — ^Recovery  on  the  eleventli  day 

CCXVIIL Eryapelas  in  an  Litemperate  Man — Slow  Rec-overr 

CCXLX — ^Variola — ^Severe  confluent  case  ... 

CCXX. — ^Variola— Discreta 

CCXXI. — ^Variola  treated  locally  with  a  mask  of  calamine  and 
CCXXIL — Syphilitic  Ulceration  of  the  fece .... 
CCXXUL — Syphilitic  Laryngitis 


oil 


Base 

814 

S-21 

S26 
S44 

847 
852 

853 
S59 
859 
S59 
860 
860 
862 
863 
864 
866 
866 
867 
868 
868 
869 
869 

869 
869 
870 
870 

880 
882 
885 
886 
888 
839 
890 
891 
892 
892 
893 
894 
S96 
899 
900 


9M 


TABLE   OF   CASES. 


Case 

CCXXIV. — Syphilitic  Eupia.  followed  by  Keloid  Growths  on  the  Cica 

trices — Syphilitic  Psoriasis      ..... 
CCXXV. — General  Rheumatism  treated  by  nitrate  of  potash 
CCXXVI. — General  Rheumatism  with  endocardial  murmur  . 
CCXXYII. — Rheumatism  treated  by  nitrate  of  potash     . 
CCXXVIII. — Rheumatism  with  mitral  incompetency 
GCXXIX.  to  CCXXXII. — Treatment  of  Rheumatism  by  Lemon-juice 

CCXXXIIL — Diaphragmatic  Rheumatism 

CCXXXIV. — Rlieumatic  Iritis,  following  Acute  Rheumatism — Recovery 
CCXXXV. — Chronic  Gout  with  Tophaceous  Deposits  in  all  the  Joints 

CCXXXVL— Scorbutus 

CCXXXVII.— Scorbutus,  with  epistaxis— Treated  by  full  diet  . 

CCXXXVIIL— Sudden  Polydipsia— Incurable 

OCX  XX IX. — Polydipsia — Excessive    amount    of   Albuminous    Urine — 

Phthisis  Pulmonalis — "Waxy  Liver,  Kidneys,  and  Spleen 

CCXL. — Great  Obesitj^ — Fatty  Degeneration  of  Heart  and  Muscular 

System  generally — of  Liver  and  Kidnej'S — Hypertrophy 

and  Dilatation  of  Heart 


900 
911 
912 
913 
913 
914 
916 
917 
919 
920 
921 
923 

924 


926 


INDEX. 


Abdoraon,  auscultation  of,  58;  inspection  of,  80; 
post-uiortcm  examination  of,  24;  view  of  the 
viscera  in,  26. 

Abscfss,  pathology  of,  138;  in  the  brain,  cases 
of,  329;  in  the  abdomen,  410;  in  the  liver, 
case  of,  575;  inthelnng,  cases  of,  C4S;  in  the 
kidney,  cases  of,  737,  7-10,  742. 

Acarus  scablei,  description  and  treatment  of, 
7S9. 

Achorion  Schoenleini,  history  of  the,  798.  See 
Favus. 

Acne,  diagnosis  of,  780 ;  treatment  of,  786. 

Aconite,  case  of  poisoning  by,  577,  585;  symp- 
toms of,  587 ;  inlhience  of  on  the  heart,  408. 

Address  to  graduates  in  medicine  in  1849,  929. 

Adenoma,  170. 

Adhesions,  between  serous  surfaces,  pathology 
of,  129  ;  of  arachnoid,  case  of,  327 ;  of  perito- 
neum, case  of,  501 ;  of  pericardium,  523 ;  of 
pleura,  619. 

Albumen  and  oil  considered  as  types  of  nutri- 
tive substances,  100. 

Albumen,  detection  of  in  urine,  94;  in  solution, 
210;  raemliranous,  211;  fibroid,  212;  celloid, 
213;  molecular.  214. 

Albumiuoiis  degeneration,  210;  concretions,  238. 

Albumiuuria.  persistent,  cases  of,  749 ;  patho- 
logy of,  765 ;  diagnosis  of,  769 ;  treatment  of, 
772. 

Alison,  Dr.,  his  views  as  to  Mood-letting  in  in- 
flammations, 251 ;  Dr.  Scott,  his  stetho-gonio- 
meter,  35. 

Alkaline  lotions  in  skin  diseases,  784. 

Amaurosis,  case  of  partial,  899. 

Ammonia,  urate  of,  microscopic  appearance  of, 
89. 

Amphoric  resonance  in  cases,  623,  625. 

Amyloid  and  amylaceous  concretions,  247;  in 
the  auditory  nerve,  ib. ;  in  the  pancreas,  ib. ; 
in  the  brain,  335. 

Andral's  opinion  of  the  expression  "  inflamma- 
tion," 123,  note. 

Anaemia,  case  of,  844 ;  pathology  and  treatment 
of,  846. 

Aneurism,  nature  and  varieties  of,  181 ;  cases  of, 
in  arch  of  aorta,  557  ;  varicose,  communicating 
with  pulmonary  artery,  504;  of  arteria  inno- 
minata,  568 ;  of  thoracic  aorta,  575;  of  supe- 
rior mesenteric  arterv.  577  ;  eeneral  diagnosis 
of.  5^7;  pathology  of,  530;  treatment  of,  591 ; 
Valsalva's  treatment  of,  583. 

Angina  pectoris,  656;  case  of,  539. 

Angionoma,  181. 

Anorexia  in  phthisis,  treatment  of,  692. 

Antimonials.  treatment  of  pneumonia,  by  large 
.loses  of.  272.  .    J'       S 

Anxietv  and  despondency'  in  phthisis,  treatment 
of.  6',i5. 

Aortic  valves,  disease  of,  540. 

Apoplexy,  definition  of  304,  402;  cases  of,  356; 
])re(lisposina  cause  of,  373;  histology  of,  ib. ; 
diairnosisof,  375;  pathologvof,  354;  treatment 
of.  ;H77. 

Appetite,  treatment  for  loss  of  in  plithisis,  692. 

Arteries,  cerebral  disease  from  obstruetion  of, 
8-15;  pathology  of,  354 ;  fatty  degeneration  of, 
220 ;  mineral  degeneration  of,  235. 

Arteritis,  chronic,  case  of,  533. 

Ascites,  microscopic  appearances  in  fluid  of,  87; 
from  enlarL'cmcnt  of  liver.  463.  523 ;  from  peri- 
tonitis. 503  :  from  abdominal  cancer,  504;  from 
cirrhosis,  480;  from  ovarian  disease,  721. 

Assimilation  of  the  food,  lUl ;  ettects  of  bad  assi- 
milation. ]iiT. 

Atelectasis.  6i!6. 

Atheroina.  cystic,  166;  of  blood-vessels,  220. 

Atrophy  of  face,  remarkable  case  of,  122. 


GO 


Auscultation,  general  rules  for  practice  of,  40; 
of  abdomen,  58  ;  of  circulatory  organs,  special 
rules  for,  55 ;  sounds  elicited  in  health  and  dis- 
ease, ib. ;  modifications  of  healthy  sounds,  56  ; 
new  or  alinormal  sounds.  57;  of  piilmonary 
organs,  S]iecial  rules  for,  51 ;  sounds  elicited 
by,  ib. ;  alterations  of  natural  sounds,  52 ;  new 
or  abnormal  sounds,  53 ;  of  the  large  vessels, 
68;  relative  value  of  sounds  in,  54;  of  aneu- 
risms, 5&8. 

Bael,  Indian,  use  of  in  dysentery,  482. 

liile,  detection  of,  in  urine,  94. 

Kiliary  calculi,  240. 

Uladder,  percussion  of,  48;  urinary  calculi  in, 
242 ;  opening  of  ovarian  cyst  into,  716 ;  fun- 
goid ulceration  of,  745. 

Blood,  appearance  of,  under  the  microscope,  75; 
in  thickened  blood.  76;  in  hiematocele,  ib. ; 
in  leucocythemia,  77,  816;  appearance  of,  in 
a  case  of  choler.a,  77 ;  fol-mation  of,  from  ali- 
mentary matters,  and  the  changes  it  under- 
goes in  the  lungs,  101 ;  structure  and  chemical 
composition  of,  ib ;  formation  and  sustenta- 
tion  of  tissues  by  the,  102;  re-absorjition  of 
transformed  tissues  into  the,  ib;  Zimmer- 
mann's  views  as  to  the  formation  of  fibrin  in, 
103 ;  arguments  in  favour  of  this  opinion,  104 ; 
pathological  changes  in  the,  ib. ;  diseases  of  the, 
100,  813;  causes  of  disease  in  the,  107;  prin- 
ciple of  treatment  of,  ib. ;  post-mortem  exami- 
nation of,  24;  microscopic  examination  of,  76; 
mixture  of  pus  with,  850. 

Blood  corpuscles,  relation  between  the  colourless 
and  coloured,  829;  origin  of  the,  b32 ;  ultimate 
destination  of  the,  887;  structural  alterations 
in,  76. 

Blood-forming  glands,  structure  of,  883. 

Blood-letting,  diminished  enjployment  of  in 
treatment  of  acute  intlaninialioiis.  251 :  former 
reasons  for,  erroneous.  2.'>7  ;  loe;il.  observations 
of  Dr.  J(jlin  S^truthers  on.  202 ;  can  the  materies 
morbi  in  the  blood  be  diminished  by  '!  257  ;  can 
it  diminish  the  flow  of  blood  to  tiie  inllamed 
part?  258;  can  it  diminish  the  amount  of  blood 
in  an  inflamed  part?  260 ;  should  it  be  indi- 
cated by  the  character  of  the  pulse?  202;  in 
acute  pneumonia,  270;  useful  as  a  palliative, 
263;  and  in  over-distension  of  the  ri;,dit  side' 
of  the  heart,  venous  <-on-vjtioii,  ei:t;dii;emeiit, 
etc.,  276;  in  functional  nervous  disorders,  408. 

Blood-vessels,  changes  in  ju-evious  to  intiamma- 
tion,  123;  new  f.n-mation  of,  184;  fatty  defe- 
neration of,  220  ;  mineral  degeneration' of,  286. 

Bone,  fatty  degeneration  of,  224;  formation  of 
new,  193;  m<irbid  growths  of,  192. 

Borborygmi,  58. 

Brain,  distinction  between  pressure  on  and  com- 
pressi.m  of,  116;  i)roi)er  functions  of  the.  111 ; 
amyloid  concretions  in  the,  247;  softenings  of 
the.  3115;  abscess  in  the,  329  ;  chronic  inflam- 
mation of  tlu',  833 ;  obstruction  of  arteries  in 
the,  345;  hemorrhage  in  the,  356;  cases  of 
tubercle  in  the.  322,  325;  cancer  of  the,  878; 
dropsy  of  the.  381 ;  acute  inflammation  of  the, 
329;  functi.jual  disorders  of  the.  402. 

Breathing,  bronchial  or  tubular,  53. 

Bright's  disease,  casts  of  uriniferous  tubes  in, 
90;  cases  of,  749;  pathologv  of.  765 ;  forms  of, 
766 ;  diagnosis  of,  709  ;  treatment  of,  772. 

Bronchi,  injections  of  the,  in  pulmonary  diseases, 
611. 

Bronchitis,  acute  cases  of,  602;  natui-e  and  treat- 
ment of  604;  chronic,  cases  of,  605;  causes  of, 
607;  treatment  of,  609. 

Bronchophony,  52. 

Bronzing  of  the  skin.  Dr.  Addison  on,  229. 


946 


INDEX. 


Bniit  (le  (liable,  657. 
Bulla,  definition  of,  776. 

Calculi,  biliarr,  240;  urinary,  lb.;  renal,  241; 
vesical,  242 ;  prosUitic,  244;  intestinal,  246. 

Callosities,  174;  cause  of,  ib. 

Cancer,  general  description  of,  133;  scirrhous, 
ib. ;  encephaloniatous,  134;  cells  in  simple 
and  compound.  135;  retieulare  of  Muller,  ib. ; 
colloid.  136;  chimney-sweeps',  177;  villous, 
179 :  of  the  brain.  378 :  of  the  liver.  472 ;  of  the 
lung.  696.  69S;  of  the  skin.  93:  of  the  cesopha- 
gus,  426 ;  of  the  stomach,  448 ;  of  mesenteric 
glands,  456 ;  of  abdominal  organs  simulating 
peritonitis,  504;  of  the  peritoneum,  508. 

Cancerous  growths.  196— (See  Cancer) — cyst  of 
the  liver,  475 ;  peritonitis,  506. 

Canerum  oris,  143. 

Cantharides,  action  of,  407. 

Capillaries,  changes  which  take  place  in,  preced- 
ing inflammation.  124 ;  contraction  of  the,  note, 
lb.:  new  formation  of,  1S4. 

Carbonaceous  lungs,  6i'9;  morbid  anatomy  and 
pathology  of,  702 ;  treatment  of,  705 

Carcinoma,  196.    See  Cancer. 

Cardi.ic  sounds,  55 ;  diseases,  rules  for  the  diag- 
nosis of  512. 

Caries,  scrofulous,  394;  cancerous,  395;  from 
pressure  of  aneurism,  577. 

Cartilage,  morbid  growth  of.  1S6:  ulceration  of, 
18S;  fatty  degeneration  of,  223. 

Cartilages,  loose.  157. 

Cartil.aginous  LTowths.  1S6;  forms  and  structure 
of,  ib. :  in  articulations.  1S8. 

Cases,  method  of  taking,  19. 

Casts  of  the  tubuli  uriniferi,  varieties  of  in 
Bright"s  disease,  770. 

Catalepsy,  definition  ol^  403. 

Cell  therapeutics,  258. 

Cells,  importance  of  in  practice,  14;  fatty  dege- 
neration of.  217 ;  cell  fibres.  \hi ;  fusiform,  ib. ; 
cell-therapeutics.  2.5^:  plastic  or  i>yoid,  129; 
gi-anule.  lol ;  fibre.  132:  of  cancer.  133;  de- 
velopment of  morbi<l  growths  by.  201 ;  pig- 
ment. 231 ;  transformation  of  exudation  by,  in 
pneumonia.  265 ;  in  pericarditis.  266 ;  in  pleu- 
risy, 129  :  on  mucous  membranes,  ib. ;  in  the 
brain,  132;  in  healing  granulations,  ib;  en- 
largement of,  in  pregnant  uterus,  151 ;  atrophy, 
o£  after  delivery.  220;  in  malacosteon,  2M. 

Cephalaliria.  treatment  of,  408. 

Cerebral  and  s])inal  softenings,  pathology  of, 
8ii5 ;  origins  and  varieties  of,  ib. ;  necessity  for 
microscopic  examination  of.  310 ;  cases  of,  310, 
333. 

Cerebral  disease  from  obstrnction  of  arteries, 
cases  of,  345 ;  pathology  of.  354. 

Cerebral  disorders,  classification  of  functional, 
402. 

Cerebral  hemorrhage,  cases  of.  356 ;  predisposing 
cause  of  373 :  microscopic  appearances  of,  374 ; 
diasnosis  lit'.  375:  tre.itment  of,  377. 

Cerebr.al  mc-nindtis,  cases  of,  319;  seat  of.  .323; 
micriisciipic  apjiearances,  ib. ;  diagnosis  of, 
324:  treatment  of.  ib. :  pathology  of,  325. 

Cerebritis,  acute,  cases  of.  329 ;  chronic,  cases 
of,  *33:  pathology  of.  34;^. 

Cerebro-spinal  disorders,  classification  of  func- 
tional. 403. 

Chest,  inspection  of.  29;  mensuration  of,  32; 
motions  of  during  respiration,  29 :  post-mortem 
examination  of,  24;  view  of  viscera  in,  26; 
percussion  of  40:  ans?ultation  of,  51. 

Chicken-]iox.  identical  with  small-pox,  897. 

Chlorides  in  urine,  detection  of,  96 ;  absence  of 
in  pneumonia,  643. 

Chloroform  not  an  anaesthetic.  407;  inferior  to 
cold  as  a  true  anajsthetic.  409. 

Chlorosis  ana-mia.  cases  of  844. 

Cholera,  microscopic  appearance  of  blood  in  a 
case  of,  77. 

Cholesteatoma,  165. 


Chorea,  definition  of,  402. 

Chorion,  structure  of  a  cystic,  163. 

Chyle  of  a  dog,  686;  of  a  cat,  832. 

Cicatrization,  process  of,  132, 

Cicatrix,  structure  of,  152. 

Circulatory  system,  examination  of,  19  ;  diseases 
of  the,  512;  rules  for  diagnosis  of,  ib. 

Circulatory  organs,  auscultation  of.  55;  sounds 
elicited  by,  in  health  and  disease,  ib. ;  modi- 
fications of  healthy  sounds  of,  56 ;  new  or  ab- 
normal sounds  in,  57. 

Cirrhosis  of  liver,  cases  of,  467;  pathology  of, 
470 ;  treatment  of.  ib. 

Clinical  course,  mode  of  conducting,  6. 

Climate,  influence  of  in  phthisis,  689;  in  produc- 
ing fatty  liver,  465. 

Cod-liver  oil  as  a  remedv  for  phthisis,  687;  in 
favus,  812. 

Colchicum  in  scarlatina,  S92. 

Cold,  action  of  on  the  nervous  system,  407 ;  in 
intiammation,  146;  in  cephalalgia,  408;  in 
fever.  877. 

Collapse  of  lung,  606. 

Collier's  lung,  699;  pathology  and  treatment  of, 
702. 

Colloid  cancer.  136. 

Colostrum  of  human  female,  74. 

Compression  and  pressure,  distinction  between, 
116. 

Concretions.  237:  albuminous.  238:  fatty,  ib. ; 
biliary.  24<l:  pigmentary,  239;  mineral,  ib. ; 
urinary,  240;  renal,  ib. :  vesical,  242;  prosta- 
tic, 244;  hairy,  ib. ;  vegetable  fibrous,  245; 
intestinal,  ib. ;  amyloid  and  amylaceous,  247. 

Condylomata,  174. 

Congelation  a  true  an.fsthetic.  409. 

Congestion,  preceding  inflanmiation,  124;  of  the 
right  side  of  the  heart,  bleeding  useful  in,  276. 

Congestive  disorders  of  the  nervous  system,  404. 

ConiujM,  see  Hemlock. 

Contagion,  definition  of,  885. 

Contractility  defined.  115. 

Convulsion,  definition  of.  304,  403. 

Cord,  spin.al.  cases  of  structural  diseases  of  the, 
385:  pathology  of.  397;  functions  of  the,  112; 
functional  disorders  of  the,  402. 

Corns.  174:  causes  of,  ib. 

Corpuscles  of  the  blood.  75;  in  thickened  blood, 
hiematocele  and  cholera,  76;  in  leucocythemia, 
77,  81S:  relation  between  the  coloured  and 
colourless,  829 ;  origin  of  the,  882 ;  ultimate 
destination  of  the.  8.37. 

Corpuscles,  jius.  appearance  of  In  healthy  pus, 
78 ;  in  scrofulous  pus,  ib. 

Corpuscles,  salivary,  72;  tubercle,  77, 137. 

Coryza,  nature  and  treatment  of.  604. 

Cough  and  expectoration  in  phthisis,  treatment 
of,  692. 

Countenance,  inspection  of  the,  29. 

Cracked-pot  sound,  48. 

Cranium,  amount  of  fluids  within  the,  115; 
views  of  I)rs.  Munro,  Abercrombie,  and  Wat- 
son, ib. ;  experiments  of  Bonders  and  Kellie, 
116;  observ.ations  of  Dr.  Burrows,  117;  obser- 
vations of  Dr.  John  Eeid,  118. 

Cutaneous  eruption.s,  microscopic  examination 
of.  91 ;  classification  of.  775;  diagnosis  of,  779 ; 
treatment  of,  783 ;  on  the  scalp,  782. 

Cystic  duct,  occlusion  of  458. 

Cystic  growths,  161:  simple,  162;  compound, 
ib. :  contents  of,  163;  hygromatous.  ib, ;  col- 
loid. 164:  melicerous.  165;  cholesteatomatous, 
166;  atheromatous,  ib. ;  hairy,  167:  with  teeth, 
ib. ;  osseous,  168;  cancerous,  remarkable  case 
of,  475. 

Cystine,  microscopic  appearance  of,  89. 

Cystoma,  161. 

Debility  in  phthisis,  treatment  of,  695. 

Degeneration,  albuminous,  210;  general  patho- 
logy and  treatment  of  the,  216;  colloid,  215; 
fibroid  of  Handfield  Jones,  212. 


INDEX. 


947 


De'roueration,  f:ittv.  21fi ;  of  cflls,  21T ;  of  imiscle, 
21S;  of  blodd-vossels.  2.'0;  of  tlu"  iilacciitu, 
222;  of  carlilairo,  '>->S:  of  bimc,  224;  of  the 
exudations,  ■J2a;  of  morbid  growths,  226;  of 
tlu'  heart,  554 ;  general  pathology  and  treat- 
ment of,  23:i. 

Deu'eneration,  mineral,  284;  of  blood-vessels, 
2!5;  of  the  exudations,  236;  of  nervous  tex- 
ture, 235;  of  morbid  -rouths,  237. 

Deu'eneration,  pigmentary.  227 ;  general  patho- 
loiiy,  and  treatment  of.'232. 

Degenei-atiou,  waxy,  214. 

Degenerationaof  texture,  morbid,  210. 

Delirium  tremens,  cases  of,  410;  pathology  and 
treatment  of,  412. 

Deruiatophytiu,  diagnosis  of,  7S1,  794.  See 
Favus. 

Dermatozoa,  789. 

Uespondencv  and  anxietv  in  phthisis,  treatment 
of,  6i)5. 

Determination  of  blood,  theory  refuted,  25S. 

Diabetes  Mellitus,  cases  of.  i>:4 :  theories  regard- 
iuiT  the  nature  and  treatment  of.  854. 

Diaixnosis,  etfeets  of  advanecil  knowledge  of,  250. 

Diagnosis,  mieroseopie,  of  saliva,  72;  milk,  74; 
blood,  75;  pus,  78;  sputum,  ib. ;  vomited  mat- 
ters, SI ;  fieces,  83;  uterine  and  vaginal  dis- 
ehirges.  85;  mucus,  SO;  dropsical  fluids,  87; 
urine,  ^S;  cutaneous  ern|itions  and  ulcers,  91; 
diagnosis,  general,  of  cardiac  diseases,  rules  for 
the,  512:  of  thoracic  aneurisms,  5S7;  of  abdo- 
minal aneurisms,  5i)0;  of  pulmonary  diseases, 
rules  for.  592;  of  skin  diseases,  779:  of  con- 
tinued fevers,  S70. 

Diarrliiea.  cases  of,  476;  varieties  and  causes  of, 
477:  patholou'y  of,  483;  treatment  of,  477; 
treatment  of  in  children,  486 ;  treatment  of  in 
phthisis.  693. 

Diastaltic  or  reflex  movements,  115;  classifica- 
tion of  disorders.  4(l6. 

Diet,  irregularity  in,  the  most  common  cause  of 
disease,  100  ;  causing  scurvv,  921. 

Digestion,  99;  kinds  of,  105 ;"  disorders  of,  429  ; 
pathology  and  ti-eatment  of  derangements  of, 
432. 

Digestive  system,  examination  of,  20 ;  diseases 
of  the,  421. 

Discharges,  uterine  and  vaginal,  microscopic 
examination  of,  85. 

Disease,   definition   of,  97 ;   Bright's,   cases  of, 
74^) ;   cerebral,   front   obstruction  of  arteries, 
315 ;  general  laws  of  nutrition  and  innervation 
in,  99;  irregularity  in  diet  the  most  common 
cause  of,  100 ;  importance  of  a  knowledge  of 
the  causes  of,  251 ;  cause  of  recent  changes  in 
the  treatment  of,  ib. ;  of  nutritirm,  106. 
Diseases  of  the  nervous  S3'stem,  803;  of  the  di- 
gestive system,  421 ;  of  the  circulatory  system, 
512 ;   of  the  respiratory  system,  592 ;  "of  the 
genito-nrinary   system,   706 ;   of  the  integu- 
mentary syst'em,"774;  of  the  blood,  813. 
Dropsical  fluids,  microscopic  examination  of,  87. 
Dropsy.    210;    general,    525,  728,  753;    of  the 
brain,  ease  of,  HSi ;  of  the  pericardium.  515:  of 
the  chest,  536,  543;  of  the  abdomen,  463,  467. 
Dropsy,  ovarian,   cases  of,   7<l(l;   patholoi;v  of, 
721 ;    diagnosis  of,   72'? ;    treatment  of,  "724 ; 
products  found  in  fluid  of,  87. 
Duodenum,  perforatini:  ulcer  of,  735. 
Dyspeiisia,  cases  of,  429 ;  pathology,  treatment, 

and  causes  of,  432. 
Dysentery,  cases  of  acute,  479;  case  of  chronic; 
430;  pathology  of,  483 ;  treatment  of,  486. 

Eclampsia,  definition  of.  40.3. 

Ecthyma,  diagnosis  of.  7S0;  treatment  of,  786. 

Eczema,  diagnosis  of,  780;  treatment  of,  736. 

Embolismus.  8o6. 

Emboli  in  the  brain,  pathology  of,  354 ;  in  the 

lunsr.  658. 
Emphysem.a.  pathology  of,  608;   cases  of,  606, 

609;  treatment  of,  ib. 
Emprosthotonos,  definition  of,  402. 


Empyema,  cases  of,  621 ;  paracentesis  for,  629. 

i'>ncephaloma,  134. 

Knchondroma,  186 ;  structure  of,  ib. ;  diagnosis 
of,  188. 

Endoearditis.  532. 

Eni:orL'einent,  bleeding  useful  in,  276. 

Entoznon  follieulorum,  description  of  the,  792. 

ICphelis,  diagnosis  of,  780;  treatment  of,  787. 

Eiiilejisy.  delinition  of,  304,  403;  case  of,  relieved 
bv  galvanism,  406;  case  of,  from  chronic  cere- 
bri tis,  333. 

Epithelial  growths,  173.     See  Epithelioma. 

Epithelial,  scales  in  saliva,  72 ;  ulcer,  93 ; 
growths,  173. 

Epithelioma,  173;  principal  forms  of,  174;  struc- 
ture of.  176 ;  of  the  lip  and  tongue,  ib. ;  of  the 
Ivmpliatie  ixlands,  179;  of  the  urinary  bU^ider, 
i"b. ;  iiathology  nf,  201. 

Epithelium,  fringe-like,  78. 

Ei)Ulis.  193. 

Eremacausis,  143. 

Erupticms,  cutaneous,  microscopic  examination 
of,  91. 

Erysipelas,  cases,  diagnosis,  and  treatment  of, 
s92. 

Ervthenia,  diagnosis  of,  779 ;  treatment  of,  784. 

Ethics  of  Medicine,  929. 

Examination  of  patient,  18;  by  interrogation, 
19;  by  inspection,  28;  by  palpation,  30;  by 
mensuration,  32 ;  by  succussion,  ib. ;  by  per- 
cussion, 35;  by  auscultation,  49. 

Examination,  iiost-mortem,  22;  method  and 
order  of.  23 ;  object  of,  ib. ;  of  external  appear- 
ances, 24 ;  of  head,  ib. ;  of  spinal  column,  ib. : 
of  neck,  ib. ;  of  .chest,  ib. ;  of  abdomen,  ib. ;  of 
blood,  ib. ;  by  microscopic  examination,  ib. ; 
hints  for  carrying  out  i)ost-mortem  exami- 
nation, ib. ;  knowledge  rcipiired  for  correct 
examination,  26 ;  necessary  to  determine  the 
value  of  remedies,  5b4 ;  Dr.  .Sibson's  "  Medical 
Anatomj-,'"  27. 
Exanthemata,  definition  of,  775 ;   diagnosis  of, 

779  ;  treatment  of,  784. 
Excrescence,  ca\iliflower.  177. 
E.xcretion  of  ettVte  matters  from  the  bodj",  105. 
Exophthalmia.  case  of,  342. 
Exostosis,  191. 
Expoct(n'ation  and  cough  in  phthisis,  treatment 

of,  691. 
Experience,  past  and  present,  in  the  treatment  of 

inflammations,  254. 
Exudation,  definition  of  the  term,  128;  varieties 
of,  ib. ;  production  of,  124;  theory  of,  126; 
vital  transformations  of  the,  128;  simple,  ib. ; 
cancerous,  183  ;  tul)ercular.  137  ;  pathology  of 
the  three  kinds  of,  138:  death  of  the,  141; 
general  treatment  of,  146 ;  fatty  degeneration 
of  the,  225;  mineral  degeneration  of  the,  236  ; 
essential  to  inflammation,  252;  transformation 
of,  in  pneinnonia,  265;  in  cerebritis,  305;  in 
pericarditis,  260;  in  pleuritis,  618;  seat  of  in 
dysentery,  4b4. 

Face,  remarkable  case  of  atrophy  of,  122. 

Fatty  concretions,  238. 

Fatty  degeneration,  216 ;  of  cells,  217 ;  of  muscle, 
21S;  of  blood-vessels,  220;  of  the  i)lacenta, 
222;  of  cartilage,  223;  of  bone,  224;  of  the 
exudations,  225;  of  morbid  growths,  226;  of 
the  brain,  307 ;  of  the  liver.  464 ;  of  the  cardiac 
valves,  553 ;  of  the  heart,  554;  of  the  kidney, 
767. 

Fatty  growths,  159;  steatomatous  and  lipo- 
matous,  160;  fibro-lipomatous,  161. 

Favus  crust,  composition  of.  92. 

Favus  of  the  seal|i,  diagnosis  of,  7.S1;  cases  of, 
794;  history  of  favus  as  a  vegetalde  i)arasite, 
798  ;  mode  of  development  and  symptoms  of, 
798;  causes  of,  SOI;  pathology  (jf,  S(i3:  treat- 
ment of,  810;  on  the  face  of  the  mouse,  802, 
note. 

Febricula,  characters  of,  868 ;  cases  of,  859. 

Febrile  symptoms  in  phthisis,  treatment  of,  694. 


948 


INDEX. 


Fern,  male  shield,  as  a  vermifuge.  495. 

Fever,  continued,  chanpres  of  type  in,  255,  285 ; 
symptoms  of.  S56:  forms  and  characters  of, 
8b7 ;  diagnosis  of.  870 ;  morhid  anatomy  of  the 
Edinburgh  efiidemic  of,  during  1846^7,  972 ; 
treatment  of.  876. 

Fevers,  eruptive.  8s4. 

Fever,  intermittent,  case  of,  8S2;  nature  of,  883; 
treatment  of,  8S4. 

Fever,  relapsing,  character  of,  858 ;  case  of,  860 ; 
identical  with  the  ^ynocha  of  Cullen,  861. 

Fever,  remittent,  case  of,  880;  nature  and  treat- 
ment of.  8S1. 

Fever,  therapeutic  action  of  quinine  in,  879. 

Fever,  typhoid,  character  of,  858;  cases  of, 
treated  by  quinine,  S62;  diagnosis  of,  870; 
nature  of.  875:  morbid  anatomy  of.  872. 

Fever,  typhus,  character  of,  858 :  cases  of,  treated 
by  quinine.  866;  cases  of.  treated  without 
quinine,  869;  diagnosis  of.  870 ;  treatment  of, 
876. 

Fibres,  molecular,  152 ;  nuclear,  ib. :  cell.  ib. 

Fibrin,  origin  of,  in  the  blood.  103;  Zimmer- 
mann's  opinion,  ib. ;  arguments  in  favour  of 
this  opinion,  ib. 

Fibroma.  151. 

Fibrous  growths,  151 ;  molecular,  nuclear,  and 
cell,  152;  flbro-nucleated  and  fibro-cellular, 
ib. :  sarcomatous  or  soft.  153 ;  dermoid  or  hard, 
155 :  neuromatous.  158. 

Fistula,  recto-vesical.  742. 

Fluctuation,  examination  of  patient  b\-,  31. 

F«ces,  microscopic  examination  of.  S3. 

Food,  assimilation  of  the,  101;  etfects  of  bad 
assimilation.  107;  effects  of  improper  quantity 
or  quality  of.  1-21 ;  in  scorbutus.  921. 

Foramen  ovale,  enlarged,  case  of  548. 

Freckle,  diagnosis  of  780;  treatment  of,  787. 

Function.s.  influence  of  dei-angement  of  one  over 
another  order  -if  121. 

Functions  of  the  bodv.  influence  of  predominant 
ideas  on  the.  292. 

Fungus  ha-matodes,  185. 

Fungus  fi-om  a  favus  crust,  92 ;  in  the  ear,  ib. 

Gansrene.  moist.  141 ;  dry,  143 ;  of  the  intestine, 
483 :  of  the  lungs.  651 ;  from  obstruction  of 
pulmonary  artery.  657 ;  of  the  kidney,  742. 

Gall-bladder,  with"  gall-stones  in,  456,"  461;  en- 
largement of,  45S. 

Gall-stone,  2-38;  case  of  impaction  of,  in  common 
bile-duct.  456 ;  passage  of  into  the  gall  bladder, 
458. 

Gastric  glands,  organic  ch.anges  in,  453. 

Genito-urinarj-  system,  examination  of,  20 ;  dis- 
eases of  the.  706. 

Gland,  thyroid,  liability  of  to  new  formation  of 
tissue,  171 ;  enlargement  of  in  bronchocele.  215. 

Glands,  mesenteric,  liability  of,  to  increased 
growth,  172. 

Gland,  prostate,  calculi  found  in  the.  244. 

Glands,  structure  of  blood  forming,  838. 

Glandular  growths,  170 ;  forms  of,  ib. ;  structure 
of.  171 :  of  the  thyroid  gland,  ib. ;  of  the  lym- 
phatic glands,  172;  causes  of.  173. 

Glottis,  case  of  acute  oedema  of  the,  598. 

Glucohivmia,  cases  of,  852 ;  theories  regarding 
the  nature  and  treatment  of.  854. 

Gout,  general  pathology  and  treatment  of,  909 ; 
case  of  chronic.  919. 

Granulations,  formation  and  structure  of,  132. 

Granule  cells,  181.  21S. 

Granules  and  molecules,  deposition  of  fatty,  217. 

Growths,  morbid,  148;  classification  of  149 ;  ulti- 
mate elements  of,  ib. ;  general  pathology  of, 
197:  origin  of  198;  development  of,  199:  pro- 
pagation of,  202 ;  malignancy  and  non-malig- 
nancy of.  204 ;  curability  of,  ib. ;  Van  der  Kolk"s 
viewsof  causes  of  propagation  of  20C:  decline 
or  degeneration  of,  207 ;  general  treatment  of. 
208 :  means  of  retardation  and  resolution  of, 
ib. ;  means  of  extirpation  of  ib. :  necessity 
for  microscopic  examination  of,  2C9 ;  constitu- 


tional treatment  of,  210 ;  fatty  degeneration  of 
226 ;  mineral  degeneration  of,  237. 

Growths,  morbid,  of  texture,  14b;  fibrous.  151  ; 
fatty,  159;  cystic,  161 :  melicerous,  105;  eho- 
lesteatomatous,  ib. ;  atheromatous,  166;  glan- 
dular, 170;  cartilaginous,  186 ;  erectile,  li-3; 
Bteatomatous  encysted,  166;  epithelial,  173; 
vascular.  181;  osseous,  190;  myeloid,  193;  can- 
cerous, 196. 

Growths,  distinction  of  cancerous  from  other, 
196. 

Gruby's  pocket  microscope,  64. 

II;ematocele,  appearance  of  altered  blood  cor- 
puscles in  the  fluid  of  an,  76. 

niemoi)tysis  in  phthisis,  treatment  of  f93. 

Hairy,  formations.  ISO;  concretions,  244. 

Hammer,  Dr.  Winterich's.  36. 

Head,  post-mortem  examination  of  24. 

Headache,  definition  of,  4o2 :  treatment  of,  408. 

Healing  i)rocess,  results  of  the,  14S. 

Health  and  disease,  general  laws  of  nutrition 
and  innervation  in.  99. 

Heart,  functional  disorders  of  the,  556;  treat- 
ment of,  557. 

Heart,  rules  for  the  diagnosis  of  diseases  of  the, 
512. 

Heart,  sounds  of  the,  53 ;  percussion  of  the,  40 ; 
mechanical  injuries  of  the  valves  of,  650 ;  exu- 
dation into  or  on  the  surface  of  the  valves  of, 
551:  dejiosition  of  fibrin  on  the  valves  of,  652; 
degeneration  of  the  valves  of  the,  553 :  fatty 
degeneration  of  the.  654;  hypertrophy  of  the, 
ib. :  inflammation  of  the  substance  of  the,  655. 

Heart,  valvular  diseases  of  the,  532;  cases  of, 
58:3;  causes  of,  550;  pathologj-  of,  ib. ;  treat- 
ment of  555. 

Heat,  source  of  animal,  105. 

Hemiplegia,  definition  of  403;  cases  of,  848; 
pathology  of,  375;  treatment  of  377. 

Hemlock,  case  of  poisoning  by,  413 ;  symptoms 
of,  416 ;  physiological  action  of,  ib. ;  death  of 
Socrates  b}-,  41s;  identity  of  ancient  with 
modern,  ib. 

Hemorrhage,  cerebral,  cases  of,  356 ;  predispos- 
ing cause  of.  373 ;  microscopic  appearances  of, 
374 ;  diagnosis  of  375 ;  treatment  of,  377. 

Hepatitis,  case  of,  454. 

Herpes,  diiignosis  of,  779 ;  treatment  of^  785. 

Homy  productions,  l80. 

Hutchinson's  spirometer,  35. 

Hydrocele.  164. 

Hvdrocephalus.  acute,  cases  of  312 ;  nature  of, 
"316  :  treatment  of  317. 

Hydrocephalus,  clu-onic.  case  of  3S1. 

Hydro-pericardium,  515 ;  pathology  of,  528 ; 
treatment  of  531. 

Hvdrophobia.  definition  of,  403. 

Hydj-o-thorax.  5:36,  543. 

H  vpertroj>hv,  148 ;  of  the  liver,  463 ;  of  the  heart, 
'554. 

Hypnotism,  297. 

Hysteria,  definition  of,  403 ;  treatment  of,  408. 

Ichora'mia,  case  of  847 ;  theories  regarding  the 
nature  of.  849. 

Ichthyosis,  diagnosis  of.  7S0 :  treatment  of  787. 

Ideas.  predominant.influence  of  on  the  functions 
of  the  body.  292. 

Ileus,  case  of  488 :  following  ovariotomy,  case 
of,  706 :  pathology  of  490 ;  treatment  of,  491. 

Illusions,  spectraf,  cases  of,  399,  410 ;  theory  of, 
297. 

Impetigo,  diagnosis  of,  7S0 ;  treatment  of,  785. 

Incompetency  of  aortic  valves,  cases  of  533 ;  of 
mitral  valve,  cases  of  £36 ;  of  tricuspid  valve, 
cases  of  543. 

Induration.  143. 

Infection,  definition  of  938;  purulent,  809. 

Inflammation,  Anclral's  opinion  of  the  expres- 
sion. 123.  note. 

Inflammation,  fallacious  character  of  past  expe- 
rience in  the  nature  and  diagnosis  o^  251,  262 ; 


INDEX. 


949 


definition  of  the  term,  252;  unchangeable 
nature  of.  2M ;  natural  progi'ess  of,  269 ;  dimi- 
nished  emidoyment  of  blood-letting  in  acute, 
251;  former  reasons  for  bleeding  erroneous; 
257 ;  value  of  bleeding  in.  270 ;  etfects  of  gene- 
ral blood-lettiniT  on  local.  260  :  character  of  the 
pulse  as  an  indication  for  blood-letting  in,  262 ; 
real  use  of  blood-letting  in,  276  ;  reply  to  ob- 
jections as  to  treatment  of  internal,  277.  See 
also  Exudation. 

Inttuenz.T,  nature  and  treatment  of.  604. 

Innervation  and  nutrition,  general  laws  of.  in 
health  and  disease,  9i1. 

Innervation,  function  of.  lOS ;  influence  of  dis- 
ordered nutiitiou  on.  121. 

Inoma.  149. 151. 

Insanity,  definition  of,  402. 

Inspection,  examination  of  patient  by,  28. 

Integumentary  system,  diseases  of  the,  774 

Integumentary  system,  examination  of,  20. 

Intestinal  concretions,  245. 

Intestine,  case  of  obstruction  of  the  large,  486. 

Intestines,  percussion  of,  46 ;  diseases  of  the,  476 ; 
condition  of  in  typhoid  fever,  S73. 

Intestine,  small,  case  of  strangulation  and  per- 
foration of.  fr(jm  inguinal  hernia,  4S6. 

Iritis,  case  of  rheumatic,  917. 

Irritation  of  the  nerves  of  special  sense,  defini- 
tion of,  403. 

Irritation  of  special  nerves  of  motion,  definition 
of;  403. 

Irritation,  spinal,  definition  o£  402. 

Itch  insect,  descrijition  and  treatment  of  the,  7S9. 

Jaundice,  cases  of,  454,  456,  458,  468. 

Kamala.  as  a  vermifuge.  -^98. 

Keloid  growths,  case  of,  9;10. 

Kidney,  percussion  of  the,  48 ;  waxy  degenera- 
tion of  the.  214:  calculi  in  the.  241 ";  inflamma- 
tion of  the,  726 :  abscess  in  the.  737 :  scrofulous 
abscesses  in,  740 ;  calculous  inflammation  and 
gangrene  of,  742 ;  chronic  inflammation  of,  and 
cystic,  745 :  orisrins  of  cystic  disease  of  the. 
747;  Bright"s  disease  of  the.  74S:  remarkable 
case  of  Brighfs  disease  of  the,  recovering  un- 
der the  influence  of  super-tartrate  of  potash, 
753 ;  atrophied,  763 ;  see  Bright s  disease,  also 
XepJiriti.-i. 

Laryngitis,  cases  of.  593:  method  of  applying 
topical  remedies  in,  595;  svniptoms  0^597; 
diagnosis  of.  600 :  treatment"of.  601. 

Laryngitis,  syphilitic,  case  of.  900. 

Lead,  case  of  poisoning  with,  41S ;  treatment  of. 
419. 

Lenses,  objective,  of  microscope,  65. 

Lentigo,  diagnosis  of,  7S0 ;  treatment  of,  7S7. 

Lepra  tuberculosa,  diagnosis  of,  780 ;  vulgaris, 
diagnosis  of.  ib. ;  treatment  of,  7S6. 

Leucocythemia.  S13:  definition  of.  S14:  cases  of, 
ib. ;  pathology  and  treatment  of.  S27;  discovery 
of.  840 :  appe.ii-ance  of  blood  in.  77. 

Lichen,  diairnosis  of,  7-0;  treatment  of,  786. 

Life,  Beclard's  definition  of,  97. 

Lime,  oxalate  of,  microscopic  appearance  of,  89. 

Lifioma,  159. 

Lithic  acid  calculi,  241. 

Liver,  percussion  of.  44:  waxv  degeneration  of 
the.  214  467 :  diseases  of  the." 453 :  case  of  acute 
congestion  of  the,  454 ;  cases  of  enlargement 
of  the.  46:3;  fatty  enlargement  of  the,  464; 
cii-rhosis  of  the,  467 ;  cancer  of  the,  472 ;  nut- 
meg, 471. 

Lungs,  percussion  of.  40 :  abscess  of  the,  648.  G54 ; 
case  of  gangi-ene  of  the,  651 ;  condition  of.  in 
typhus  fever,  t>73:  fistulous  openings  in.  621 ; 
partial  atrophy  of  the.  737 ;  compre.<sion  of  the, 
in  empyema,  629  :  collapse  of  the.  606 :  fedema 
of  the.  730 ;  h;em<irrhage  into  the.  586.  540 ; 
inflammation  of  the  —  see  Pneumoniu,  and 
names  of  special  diseases  of  the. 

Liings,  cancer  of  the,  case  of,  696 ;  forms,  diagno- 
sis, and  treatment  of,  693. 


Lungs,  carbonaceous,  cases  of,  6B9 ;  nature  and 

causes  of,  702  ;  treatment  oi.  705. 
Lupus,  diagnosis  of,  780 ;  treatment  of.  787. 
Lymph,  plastic  formation  and  structure  of,  129. 

Maculae,  definition  of,  776 ;  diagnosis  o£  780 ; 
treatment  of.  7s7. 

Magnesia,  triple  phosphate  or  ammonio-phos- 
phate  of,  microscopic  appearance  of,  t9. 

Magnetism,  animal,  295. 

Malignancy,  in  morbid  growths,  discussed,  202. 

Mamma.  c(mi pound  cystic  sarcoma  of,  163;  cause 
of  increased  growth  in,  173. 

Medical  Eeform,  10 ;  bill  which  passed  the  legis- 
lature, in  IsoS,  11. 

Medicine,  relation  of  the  science  to  the  art  o£  2 ; 
I)resent  state  of  practical,  13 :  principles  of,  97 ; 
ethics  of.  929. 

Melanin,  231. 

Melanoma,  230. 

Meningitis,  cerebral,  cases  of.  319  ;  seat  of;  323; 
microscopic  examination  of.  ib. ;  diagnosis  of, 
824 ;  treatment  of,  ib. ;  pathology  ot  325. 

Menstrual  discharge,  microscopic  appearance  of, 
85. 

Mensuration,  examination  of  patient  by,  32. 

Mentagra,  diagnosis  of.  7S1 ;  ti-eatment  of.  795. 

Mercurial  poisoning,  899  ;  of  neuro-spinal  func- 
tions. 407. 

Mercury,  iuutilit.v  of,  in  inflammations,  147, 276 ; 
in  acute  hydrocephalus.  Sis ;  in  jaundice,  467 ; 
in  pericarditis,  531 :  Graves"  extravagant 
praises  of  opposed  bv  facts.  532:  injurious  in  sv- 
j.hilis.  cases  of.  899."  900:  treatment  of  syj.hiiis 
b.v.  9il7  ;  not  necessary  in  iritis,  918. 

Mesenteric  glands,  in  tyiihoid  fever,  874,  172; 
hypertrophy  of.  in  leucocythemia,  S14. 

Mesmeric  mania  of  1851,  301. 

Mesmerism,  292. 

Metallic  tinkling,  54;  in  pneumo-thorax,  623; 
cause  of.  630. 

Micrometer,  6S. 

Microseope,  principal  applications  of.  to  diagno- 
sis. 71 :  saliva,  72 :  milk,  74 ;  blood,  75 ;  puiC  78 ; 
sputum,  ib. ;  vomited  matters,  SI ;  fueces,  S3 : 
uterine  and  vaginal  discharges,  85:  mucus,  86; 
dropsical  fluids,  s7 :  urine,  8i ;  cutaneous  erup- 
tions and  ulcers.  91;  necessity  of  employing, 
to  determine  the  nature  of  cerebral  and  spinal 
softenings,  305. 

Microscope,  use  of  the,  in  examination  of  patient, 
59;  Oberhaeusers,  62;  Gruby"s  compound, 
pocket,  64:  objective  lenses  of"  65;  eye-piece, 
66;  methods  of  illumination,  ib. ;  test  objects 
for  the.  67 :  methods  of  mensuration  and  de- 
monstration, ib. ;  how  to  observe  with  a.  69. 

Microscoidc  objects,  physical  characters  which 
distinguish.  70. 

Milk,  microscopic  examination  of,  74. 

Mind,  evolution  of  the  power  of.  dependent  on  the 
hemispherical  ganglion,  facts  in  pn)of  of.  111. 

Mineral  substances  essential  to  nutrition,  100. 

Mineral  degeneration.  234:  of  blood-vessels.  235; 
of  nervous  texture,  ib. ;  of  the  exudations,  236; 
of  morbid  gi-owths.  237. 

Mineral  concretions,  239. 

Mitral  valve,  cases  of  disease  of,  536. 

Molecules  and  granules,  deposition  of  fatty,  217. 

Moles,  diagnosis  o£  780. 

Molluscum  contagiosum,  165;  diagnosis  of,  780. 

Mono-ideism.  tiote.  299. 

Moore's  test  for  sugar  in  urine.  95. 

Mortification,  or  moist  gangrene.  141. 

Motion,  contractile,  diastaltic.  and  voluntary,  114. 

Motions.  iiTCgular.  definition  of,  402. 

Mouth,  diseases  of  the.  421. 

Movements,  contractile,  diastaltic  or  reflex,  and 
voluntiiry.  114 

Mucus,  g-eiatinous.  structure  of.  from  os  uteri, 
85;  microscopic  examination  of,  s6. 

Muguet,  minute  structure  of  exudation  in.  73. 

Murmurs,  laryngeal  and  ti-acheal,  51 ;  bronchial, 
ib.;  vesicular  respiratory,  52 ;  cavernous,  53 ; 


950 


IXDEX. 


^^'1^^^":^^^^^:^:^^^  :  ^S'^i-^l^tory.anscultation  of;  55;  sounds 


nr  ,;/k  '  .•'  •  I'-^J'^'-'i-'iial  urlVietion.  ib. ;  valvular 
Muscie,  latU  (if-eiierati.in  of.  21S 
^Si?l^^r"  "''^''  chrouieoasesoASSS. 

Na-vi,  diagnosis  of.  TSO;  treatment  of,  7S7 
Jsau^ea  and  vomiting,  treatment  of  in  phthisis, 

Neck,  post-mortem  examination  of  24  I      a-  .-'-:•■'■—->"' 

Nephritis,  acute    e.-ise<  ,.f   tor.  ..  O'agnosis  of.  723  •  tr 

T^O;  b^orr^^'^^b^,^,,t^^^-t^je,  \  Ovariotomy,  case  oi;1 


7-10;   cal- 


rm.  K      .  '  "r"""-^  "'i   'ao;   aes 

^cluS^S;:^- '?^  ^•=^"^'<'- 

ot-loa'  '^"''■''''  "'''"'■•  '^'^'^nitions  of  irritation 
Nerves,  function  and  properties  of  113 
JNorvous  system,  examination  of   19  •   trener-il 
anatomy  and  physiology  of  the.  ios    st?uctul 
st'xti'/'T^''"''?^  of  the,ib.;  refle.xand  div 
t  .ms oi-  ■  hi"?*-  *.*"t"°","^"^^-«  views.ni;  func- 
tions  ol  the  bram,  ib. ;  functions  of  spinal  cord 
112;  general  pathologv  of  115;  effects  of  sti 
mull  or  disease  on  the  functions  of  the  11  '^ 
influence   of  rapid  and  slow   lesions  of   on 
svmtitoiiis    loo-   )„« „^    ".S10II5,  oi,   on 


Organs,  pulmonary,  auscultation  of  51  •  sounds 
produced  by.  ib  ;  circulatory,  auscu  tktion  of 
^.•ta^ro^^sr"^'''^  '•^'  ''■■■  ^'^'^-'-'-anf' 

Ovarian  dropsy,  cases  of.  706:  patholo^'v  of  721  ■ 
diagnosis  oi:  723 ;  treatment  of  724   '^  ' 


^m^ne^.^Th'l''-  ^?f  '''''''  «'''  "2;  myeloid, 
ill'  "*''''  '^-S  >»>  "le  eye  and  other  teitures, 

&mrm'''^''^^"'^^"^^"'''-'lS6. 
Osteoma,  cystic,  of  femur  and  tibia.  168 

""  s^nafiS"!,^'^"^  ^  *«  ^'^'^  structure  of  the 
Oxaluria,  cases  of,  430. 


symptoms,  120rinflrncrof'sS"o7dt^e     ^l"'!-' -'-' -se  of,  418. 

^.r^oi;!::^— "^i^^i^'t-^™^ :  ^aS^iS:-""-  -  ^«--  ^-  ^-^  ^^ 

^n^nnes  of  the,  120;  influence  ot,  on  m.trit?°n!  '       of  mV.""'  °^  """  ^''^''  -^"'^^  '"'^  treatment 
Nervous  system,  diseases  of  the.  303  >  ^''''.'^''^'as-  ''"ses  of  cancer  of  448,  461 ;  Bernard-g 

Nervous  system,   functional    disoiSers  of  th  .    '       ^ '.<-"s  "♦ '•- <'■ =  --    '     '•^'"•a  s 

:issifi<.nt>,>„  ,.e  A^.^.  ^  i..'^^  1'  tii^N  1  Painllom.,  

^nt*""'"""- "''  ''^'    •I'^nosis  of,  780; 

minis.  706.  -''^''''''^^^-^   thoracis,  625;  abdo- 

Pai-alysis.  definition  of  304-  cases  of  949  -iaa. 

u!];:;!'::"i'-'!:;^'^=  "^abdt^n^ns 


ervous  system.   fu'nctionar"dis"oi5ers  of  t>, .       t.  ^  '"iJ^*  "*  "'**  functions  of,"462. 

3-.'9;  classification  of  402;  pa  ho^/v^  of  4.U  •'  i  ?'!«'  "ma,  175. 
,    causes  of,  ib. ;  treatment  of,  4^.s     ".^e  of  39^  •'        "^'''''f '  'I'^fl"*""" 

congestive  disorders  of  the  404  ■  diastaltic  ..;     p  f'^atment  of.  786. 

thellof  ""■""'  "f  the,  406 ;'  toxic  Sers  of     P--"-"-"'-^^*'*  "'^iti 
V,!!^r!!f  ^''^t",''^-  mineral  degeneration  of.  235 

in]r  o^ltl^'   '^''^'^  "^  ^''-^  --^=^--1 
Neuralgi.a.  definition  of,  403;  treatment  of  403 
Neural  disorders,  classification  of  403 


„    -^~^.  .^..,,  ^...osification  of  403. 

Sr^mrm  15^^"''  <='-^"^-"-  of,  404. 

Nihilismus,  16. 

Noli  me  tangere,  177. 

Noma.  144. 

Nutrition,  complemental  ''58 

^f^lllr  "?'l.'n°'>"-ation,  general  laws  of  in 
health  and  disease  99  ' 

Nutrition,  function  of  99;  division  of  process 
into  five  stages,  ib. ;  introduction  of  apmS 
ate  alimentary  matters.  lo„:  formatiirfr^m 
thereof  a  nutritive  fluid,  the  blood,  and  the 
changes  It  undergoes  in  the  lun£rs,101    pLia^e 

Tissues  lo"  ■  '""y  '''''"''  '"  ''"  t^^"^^fo«"-J  inTo 
tissues,  102 ;  disappearance  of  transformed 
tissues,  and  their  re-absorption  into  the  blood 

boaj'Tol.''""  ''^'^'''  '^''''  °^='"^^*  fr*'^  "1"=' 

Nutrition,  importance  of  albumen,  oil.  and  mi- 
neral substances  in  the  process  of  loo 

J«utritiori.  diseases  of  106 ;  causes  of,  107  •  prin- 
ciple ot  treatment  of,  ib  '  ^ 

^Sm.'^''"''^'''"''  ^°'l"<'n<^e  of  on  innerva- 

i 

Oberh«user-s  microscope  for  medical  men,  62        I 

Obesity.  lo9  ;  case  of  9-'6 

(Edema,  of  the  brain,  3.7:  of  subarachnoid  cel- 
lular tissue    case  of,  334;   of  the  le-s  from  ' 
cirrhosis.  480;   from  car.liac  disease    fril    of  I 

CEgophony,  54. 

CEsophjiaus.  case  of  stricture  of  from  epithelio-  ' 

ma.  423 :  cancer  of  338.  4-'6  470         ^l"t"eiio 
Oil  and  albumen,  importance  of  in  the  process 

of  nutrition.  100.  c  ^.loctss 

Oligocythemia,  846. 
Opisthotonos,  definition  of  40'' 
Opium,  case  of  poisoning  by,  418. 


auditorv  nerves,  ;^2 
:^3r:^,;i:^?'^l:'^.:;!^^''^=— ^SSS;ca„se 

Pattn'r'^'.V'ih"?  of  adv.-,nced  knowledge  of  250. 
torv  sVTt^  ^1"'  examination  of  18;^circHla- 
lory  S3  stem,  19  respiratorv  system  ib  •  ner 
voiis  system,  ib. ;  digestive  svstem.  20  4ni 
r""T"H-'lT'  '^•- '  i"t'-f-'ument.arv  svltem 
b  antecedent  history,  ib.;  hints  for  carrying 
out  examination,  21.  "'  "-.uj^m^ 

Patient,  ex.amination  "of  bv  inspection    "8  ■  bv 

s^iofrs^^^i^!T^^"^^^ 

40:u.eof^K:^n^a^i,='::j^^: 
PecLifoq^^nf  '"''  "  ---nation  of,  94."' 
Pemphigus,  diagnosis  of,  779;  treatment  of  7<^ 

i  ^'^'-"t^- lunl^th"'"f"r''"'"'«'  ^P^"^'  -^'^^for. 

;         ,?"*•  ^°-'  of  heart.  4;3;  of  liver  ib  •  of 

I      t'rr"-  -^,1  "^  stomach  and  intestin ef  b  •'  of 

ki.lneys.  48;  of  bladder,  ib.;  of  aneurisms  A<38 

Percussion  hammer,  utility  of  gg         '^^"'688. 

,  Perforation  of  the  stomach,  cases  of  440-  of  the 

I      ^odenum,  735 ;  of  the  intestine  frtlnherniX 

Pericarditis,  changes  which  take  place  in  the 

I      t>r '''Ji^- "°  "^^  266 ;  ™ses  of  514;  pa?holo°v  of 

i      S,^S^-|^^^^«^-"*^-o^ 

I  Peritonitis,  cases  of;  499;  acute,  ib.;  tubercul.ar 

50l;Sn::ro^.t|-*-lo'^--esembHS 

Pharyngitis,  case  of  follicular  422 

Pharvnx.  diseases  of  the,  421.        ' 

Phk-bohtcs.  ].'i7. 

Phosphorus,  in  spinal  diseases.  391 

^^n;|-:^^::^^^,ll^=-—d  causes 

Phtosis  of  colliers,  appearance  of  sputum  in,  81, 


IXDEX. 


951 


Phthisis  puhnonalis.  cases  of.  658:  natural  pro- 
gress of,  tendenev  to  ulceration,  ami  modes  of 
arrestment  of,  (iT5;  patholo^'v  and  general 
treatment  of,  6S4;  indications  for  the  treat- 
ment of,  685;  cod-liver  oil  as  a  remedy  for, 
68T :  value  of  microscopic  examination  of  spu- 
tum in.  80. 

Phthisis  puhnonalis.  sjiecial  treatment  of,  601 ; 
cough  and  txpectoration,  6!'2 :  loss  of  appetite, 
ib. ;  nausea  and  vomiting,  6;  3:  diarrhcea.  ib. ; 
hamojjtysis.  ib. ;  sweating.  6'J4:  febrile  symp- 
toms, ib. ;  debility,  695;  despondency  and 
anxiety,  ib. 

Picrotox'ine,  efl'ects  of.  4(l7. 

Piirmeutary  de^'eueration.  '227;  general  patho- 
logy and"  treatment  of,  282:  concretions,  289. 

Piirniiiit,  formation  and  varieties  of,  227 ;  causes 
ot;  2o2. 

Pityria^is,  diagnosis  of,  780;  treatment  of,  787; 
parasitic,  case  of.  797. 

Picirrv's  pleximeter.  80. 

Placi-nta.  fatty  di-generation  of  the.  222. 

Pleiiritis.  cases  of.  613 :  pathology,  diagnosis,  and 
tri-atment  of.  CIS:  chronic,  cases  of,  616. 

Pleurosthotonos.  defiuiti<in  of,  402. 

Pleximeter  of  M.  Piorry,  36. 

Pneumonia,  acute,  microscopic  appearance  of 
sputum  in,  87 ;  changes  which  take  place  in, 
26.");  natural  jirogress  of  a.  209:  treatment  by 
bleeding,  270 ;  results  of  antiphlogij-tic  treat- 
ment ot  271 :  results  of  dietetic  treatment  of, 
272 ;  results  of  treatment  directed  to  further 
the  natural  progress  of  the  disease,  273 ;  bleed- 
ing, a  palliative  in,  276;  treatment  by  mer- 
curials, ib. ;  chronic  cases  of.  64S:  reply  to 
objections  concerning  treatment  of,  277;  cases 
of.  630 ;  diagnostic  value  of  the  absence  of 
chlorides  from  the  urine  in,  643:  general 
pathology  and  treatment  of  acute.  646. 

Pneumo-thorax,  cases  of.  623;  remarkable  death 
in  a  case  of,  625;  metallic  tinkling  in.  627. 

Poisoning  b^'  alcohol,  410 ;  by  opium,  413 ;  by 
hemlock,  ib. ;  by  lead,  41S;  by  aconite,  t85;  by 
merciu-v.  899. 

PolvcvtluVniia.  846. 

PolVd'ipsia.  cases  of.  923. 

Polypus,  soft.  l.!>5;  hard,  156;  in  the  heart,  546. 

Polysarcia.  926. 

Porrigo,  detinition  and  varieties  of.  7S2. 

Post-mortem  examination.  22 ;  method  and  order 
of.  23;  hints  for  canying  out,  24 ;  knowledge 
required  for,  26. 

Posture  of  patient,  inspection  of.  28. 

Pressure  and  compression,  distinction  between, 
116. 

Probang,  method  of  using,  in  laryngitis,  &95. 

Prostatic  concretions.  244. 

Prurigo,  diagnosis  of,  7S0;  treatment  of,  786. 

Psoriasis,  diagnosis  of,  780;  treatment  of.  786. 

Pulmonary  organs,  special  rules  for  auscultation 
of.  51 :  sounds  produced  by,  ib. 

Pulmonary  diseases,  injections  of  the  bronchi  in, 
611 :  case  of,  609. 

Pulmonary  artery,  varicose  aneurism  of.  £64. 

Pulse,  characters  of  19;  as  an  indication  for 
bleeding.  262. 

Purgatives,  use  of,  in  intestinal  disease.  478. 

Purpur.%  diagnosis  of,  780 :  treatment  of,  787. 

Pus,  microscopic  examination  of.  7S.  130;  forma- 
tion of.  in  pneumonia.  265;  effects  of  mixture 
with  the  blood,  649;  injection  of,  into  the 
blood,  850. 

Pus.  scrf)fulous,  microscopic  appearance  of,  78, 
180. 

Pustula?,  definition  of,  776 ;  diagnosis  of,  780 ; 
treatment  of,  785. 

Pvaiuia.  case  of.  847;  theories  regarding  the 
"nature  of.  849. 

Pvilitis.  cases  of,  726. 

Pyrosis.  437. 

Quain's  stethometer,  32. 

Quinine  in  continued  fever,  therapeutic  action 


of.  S79:  in  intermittent  fever,  8S4;  in  hectic 
fever,  695. 

Eammollissement.    See  Softening. 

Rattles,  moist.  53. 

Reeto-vesical  fistula,  case  of,  742. 

Remedies,  indications  for  the  use  of,  260. 

Renal  calculi.  "241. 

Resonance,  vocal.  54. 

Respiration,  motions  of  chest  during,  £9. 

Respiration,  natural  and  exaggerated,  51;  pue- 
rile. 52  :  alterations  of,  63. 

Respiratory  sounds.  51:  alterations  in  natural, 
62 ;  new  or  abnormal  sounds  of,  68. 

Respiratory  system,  examination  of.  19. 

Respiratory  system,  diseases  of  the,  6ii2;  rules 
for  the  diagnosis  of.  ib. 

Reticulum  of  cancer.  225. 

Rheumatism,  general  pathology  and  treatment 
ot  909;  treatment  of,  by  nitrate  of  potash, 
910;  treatment  of,  by  lemon-juice,  914;  dia- 
phragmatic, case  of,  'jl6. 

Ringworm.  787. 

Roseola,  diagnosis  of.  779 :  treatment  of.  784 

Eupia,  diagnosis  of,  780 ;  treatment  of.  786. 

Saliva,  microscopic  examination  of.  72. 

Salm(»  salar.  structure  of  the  spinal  cord  in,  1C9. 

Sarcina  ventriculi.  83. 

Sarcoma.  153;  cystic.  169:  compound  cystic,  of 
the  mamma.  163:  osteo,  154.  188. 

Scabies,  diagnosis  of.  779;  treatnient  of,  785. 

Scalp  diseases,  treatment  of.  7&7. 

Scarlatina,  cases  of  8S5;  diasrnosis  and  treatment 
of,  SS7;  colchicum  in,  940;  bodies  found  in 
urine,  in  a  case  of,  90. 

Scirrhus.  183. 

Scorbutus,  cases  of  920 ;  epidemic  of.  in  Edin- 
burgh, 921 ;  observations  of  Dr.  Christison  and 
Ur.  Lonsdale  on,  922;  Fir.  Gan-od  on,  ib. 

Scrofula,  see  Tuheiciilur  Exudaiion. 

Scrofulous  pus  cells.  78.  ISO. 

Sectio-cadaveris.  method  and  order  of.  23;  object 
of,  ib, ;  external  appearances,  24;  head,  ib. ; 
spinal  column,  ib. :  neck.  ib. :  chest,  ib. :  abdo- 
men, ib. :  blood,  ib. ;  hints  for  carrying  out 
post  iiioitem  examination,  ib. :  knowledge 
reqinred  for  correct  examination.  28. 

Sensation,  definition  of.  113. 

Sensibility,  definition  of,  11.5. 

Sibson,  Dr..  his  "Medical  Anatomy,"  27;  his 
chest  measurer.  33. 

Silver,  nitrate  of.  action  and  use  of.  in  laryngitis, 
595. 

Skin  diseases,  classification  of,  775;  definitions 
of,  ib. ;  diagnosis  of.  779 ;  varieties  of.  7^1 ; 
treatment  of,  7f3;  scaly  diseases  of.  174; 
treatment  of,  7?4;  treatment  of  syphilitic  dis- 
eases of  the,  7S8. 

Small-pox,  cases  of,  893;  general  treatment  of, 
894 :  ectrotic  treatment  of,  ib. ;  greater  fre- 
quency of.  896;  relation  of,  to  varicella,  697; 
identical  with  cow-pox.  898. 

Socrates,  his  death  by  takii.g  hemlock.  418. 

Softening,  cerebral  and  spir.al,  pathology  of.  8C6; 
exudative  or  inflammatory,  ib. :  hemorrhagic, 
806:  fatty,  307;  scrims"  or  dropsical,  ib. ; 
mechanical,  308 :  putrefactive,  ib. ;  necessitj' 
for  microscopic  examination  of.  310:  cases  of, 
ib. ;  cerebral,  cases  of,  £88 ;  spinal,  cases  of,  £92. 

Solanoma,  1S7. 

Sounds  produced  by  percussion.  87 ;  elicited  over 
lungs.  42;  produced  by  pulmonary  organs.  51 ; 
cracked-pot  sound.  43;  alterations  of  natural, 
52 :  abnormal.  53 ;  rubbing  or  friction,  ib. ;  rela- 
tive value  of  in  auscultation.  64:  of  the  circula- 
tory organs.  55:  diagnostic  of  diseases  of  the 
circulatory  systenu  512:  of  aneurisms,  688; 
diasnostic  of  diseases  of  the  respiratory  sys- 
tem. 5<.'2. 

Spasm,  definition  of,  804,  408 ;  of  the  jaw,  case  of, 
366, 


952 


INDEX. 


Spermatocele,  appearance  of  spermatozoa  in  fluid 
of,  S7. 

Spinal-column,  post-mortem  examination  of,  24. 

Spinal  cord,  functions  of,  112. 

Sijinal  softening,  pathology  of,  305;  origins  and 
varieties  of,  ib. :  necessity  for  microscopic 
examinatiiin  of.  310;  cases  of,  392. 

Spinal  irritatiiii),  di-tinition  of,  402. 

Spinal  (lisordrrs.  classitication  of  functional,  402. 

SpiruuKter  of  Mr.  Hutchinson,  35. 

Spleen,  percussi<in  of,  4G;  waxy  degeneration  of 
the,  214;  hypertrophy  of.  in  leueocythemia, 
814,  829 ;  morbid  anatomy  of,  in  fever,  872. 

Sputum,  microscopic  examination  of,  78;  value 
of  microscopic  examination  of,  SO ;  microscopic 
appearance  of,  in  acute  pneumonia,  87 ;  ap- 
pearance of,  in  black  phthisis  of  colliers,  SI, 
7ii2  ;  elastic  tissue  in,  SO. 

Squama-,  definition  of,  776;  diagnosis  of,  780; 
treatment  of,  780. 

Starvation,  svmjitoms  of,  121. 

Steatoma,  160.  166. 

Stetho-goniometer  of  Dr.  Scott  Alison,  35. 

Stethometer  of  Dr.  Quain,  32. 

Stethoscope.  49  :  hints  for  choice  of.  50. 

Stomach,  percussion  of  40:  liairy  concretions  in 
the,  244;  functional  disorders  of  the,  429;  or-   j 
gauic  diseases  of  the,  43S;  ulceration  of  the,  , 
cases  of,  ib. ;   perforation,  cases  of,  440;  fre-  [ 
quency  of  ulceration  in.  446 ;  symptoms  and 
treatment  of  ulcers  in,  447 ;  cases  of  cancer  of 
the,  448 ;  structural  changes  in  glands  of.  451 ; 
remarkable  case  of  emphvsema  of  the  coats  of, 
625. 

Stramonium,  action  of,  407. 

Stricture,  148;  of  intestine,  4S6,  483,  706. 

Strychnine,  action  of  407. 

Succussion,  examination  of  patient  by,  32. 

Sugar  in  urine,  detection  of,  95. 

Supra-renal  capsules.  Dr.  Addison's  views  of, 
229 ;  case  of  disease  of,  without  bronzing  of 
skin,  649. 

Sweating  in  phthisis,  treatment  of,  694. 

Syphilis,  cases  of.  S99;  observations  on.  902; 
"svmptoms  of,  ib. :  diagnosis  of,  9r3;  i)ropaga- 
tion  of,  904 ;  pathology  of,  905 ;  treatment  of, 
906. 

Syphilitic  diseases  of  the  skin,  treatment  of,  788. 

System,  nervous,  general  anatomy  and  physio- 
logy of,  IDS;  general  pathology  of,  II 5. 

Tape- worm,  see  Toenia  solium. 

Tests,  chemical,  use  of  in  examination  of  pa- 
tient, 94. 

Tetanus,  definition  of,  402. 

Therapeutics,  recent  changes  in.  250. 

Thorax,  inspection  of.  29;  mensuration  of,  38; 
motions  of  during  resjnration,  29 ;  post-mor- 
tem examination  of,  24;  view  of  viscera  in, 
26. 

Thrombosis,  356. 

Tissues,  formation  and  sustentation  of,  by  the 
blood,  102;  attractive  and  selective  property 
ofthe.  ib.;  re-absorption  of  transformed  tissues 
into  the  blood,  ib. ;  Ziimuermanns  opinion 
and  arguments,  103. 

Texture,  morbid  degenerations  of,  210;  morbid 
growths  of,  148. 

Taenia  solium,  oi-igin  and  development  of  the, 
492;  cases  of,  495;  treatment  of,  497. 

Tonsillitis,  case  of.  421. 

Toxic  disorders  of  the  nervous  system,  407; 
treatment  of,  409. 

Trance,  definition  of.  402. 

Tracheotomy,  in  laryngitis.  509. 

Treatment,  palliative,  and  cur.ative,  251. 

Tricuspid  valve,  cases  of  disease  of,  543. 

Trismus,  definition  of,  402. 

Trommer's  test  for  sugar  in  urine,  95. 

Tubercle  corpuscles,  79. 137. 

Tubercuhe,  definition  of,  776 ;  diagnosis  of,  7S0 ; 
treatment  of,  7S7. 

Tubercular  exudation,  137;  general  pathology 


of.  139.  6^;  general  treatment  of,  146,  6s4. 
See  Phfhi.yis. 

Tuniiur  heteradenemique  of  M.  Eobin.172. 

Tumours,  classification  of  149 ;  fibrous.  1.51 ;  sar- 
comatous or  soft  fibrous,  1.53;  dermoid  or  hard 
fibrous,  155;  neuromatous  fibrous,  158:  fatty, 
159;  fibrolipomatous,  100;  cystic,  161;  sim- 
ple cystic.  162;  compound  cystic,  ib. ;  osseo- 
cystic,  168;  glandular.  170;  epithelial,  173; 
horny,  IsO;  aneurismal.  181;  cases  of,  557; 
erectile,  183 ;  varicose,  1 84 .  enchondromatous, 
186;  osseous,  190;  myeloid,  193;  cancerous, 
196. 

Ulcer,  cancerous,  of  skin,  microscopic  appear- 
ance of  93 ;  cutaneous,  microscopic  examina- 
tion of,  92 ;  of  tonsil,  case  of,  421 ;  of  cesoiiha- 
gus,  424;  of  stomach.  4;^s;  of  duodenum,  735; 
of  intestine,  4SS ;  typhoid,  874. 

Ulceration,  144. 

University  (Scotland)  Bill,  11. 

Uric  acid,  microscopic  appearance  of,  88. 

Urinary  concretinns.  240. 

Urine,  microscopic  examination  of,  88;  specific 
gravity  of  94:  detection  of  albumen  in,  ib. ; 
detection  of  bile  in,  ib;  detection  of  sugar  in, 
95 ;  detection  of  chlorides  in.  90 :  diagnostic 
value  of  the  absence  of  chlorides  from  the,  in 
jineumonia,  643;  examination  of  in  Bright's 
disease,  709;  various  kinds  of  casts  in,  770. 

T^rticariii,  diagnosis  of,  779 ;  treatment  of  784. 

Uterine  discharges,  microscopic  examination  of. 

Uterus,  appearance  of  cancerous  juice  from  the, 
86;  fibrous  structure  of  the.  151;  fatty  dege- 
neration of,  after  delivery,  220. 

Vaccination,  mode  of,  897;  Dr.  Weir's  scarifica- 
tor for,  ib. 

Vatrinal  discharges,  microscopic  examination  of, 
85. 

Valsalva's  treatment  of  aneurism.  5S3. 

Valves  of  the  heart,  diseases  of,  532. 

"\'an  der  Kolk's  observations  on  phthisic.il  spu- 
tum, SO;  views  as  to  the  propagation  of  cancer. 
206. 

Varicella,  identical  with  small-pox,  897. 

Varicose  aneurism,  between  vena  cava  and 
aorta,  181 ;  case  of.  communicating  with  the 
pulmonary  artery,  564;  signs  of,  567;  patho- 
logy and  treatment  of  568. 

Variola,  cases  of  893;  ti-eatment  of  894;  obser- 
vations upon,  896.    See  Small-jiox. 

Varix.  184. 

Vascular  growths.  ISl ;  aneurismal.  ib. ;  erectile, 
183;  varicose,  184;  of  new  vessels,  ib. 

Vegetation,  dendritic,  179. 

Veipeau  on  the  propagation  of  cancer,  904,  207. 

Vermifuge  remedies,  497 ;  male  shield  urn,  495; 
kamala,  49S. 

Verruca  achrocordon,  91,  176. 

Vesical  calculi.  242, 

VesiculiS,  definition  of,  775;  diagnosis  of,  779; 
treatment  of  784. 

Vessels,  auscultation  of  the  large.  58. 

Villi,  formation  of  in  pericarditis,  267. 

Vocal  resonance,  54. 

Voluntary  motion,  115. 

Vomited  matters,  microscopic  examination  of, 
81. 

Vomiting  and  nausea  in  phthisis,  treatment  of, 
693. 

Warts.  174. 

Waxy  degeneration.  214. 

Weir's  vaccinating  instrument,  897. 

Winterich's  percussion  hammer,  36. 

Woorari,  effects  of  407. 

Worms,  intestinal,  492 ;  varieties  in  man,  495. 

Zimmerman's  opinion  regarding  the  origin  of 

fibrin  in  the  blood.  1C8.  " 
Zymosis,  definition  of  the  term,  885. 


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